Kogler 1996

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PII: SO268-0033(96)00019-8

ASB Clinical Biomechanics Award 1995

Biomechanics of longitudinal arch support


mechanisms in foot orthoses and their effect
on plantar aponeurosis strain
G F Kogler co’, S E Solomonidis c Eng2, J P Paul Prof Eur lng2

‘Orthopaedic Bioengineering Research Laboratory, Southern Illinois University School of


Medicine, Springfield, IL, USA; 2Bioengineering Unit, University of Strathclyde, Glasgow,
Scotland, UK

Abstract
Objective. The purpose of this investigation was to quantify the longitudinal arch support
properties of several types of foot orthosis.
Design. An in vitro method that simulated ‘static stance’ was used to determine arch
support capabilities, with plantar aponeurosis strain implemented as the performance
measure.
Background. A longitudinal arch support mechanism of an orthosis resists depression of
the foot’s arches by transferring a portion of the load to the medial structures of the foot.
Since the plantar aponeurosis is in tension when the foot is loaded, a quantifiable decrease
in strain should occur with an adequate orthotic arch control mechanism.
Methods. A differential variable reluctance transducer was surgically implanted in the
plantar aponeurosis of cadaveric donor limb feet (n = 7). Each specimen was mounted in an
electromechanical test machine which applied a load of up to 900 N axially to the tibia. The
test schedule was divided into seven test conditions: specimen barefoot; specimen with
shoe and specimen with shoe and five different orthoses.
Results. The University of California Biomechanics Laboratory Shoe Insert and two other
foot orthoses significantly decreased the strain in the plantar aponeurosis compared to the
barefoot control and were considered effective arch supports (P<O.O5). The functional foot
orthosis, stock orthosis, and test shoe did not effectively reduce plantar aponeurosis strain.
Significant variations of time required to achieve the specified load levels were recorded
among the test conditions, indicating the relative cushioning properties of the shoe/
orthosis systems.
Conclusions. The patterns of plantar aponeurosis strain observed in cadaveric tests
suggest that certain types of orthoses are more effective than others in the support of the
foot’s longitudinal arches. It is suggested that to support the longitudinal arches of the foot
effectively the medial surface contours of the orthosis must stabilize the apical bony
structure of the foot’s arch. Copyright @ 1996 Elsevier Science Ltd.

Relevance
Reducing tension in the plantar aponeurosis is an important treatment objective for orthotic
management of plantar fasciitis. Therefore it is of great clinical interest to know whether the
longitudinal arch support mechanism of specific foot orthoses have benefits with respect to
the loading of the plantar aponeurosis.

Key words: Foot orthoses, longitudinal arch support, plantar aponeurosis, plantar fasciitis,
biomechanics, shoes

Clin. Biomech. Vol. 11, No. 5, 243-252, 1996

Introduction is accomplished by producing surface contours on the


Foot orthoses modify the way ground forces are orthosis to interact with the foot. During load trans-
mission, the foot adapts to these conformations to
transmitted to the foot and its internal structures. This
produce or resist motion for the desired orthotic effect.
To control the foot’s longitudinal arches, the arch
Received: 17 November 1995: Accepted: 6 February 1996 support mechanism of an orthosis attempts to restrain
Correspondence und reprint requests to: Gtza F Kogler, Orthopaedic the motions associated with arch depression. The
Bioengineering Research Laboratory, Southern Illinois University
School of Medicine, PO Box 19230, Springfield, Illinois, 62794-9230 concerted movements that lower the foot’s arch are
USA hindfoot adduction-pronation-plantarflexion and fore-
244 Clin. Biomech. Vol. 11, No. 5, 1996

foot abduction-supination-dorsiflcxion’ Despite the performance measure to evaluate their longitudinal


wide use of longitudinal arch support mechanisms for arch support mechanisms. An experimental set-up with
the treatment of various foot pathologies, few scientific cadaveric lower limbs was used to test the orthoses with
studies have documented their biomechanical influence the barefoot condition serving as the control”.
cm toot functian and their effectiveness as a structural Furthermore, the design characteristics of the test
support. devices were examined to establish which orthotic
Repeated loading of the foot and excessive tension of practices influence strain reduction and arch support.
the plantar fascia have been implicated by several
authors as a cause for the condition of plantar fasciitis
Methods
which result\ in symptomatic heel pain and inflamma-
tj()$ : In order to avert such pathological results. the Seven fresh frozen cadavcric lower limbs disarticulated
objcctivc of orthotic intcrvontion is to resist depression at the knee were used in the study. Their age ranged
trf the foot‘< ;trch during weight bearing through from 5 1 to 75 years with a mean of 56.9 years (Table 1).
skeletal support; therehv decreasing tension in the Specimens were evaluated for clinical and radiographic
plantat aponeurosis’. The mechanical relief prevents normality by an orthopaedic surgeon prior to testing.
further trauma to the area and allows the healing Donor subjects had not been on prolonged bed rest
process to take its natural course. Numerous types 01 prior to death nor had they suffered from a disease
orthosis have been used tk, treat plantar fasciitis: ‘soft’ effecting collagen. For convenience, specimens were
orthoscCi ” .semi-ripiti’ cuthoses’,’ “I. and ‘rigid’ stored at 20°C in hermetically scaled bags for up to
()rthoses’ ” I’ ” ‘fhe diversity of orthotic techniques two weeks prior to testing. For preparatory procedures
and designs ass~rciatcd with plantar fasciitis has led to a and testing, specimens were thawed in a cold water
degree 0; uncertainty as to the magnitude of control an bath and brought to room temperature.
orthosis will provide to the foot. Preliminary steps prior to testing included the
ihr plantar aponcurosi~ plays a fundamental role in attachment of a compression plate and the imple-
focit biomechanica during standing. As the foot trans- mentation of conventional orthotic negative impression
mitt the load (,f body weight its longitudinal arches techniques and measurements for the fabrication of
lengthen and flatten. I‘hough the foot has an arciform orthoses and shoe acquisition. The proximal articular
appearance. \tructurallv ir ix not a true arch since it cartilage was removed with an orthopaedic bone saw
r-clicx on adjacent soft tissues to maintain its curved exposing subchondral bone to create a flat surface.
posture. The shape of the arch is maintained in part A compression plate was attached by six 7.2-cm-long
hecause 01 the anatomical position of the plantar cancellous bone screws. Following orthotic impressions
aponeuroci~ ;ind its inhcrcnt mechanical properties. and measurements the limb was returned to storage for
Several tnv,estipators have recognized that the load up to 5 days while the orthoses were manufactured and
transmitted !I\,. the foot develops a corresponding the shoe acquired. On the day of testing the specimen
tcnsilc for-cc rn the plantar aponeurosis”’ “. The intcr- was instrumented with a differential variable reluctance
action of the plantar aponeurosis with the skeleton of transducer (DVRT) (The Microstrain Co.. Burlington,
the loot is ;j miljor component of arch stability in the VT, USA). The DVRT was calibrated prior to each set
foot. This biomechanical aspect of the foot’s response of tests. A medial surgical approach was adopted for
to loading creates an ideal means to obtain measures the implantation of the transducer. This consisted of a
for C~sscssnlent of’ the arch support propertics of an longitudinal incision 3.0 cm in length, located 1.0 cm
nrthosts. Our hypothesis founded on the hiomechanics dorsal of the heel’s plantar surface and extending
of ;u-ch stahili?y. is that if an orthosis effectively distally from a point 2.5 cm from the posterior aspect of
supports thz flrot‘s longitudinal arches. strain in the the calcaneus. The plantar aponeurosis was exposed by
plantar aponeurosis should decrease. There arc a wide blunt dissection and the DVRT was inserted with the
variety of bi~mechanical control mechanisms that can aid of a specially designed insertion tool”. The
he incorporated into the design of a foot orthosis to transducer was placed 2.5 cm anterior to the medial
treat many different type\ of lower-extremity disorder. tuberosity of the calcaneus and parallel to the natural
In this investigation only the longitudinal arch support fibre orientation of the plantar aponeurosis in its
component and it’s influcncc on loading of the plantar
aponeurosir wax evaluated. With the exception of the
pilot study to this work?-. to the authors’ knowledge Table 1. Details of cadaveric specimens

there have been no specific studies that quantify strain Subj. Age sex 4 Height Body mass Leg mass
in the plantar aponcurosis to determine the functional NO. (VI /ml kg, !kgl
.---__-_ _..__ ___
control capabilities of foot orthoses. 1 56 F R 1.7 59.1 7.6
From a clinical perspective. it is important to know 1 56 M L 1.8 77.3 3.7
3 58 M L 1.7 80.9 4.0
how efficient an orthosis is in supporting the foot’s 4 51 M L 1.8 68.2 3.0
longitudinal arches for the relief of plantar fascia strain. 5 75 F L 1.6 55.5 2.9
6 51 M L 1.8 81.8 3.8
The aim of this study was to determine the arch support 7 51 M L 1.7 77.3 4.3
capabilities of several types of foot orthosis of various Mean 56.9 1 .J 71.4 3.5
designs. Plantar aponeurosis strain was used as a SD 8.5 0.1 10.7 0.6
Kogler et al: Longitudinal arch support mechanisms 245

plate attachment. The components were not specifically


designed to allow for tibia1 rotation and therefore some
resistance due to friction probably occurred during
tests. The voltage output from the strain transducer and
load cell were transferred via an amplifier/signal
conditioner to a data acquisition board for A/D
conversion sampled at 750 Hz for a 1.5-s test. As data
were sampled they were simultaneously stored on the
computer.

Shoe and test orthoses


The shoe chosen for these studies was a standard
‘Oxford’ type with a leather upper and a neoprene sole.
Figure 1. Lateral radiograph of a left cadaveric foot. Arrow indicates All shoes were from the same manufacturer with the
implanted DVRT strain transducer in the plantar aponeurosis 2.5 cm
anteriorto the calcaneal tuberosity. The terminal end of the transducer identical model number and style. The shoes had a heel
lead exits on the dorsal surface of the foot via a subcutaneous tunnel. and sole thickness of 31 mm and 17 mm respectively,
which resulted in a 14 mm heel height. The laces were
central region (Figure 1). The incision was closed and removed and replaced with a Velcro@ Dacron-backed
stapled. closure. A loop attached to the end of the fastener
The loading system was a Scott electromechanical permitted the use of a hand-held spring force gauge to
test machine Model CRE/SOO (GCA Precision ensure consistency in shoe closure tightness. Shoe size
Scientific, Chicago, IL, USA). A stainless steel locator was determined with a ‘Brannock device’ (Brannock
pin was used to secure the compression plate from the Co., Syracuse, NY, USA).
limb, via a mounting post to a compression/tension load Test orthosis number one (FO no. 1) was a pre-
cell situated in the cross-head beam of the test machine fabricated orthosis (Figure 3). Since it is a stock device
(Figure 2). Specimens were preconditioned just prior to no mould is required. Proper fit was determined by
testing by cyclical loading. Ten cycles were performed shoe size, with selections in either left or right, small,
at the selected test parameters which consisted of a medium, and large. The orthosis is constructed of a
cross-head speed of 508 mm/min. and a load appli- urethane polymer (Hardness, Shore A = 45) with a
cation at stated values from 0 to 900 N. Following cloth lining. The orthosis could be classified as a semi-
specimen preconditioning the reference length and rigid device. It extends from the heel to just proximal to
‘zero’ position of the strain transducer was determined. the metatarsal heads. The lateral border is trimmed so
Initial length was established by positioning the limb in
an upright position and using the relevant limb mass to
produce slight tension in the plantar aponeurosis. This
process permitted a proportional load for each
specimen calibration.
load cell
1v
/’
/’
crosshead
beam

The test schedule was divided into seven test con- --P--
ditions: specimen barefoot, specimen with shoe and
tests of five orthoses which combined specimen with
shoe and test orthosis. Five test runs were conducted
with each condition bringing the total number of
recorded test runs performed on each specimen to 35.
All specimens were subjected to the seven conditions in
a varied order utilizing a simple ‘Latin square test-
ing sequence’. This predetermined arrangement of
succession ensured that each condition was initiated at
a different stage within the schedule so that the effect of
order would be controlled. Specimens were randomly
assigned their position in the testing sequence square.
Between the different treatment conditions, legs
underwent an additional five cycles of loading to
eliminate ‘first time behaviour’ which represents initial
settling of the limb within the shoe and orthosis. The
shoe alignment plate and the mounting fixture ensured
that limb placement and position would be unchanged
as a specimen was prepared for each treatment con-
dition. With the locator pin removed, tibia1 rotation Figure 2. Diagramatic representation of the experimental set-up for
was permitted via the mounting post and compression testing the longitudinal arch support mechanism of foot orthoses.
246 C/in. Biomech. Vol. 11, No. 5. 1996

metatarsal joint is permitted to plantarflex during the


propulsive phase of gait30. The device is manufactured
of a carbon composite material (TL-61*, Medical
Material Co., Camarillo, CA, USA). Due to its rigidity
its indentation properties are not in the range for Shore
hardness tests. It has a shell construction with a heel
and forefoot post that serves as a platform to position
the shell. The orthosis extends from the heel to just
proximal to the metatarsal heads. The medial border is
located at the proximal lateral edge of the weight
bearing surface of the first metatarsal head. The
negative impression used to fabricate the functional
foot orthosis was a neutral position off-weight-bearing
technique in the prone position”. Conventional
modifications for the functional foot orthosis were
made on the positive cast.
Test orthosis number five (FO no. 5) was a custom-
Fiaure 3. illustrations of test orthoses for a left foot. FO no. 1
&fabricated stock orthosis; FO no. 2, custom viscoelastic orthosis; FO
fabricated University of California Biomechanics
no, 3, custom semi-rigid orthosis; FO no. 4. custom rigid functional Laboratory (UC-BL) shoe insert (Figure 3). It was
orthosis; FO no. 5. custom rigid LJGBL shoe insert.
constructed of carbon composite materials. It is a ‘rigid’
device whose indentation properties are not in the
as IWI to t:nclimpass the plantar surface of the fourth range for Shore hardness tests. The orthosis en-
and fifth I‘ilXS The device ic cpecifically designed for compasses the heel and terminates at the distal border
trez8tmcnt 01 aculc plantar fasciitis. of the metatarsal heads. The negative impression was
Ted orthosis number two (FO no. 2) was a custom taken in a simulated partial weight-bearing position
orthosis that rtsquires a mould for fabrication (Figure 3). with emphasis on positioning: external rotation of the
The arthnsi:. ;“; manufactured from two materials; the tibia, forefoot adduction. and placement of the
Fast *t room tcmperaturc vulcanizing (RTV) liquid calcancus in additional inversion from that achieved
vlxot’lastic pol!/mer (Hardness. Shore 00 = hX) and the from the external rotation’. No modifications wcrc
liner <I &,t.hxovered microcellular rubber neoprene done to the positive cast. The orthosis is designed to
Sp~nc:c~~~( t lardness. Short 14 =: 20). It is categorized as control the hindfoot and forefoot via its calcancal heel
:t -ill!“?’ tbrthosis and its borders encompass the entire cup and its substantial medial and lateral extensions.
plantar iuriace’ of the foot. The negative impression
technique Mits hased on a neutral position semi-weight
hearing pt(?/ayiyrcnc‘ foam ztcp-in’“. No modification5
wcrc ma& it1 the positi\c cast. Additional foot Following the mechanical tests. surface contour plots
posirioning iniiucied adduction of the forefoot relative were obtained from a representative series of test
t{> i.hc hindft-rot to clcvatc the medial longitudinal arch orthoses from the same donor specimen. <Zross-sections
i<, it5 maximum position from the digitized orthoses were prepared to compare
i cst orthr,sis number three (I-X) no. 3) was a custom the surface geometry of their arch support mechanisms.
orthosis fabz-icated from the same positive cast used to ‘I‘he upper of the test shot was cut and rcmovcd to
produce te<;t i,rthosis DUO (f;igure 3). The base con- leave an X-mm lip so that orthoses could he properly
5rrucliot: mar;:rial i5 ;i ihrrmoformablc cork in 2 oriented on the sole of the shoe. The test shoe and foot
ioamcd cnp~~l~mer matrix (I lardness. Short A T 55). orthoses were coated with a flat, neutral colourcd paint
iinccl \vith ;+cloth-covered microcellular rubber Spenco”, and mounted to a rectangular wood platform with
[H:lrdness. Shore ,A =: 120). It is catcgorizcd as a ‘semi- double-backed adhesive tape and small clips.
rigid‘ orthosi:, ,mtl its borders cncompacs the entire A Bergmann Optical Laser Scanning Device (Bergmann
plantar hurfac:: of the foot. Orthotic Laboratories. Northficld. IL, USA) was used
2”es;!rqthosis four (FO no, -I) was 21custom orthosix to obtain coordinate data for graphical analysis.
commonly reterred to ;IS a functional foot orthosis A computer aided design software program
( F;~LIW 3 ;. According t<j Anthony”’ ;i ‘functional (CADKEY@, Cadkey, Inc. Windsor, CT, USA) was
ort ho& is an orthopaedic device which is designed to used to generate cross-sectional diagrams for graphical
promote structural integrity of the joints of the foot and assessment.
. L
I~wt’r limb. !~1; resisting ground reaction forces that
cause abnormal skeletal motion to occur during the
stance phase of gait’. Three biomechanical concepts
related to its design purpose are: (1) the subtalar joint Statistical analyses of these data consisted of multiple
is positioned in neutral during the propulsive phase of procedures. where the dependent variables of percent
gait (i.e. just prior to heel-off); (2) the midtarsal joint is strain and time to load were examined separately. The
fully pronated during midstance: and (3) the first specific unit of measurement used for analysis was the
Kogler et al: Longitudinal arch support mechanisms 247

Table 2. Mean (SD) for percent strain at different test loads. (n = 7) Values to orthoses increases with increasing load. In other
below dotted line indicate foot orthoses that had efficient longitudinal
arch support mechanisms. Their values were statistically different from words, there is a complementary relationship between
all other tests (PC 0.05). the effect for subject and orthoses on time to load. In
Test load values
general, the planned comparison tests of time to load
225 N 450 N 675 N 900 N
indicate that barefoot loaded quickest and FO no. 2
took the longest time to load. Furthermore, FO no. 5
Test condition
FO no. I* 2.88 (2.01) 3.98 (2.18) 4.71 (2.30) 5.29 (2.41)
and shoe performed similarly as did FO no. 3 and
Shoe 2.50 (1.78) 3.66 (1.83) 4.50 (1.89) 5.20 (1.95) FO no. 4 while FO no. 1 performed in a similar way to
Fo no. 4’ 2.31 (1.78) 3.51 (1.89) 4.35 (1.98) 5.03 (2.05)
Barefoot 1.31 (1.46) 2.62 (I .78) 3.54 (2.02) 4.29 (2.20)
FO no. 4. More detailed comparisons can be seen in
Table 3.
FO no. 5’ -2.64 (2.88) -2.13 (3.15) -1.62 (3.34) -1.16 (3.51)
FO no. 2* -2.76 (3.53) -1.56 (3.17) -0.74 (3.02) -0.66 (2.96)
The results of the repeated measures analysis
FO no. 3* -3.58 (3.39) -2.39 (3.28) -1.59 (3.25) -0.98 (3.24) indicate that the effect of treatment was not significant
*with shoe at 225 N, but was significant for loads 450, 675, and
900 N (P< 0.01). To determine specifically which
mean of the five replicates. Descriptive information treatments differed from one another, paired t tests
was also collected and statistical significance was set at were performed between each pair of orthoses. This
the 5% level (P < O.OS), although, given the pilot resulted in 15 paired follow-up tests being performed at
nature of this work, the 10% level was also entertained each load separately. These results indicate in general
(P < 0.10). The primary analysis was conducted as a that the pattern of performance was similar to that of
Latin Square Analysis of Variance (ANOVA) consisting the raw data seen in Table 2.
of subject, treatment (orthoses), and order for both
strain and time; follow-up comparisons were performed Discussion
with Duncan’s multiple range testX2. Additional
analysis consisted of converting percent strain to a In this investigation, several types of foot orthosis were
measure x that reflects the strain value that occurred evaluated on cadaveric donor limbs to determine the
with each orthosis as a function of the barefoot efficiency of their respective longitudinal arch support
condition, x = (f-h)lb) 100, where f and b are mechanisms. Strain in the plantar aponeurosis was
respectively the strain readings corresponding to the employed as a performance measure to quantify the
foot orthosis (or shoe) and barefoot conditions. This integrity of the arch of each foot. Orthoses which
complementary procedure resulted in a one factor produced a statistically significant decrease (P~0.05)
repeated measures analysis of variance with six levels in plantar aponeurosis strain compared to the barefoot
being performed for each load separately. Follow-up control were considered effective as an arch support.
comparisons were performed with paired t-tests. Two groups of orthoses were statistically distinct, one
with effective longitudinal arch support mechanisms
and the other with devices that provided only nominal
Results reductions in plantar aponeurosis strain. Though
Results of the Latin Square, performed at each load variations in performance were anticipated, the
separately, indicate a non-significant effect of order for magnitudes of the differences were unexpected. The
time to load and a significant effect of order for per cent orthotic design characteristics that contributed to the
strain, which only accounts for approximately 10% of resultant data were of clinical interest. Test devices
the variability in the full model. Further examination of were critically examined to determine what influence
the means suggests that the use of a testing sequence
designed to control for order will probably be beneficial h I I I I I

in future studies of this type, with regard to per cent 000

strain. In addition, the effect of subject for per cent


strain was significant (P~0.05) for all loads and
675
accounted for about 57% of the variability. In general,
these results indicate that orthoses FO no. 2,
FO no. 3, and FO no. 5 showed a significant reduction
in strain as compared to the shoe, orthoses FO no. 1,
FO no. 4, and barefoot (Table 2 and Figure 4). The
remaining 13% of the variability can be attributed to
error. The results for time to load were, in general,
very similar to those of per cent strain. However, only
the effects of subject and orthoses were significant T-
-6 -5 -4 -3 -2 -1 0 1 2 3 4 5 6
(P<O.O5). The effect of subject accounted for between RELATIVE STRAIN %
70 and 88% of the variability while the effect of orthosis
Figure 4. Representative load-strain curves of the plantar aponeurosis of
accounted for between 8 and 26% of the variability. It a donor specimen showing all seven test conditions. FO no. 2. FO no. 3
is important to note that the variability due to subject and FO no. 5 demonstrated a significant (P<O.O5) reduction in strain at all
four load levels analysed compared to the barefoot control, shoe, FO no.
decreaseswith increasing load, while the variability due ‘I and FO no. 4.
248 C/in. Biomech. Vol. 11, No. 5, 1996

their individual features have on the loading of the characterized by the concurrent gross motions of hind-
plantar aponeurosis. foot adduction-pronation-plantar flexion and forefoot
Three of the orthoses studied significantly reduced abduction-supination-dorsiflexion’ The primary bony
the amount of strain in the plantar aponeurosis displacements that occur with medial longitudinal arch
compared IO the control: the UC-BL, (FO no. 5). the depression are an amalgamation of: calcaneal plantar
soft accommodative orthosis (FO no. 2), and the semi- flexion and pronation; posterior migration of the talus
rigid orthosis (FO no, 3) (P<O.OS). The findings on the calcaneus; plantar displacement of the navicular
favour the orthotic principles stated by Campbell and and cuneiforms; dorsal compression and plantar
Inman which cmphasizc decreased tension in the widening of the cuneonavicular and cuneometatarsal
plant;ir aponcurosis for treatment of plantar fasciitis’. joints; dorsiflexion of the metatarsals; and anterior
In contrasr the functional orthosis (FC) no. 3), the migration of the metatarsals with posterior displace-
srock devirt iF0 no. 1‘I and the shot alone showed ment of the calcaneus’. We theorize that to decrease
slight incrcnscs in strain compared to the barefoot the arch-flattening moments in the foot, the longi-
condition though the increa>cs wcrc not statistically tudinal arch support mechanism of an orthosis must
significant. Ir is unclear it these occurrences were the support the apical bony structures of the foots arch: the
r-esult of a ‘bowstring’ effect to the plantar aponeurosis base of the first metatarsal, medial cuneiform, and the
described by Campbell and Inman’ or an arch lengthen- talus via the navicular and sustentaculum tali of the
mg rcsponsc While the ‘howstring’ effect may bc ;I calcaneus (Figure 5). This concept is in agreement with
rcasonahle assumption with regard to the foot orthoses KabP. Zamosky”‘. and Hayward’” who recognized
(t’o !I(:. 4 J’C) no I ). ~hc response from the shot is the importance of applying orthosis-ground reaction
rw ijuitc -!a apparcrrr One explanation for the forces in this region, noting that the longitudinal arch
pcrformartcc (of the shoe may be related to its elevated should be placed at the highest medial point near the
heel hcigh: !f the plantar aponcurosis does function talonavicular joint. Niggj” studied the placement of the
4milar Lo the tie-rod component of ;I ‘truss‘ as some medial longitudinal arch support mechanism and
authors h:\v~.; suggested” ‘.’ “.‘.‘. theoretically tension reported that if it is placed in the posterior part of the
would increase as the shorter posterior strut (composed midfoot under the sustentaculum tali of the calcaneus
of the calcancus and talus) is elevated. The shank initial pronation could be reduced. Orthotic restraint in
prrjfiic: of the shoe ma? ;Ilso play a role. When the foot this region reduces the dorsiflexion moments of the
is housed \slrhin tht: shot. there in a mild cur\‘c just medial tarsal metatarsal joints. plantar flexion moment
antct-ior to tht. calcaneus which is the point of transiiion of the calcaneus and the valgus moment at the subtalar
from the heel platform to the metatarsal heads. During joint. In contrast a longitudinal arch support mechanism
load transmission this gradual curvt: could disrupt the that confines support to only distal arch structures, the
functional pcAtion of the plantar aponeurosis altering distal shaft of the metatarsals and distal portion of the
it\ normal loading pattern. Additional tests are ncedcd calcaneus. will produce a dorsiflexion moment at the
tct Jcterminc. rhe influence of these t’actors on the load tarsal metatarsal joints and plantar flexion moments at
bearing characteristics oi the plantar aponcurosis. the talo-navicular joint which translate into an arch-
Accepted theorie\ of foot function proposed by flattening effect. This may explain why the shallow
wvcral authors provides ;I fundamental basis for it
discussion oI the biomechanics of longitudinal arch
support mechanisms. Acting as ;I functional unit. the
foot can srructurally t-emodel itself to alter its loading
~%ittL’FIi lir>t h Mac(~‘onaill~” ;md Sarratian.‘-” ha\72
charactcriycd the foot in this manner. comparing it to a
‘rwisted plate in which the arch is clevatcd when the
*foot plate I i\ twisted and deprcsscd when untwisted.
An ijrthosi> ian also change the cjricntation of the
ft~:.)t \ positiim and loading response. through pre-
scribed changes in its surface geometry. The arch
support ~t”gion of an orthosis. fol- example, closelv
resembles rhc ‘twisted foot piate’ model’5.ii. t~cncc. as
the foot assimilates to the shape ot this orthotic intcr-
f;:cc. its loadingc pattern is modified. In this situation.
tension in the plantar aponeurosis decreases since the
‘trush mechanism’ is deactivated’-‘. An effective arch
%upporl mechanism is capable of redirecting the loads
t’rom plantar soft tissues to the apical bony structures 01
the foot’s medial longitudinal arch (Figure 5).
When the foot is sub,rected to the load of body- Figure 5. Plantar aspect of the bones ofthe right foot showing primary
weight in quiet standing Its longitudinal arches flatten support region for the longitudinal arch support mechanism of a foot
orthosis. Partial circle indicates the position of the vertices of the orthotic
and clongatr’“. The combined movements are generally support.
Kogler et al: Longitudinal arch support mechanisms 249

obtain a representative model of the foot for use in the


fabrication process. Foot position is of primary concern
since the orthotic control is often dependent on the
degree of manipulation imposed. The functional
MAXIMUM MEDIAL ARCH EEIGHT interpretation of orthotic control of plantar aponeurosis
OF TESTED FOOT ORTHOSES strain is associated with the skeletal foot interactions
that elevate and depress the foot’s medial longitudinal
arches. Vertical loading and external rotation of the
tibiotalar column raises the arch and shortens the foot,
II I
FO 2

I I which in turn decreases the strain in the plantar


Mly 4 132 5
aponeurosis 25 - . This action produces hindfoot supi-
nation, midfoot supination and forefoot pronation. The
FO 5
medial aspect of the foot remains in contact with the
ground due to pronation of the forefoot. Two of the
three negative impression techniques presented in this
L-J
study utilized procedures that closely paralleled these
Figure 6. Cross-sections of a representative series of test orthoses combined motions to obtain an adequate foot position.
comparing apical arch height and slope. The soft orthosis (FO no. 3).
semi-rigid orthosis (FO no. 2) and UC-EL shoe insert (FO no. 5) have
Procedures for FO no. 2 and FO no. 3 focused on two
hiaher medial borders than the stock orthosis fF0 no. 1) and functional principles, accentuation of the foot’s medial longi-
foot orthosis (FO no. 41. Slope angles are greater with FO no. 3 and FO no.
2 compared to FO no. 1 and FO no. 4. Note that FO no. 5 has a functionally
tudinal arch through adduction of the forefoot relative
different arch support mechanism’ from the other orthoses and therefore to the hindfoot and maintaining the talus in a neutral
its arch slope could not be defined and compared.
position*‘. The UC-BL shoe insert (FO no. 5) had
similar correlations, emphasizing the medial longi-
longitudinal arch support mechanisms did not show any tudinal arch by adduction of the forefoot, calcaneal
arch support properties and in fact often increased the inversion and external rotation of the tibia*. The
strain in the plantar aponeurosis relative to the bare- UC-BL was unique to the orthotic systems tested in
foot tests. Therefore it cannot be assumed that an that a greater portion of the foot position attained in
orthosis with a relatively low arch configuration is the negative impression can be preserved in the final
capable of providing partial support to the foot’s orthosis due to it’s extended trimlines at the calcaneus
skeletal structure, since sufficient control of the medial and lateral and medial borders of the foot. The
apical bony anatomy is required to influence strain effectiveness of these two techniques in reducing
reduction and arch support. tension in the plantar aponeurosis was supported by
Inspection of the surface contours and trimline our results (Table 2). In contrast, the off-weight-
delineation’s of the test orthoses revealed notable bearing technique used to fabricate the functional foot
design differences. One of the distinguishing features of orthosis (FO no. 4) does not emphasize a higher
the orthoses which decreased plantar aponeurosis medial arch nor a decrease in foot length. This tech-
strain was the surface contours of their medial and nique captures the foot in the subtalar neutral position
central regions and the magnitude of their longitudinal and locks the calcaneocuboid joint through a firm dorsi-
curvatures. In general, their medial profiles were flexion force on the fourth and fifth metatarsal heads29.
higher and the angles related to their arch shape were To avoid any undesirable supination, Michaud3’
more acute (Figure 6). This correlates with the findings suggests that a slight lateral force be used during
of Cavanagh’“‘, who examined the effect of the medial loading of the metatarsals. While the abduction force
height of an orthosis in running shoes and found that applied to the forefoot and the locking of the calcaneo-
increased thickness reduced pronation, a component of cuboid joint have the tendency to depress the foots arch
arch depression. Of the two orthoses which demon- there was no obvious reflection of this in the positive
strated poor longitudinal arch support capabilities, the cast. It is unclear to what degree the role of this type of
stock orthosis (FO no. 1) had a relatively planar medial foot positioning played on the test orthoses’ per-
surface and the functional orthosis (FO no. 4) formances, however any positive effects were probably
possessedslight longitudinal contours though nominal very small given the higher strain values observed with
in height and acuteness. Medial trimline delineations the functional foot orthosis (FO no. 4) (Table 2).
corresponded with the pattern of surface contours in Though the various negative impression techniques
that the three orthoses which showed the best arch were considered a factor in the resultant strain
support properties had more extensive medial trimlines patterns, the clinical nature of the procedures limited
compared to their less supportive counterparts our ability to isolate their individual contributions.
(FO no. 1; FO no. 4). The biomechanical basis of the two orthoses which
The negative impression techniques used in this provided minimal support to the foot’s arch differed
study were examined to determine which procedures from each other, and based on their performance they
controlled foot position to regulate tension in the do not produce plantar aponeurosis strain reduction.
plantar aponeurosis. The moulding method is an One of the principles of the functional foot orthosis
important element of an orthosis, because it is used to (FO no. 4) is that its construction permits first meta-
25u C/in. &omech. Vol. 11, No. 5, 1996

tarsal plantar flexion during the acceleration phase of was fabricated out of a soft material and the other a
gait3c~.‘-r
1 To accomplish this the width of the orthosis is rigid. An explanation for this occurrence may be that
narrowed medially and additional plaster is often the soft material ‘bottomed out’ relatively quickly,
applied to the rncdial aspect of the positive cast to allow limiting its cushioning effect. Another probable
for plantar flexion of the tirst metatarsal. If our suppo- influence to loading time is the surface geometry of the
sition 3s valid. that an effective longitudinal arch orthoses. We noted with the strain data that surface
supper?. mechanism must support the apical bony contours of an orthosis contributed to changes in foot
structures of rhc foot’s arch.. the design criterion of the loading patterns. It seems reasonable to assunie that if
tunctionat foot cbrthosis limits its arch support abilities. an orthosis can modify the way the foot accepts a load,
This observation is in agreement with Anthony who variations in loading time may occur. It was hard to
state\ ‘when ;i functional foot orthosis is prescribed and discern the contribution of the longitudinal arch
fabricated ctrrrcctly it dock not support the medial support mechanism of the orthosis to the loading titnc.
fongitudinai arch of the foot““‘. Two of the principles Of the three orthoses which had effective arch
assoLiated with the design 01 the prefabricated orthosis supports, the UC-BI, shoe insert (FO no. 5) loaded
jF0 no.>.1:i arc elevation c>f the heel and plantal approximately two tenths of a second (0.2 s) faster
Compression j )r medial structures to change the (at 900 N) than the other two devices which had the
manner in which the plantar aponcurosis is oriented longest loading times. Though rationalization of the
during loading ~l‘hc rcsuitr from our data challcngc differences in loading time proved to be difficult, the
these: concepts :+incc strain in the plantar aponeurosis results illustrate that orthoses obviously influence the
mcreascd compared to the barefoot control and alt loading time and that the changes can be quite
other test conditions (Tablt* 2) significant. Additional studies are needed to identify
‘I’hc three orthoscs (FO no. 2. I;0 no. 3. FO no. 5) the importance of material properties and surface
that dccrcasrll strain in the ptantar aponeurosis geometry to loading time. Theoretically ptantar
lyplcall! generated nefati\c strain VdLlCS. thus aponeurosis strain reduction and increased loading
indicating their orthotic control capabilities. This is of time appear to be positive design features for treatment
consequence uhen one examines the relationship of of plantar fasciitis. Since the benefits of these qualities
this occurrence to the designated zero position of the cannot be singled out as the key elements for successful
Strai3; trnnsducct Since the plantar aponeurosis management, combinations of several orthotic pro-
experience5 ijn!y ~1portion of the toad bearing forces cedures would be advisable to increase the chances for
applied to the toot’-‘. tensiie forces are rclativcly 1ow a positive clinical result.
when a ioad corresponding to the limb mass (Table 1) is There arc several limitations associated with the
t~ccd to determine the initial tcngth of the transducer. in vitro test method described herein, and it is
4 rcasonablc !f! \,i~*u analoyq to-.thc loading situation important to understand these limitations when making
created with the described reference length acquisition any clinical inferences from these results. The relatively
method. might be that of restful sitting. If one accepts ‘static‘ method of testing did not account for the
this equivocaticrn. the data suggest that longitudinal dynamics of the windlass mechanism and the influence
;rrch support mechanisms in foot orthoses can act as ;I of the plantar flexors on plantar aponeurosis strain. It
cubstitutc for the function of the plantar aponeurosis as seems reasonable to assume that during the various
a structural member during ‘static’ situations (e.g. yuict phases of gait, tensile forces in the plantar fascia arc
standing). This theor\: is supported by the mean values constantly changing. Therefore our results do not
in Table 2 and the &ain patterns in Figure 3 which address the ability of a longitudinal arch support
show that evthn at higher loads the orthoses held strain mechanism to modify tension during walking or
&cl:) below KY<). This ha\ important clinical impti- running. While measurements of strain in the ptantar
cations when plantar aponeurosis strain reduction is the aponeurosis have proved to be of value in the asscss-
desired treatment objecti\-c ment of longitudinal arch support mechanisms there
Significann variations (f’~O.05) of the time to are many other factors which may be equally as
achieve the required loads wcrc recorded among the meaningful. Foot-ankle kinematics. changes in ground
test orthoses (Table 3). The results showed a great
degree of overlap in some of the statistical groupings. Table 3. Mean (SD) for time to achieve prescribed loads. (n : 7) Results of
making it difficult to associate orthotic traits with time Duncan’s multiple range test show that all grouped values (a, b, c. d. e)
were statistically significant from one another (PiO.05)
to load performance. The hardness of material may be
one of several factors that influences loading time. The Test load values
-__..__ ---
extended loading period of the viscoclastic orthosis 225 N 450 N - 675 N 900 N

(E+‘Ono. 2) connotes a relationship between loading Test condition


time and the relative degree of hardness of the orthotic Barefoot 0.32 (0.15)d 0.47 (0.17)C 0.55 (0.19)’ 0.61 (0.21)”
FO no. 5* 0.31 (0.11 )d 0.49 (0.12)“~~ 0.60 (0.13)” 0.69 (0.14)”
materials (i.c. the softer the material. the longer the Shoe 0.33 (0.13)“,d 0.52 (0.15)” 0.63 (0.17)” 0.72 (0.18)”
loading time). However. further clarification of the role FO no. I* 0.36 (0.15)“,’ 0.56 (0.17)” 0.69 (0.19)” 0.80 (0.21 I”
FO no. 4* 0.36 (0.13)b,C 0.58 (0.15)“,” 0.71 (0.18)“.c 0.82 (0.19)“,’
which material properties play in loading time is FO no. 3* 0.40 (0.14)” 0.61 (0.16)” 0.75 (0.18jb 0.87 (0.20)”
necessary. This is evidenced by the similarity in loading FO no. 2* 0.43 10.14)” 0.67 10.16P 0.82 10.18P 0.94 10.191”
times of FO no. 1 and FO no. 4 in which one orthosis *with shoe
Kogler et al: Longitudinal arch support mechanisms 251

reaction forces, interface pressures, and centre-of- fascial strain. Phys Sports Med 1977; 5(11) 68-73
pressure measurements are a few other parameters that 5 Awbry BJ, Bernardone JJ, Connolly TJ. Prospective
could provide a more complete picture of the functional evaluation of invasive and noninvasive treatment
protocols for plantar fasciitis. Rehabil R&D Prog Report
properties of arch supports. Further studies are also 1989;26:49-50
necessary on pes cavus and pes planus feet since the 6 D’Ambrosia RD. Conservative management of
biomechanical function of these foot types may yield metatarsal and heel pain in the adult human foot.
different results. Orthopedics 1987; 10: 137-42
7 Goulet MJ. Role of soft orthosis in treating plantar
fasciitis-Suggestion from the field. Phys Ther 1984; 64:
Conclusions 1.544
8 Riddle DL, Freeman DB. Management of a patient with a
The patterns of plantar aponeurosis strain observed in diagnosis of bilateral plantar fasciitis and achilles
cadaveric tests, suggest that certain types of orthoses tendonitis. A case report. Phys Ther 1988; 68: 1913-16
are more effective than others in the support of the 9 Riegler HF. Orthotic devices for the foot. Orthop Rev
foot’s longitudinal arches. Of the five orthoses tested, 1987; 16: 293-303
10 Taunton JE, Clement DB, McNicol K. Flantar fasciitis in
three had longitudinal arch support mechanisms that runners. Can J Appl Sport Sci 1982; 7: 41-4
significantly reduced tension in the plantar aponeurosis, 11 Andrews JR. Overuse syndromes of the lower extremity.
while two did not show any substantial changes Clin Sports Med 1983; 2: 137-48
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imply that some of the orthotic designs prescribed by athletic injuries: a retrospective study. JAm Podiatr Med
Assoc 1985;75:359-62
clinicians for plantar fasciitis, may not fulfil the treat-
13 Clancy WG. Runners injuries. Fart two. Evaluation and
ment objective of decreased strain in the plantar treatment of specific injuries. Am J Sports Med 1980; 8:
aponeurosis as previously speculated. We theorize that 287-9
to control the foot’s longitudinal arch the medial 14 Doxey GE. Clinical use and fabrication of molded
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1679-82
bony structures of the arch. Hence, it is probably 15 Ferguson H, Raskowsky M, Blake RL, Denton JA. TL-61
advantageous to position the foot so that its medial arch versus Rohadur orthoses in heel spur syndrome. J Am
is elevated during negative impression procedures to Podiatr MedAssoc 1991: 81: 439-42
maximize orthotic control. The material properties of 16 James SL, Bates BT, Osternig LR. Injuries to runners.
an orthosis influence the loading time of the foot. Am J Sports Med 1978; 6: 40-9
17 Lehrman WL. Overuse syndrome in runners. Am Fumify
Devices manufactured from viscoelastic materials Phys 1984; 29: 157
absorb a higher percentage of energy imparted to the 18 Roy S. How I manage plantar fasciitis. Phys Sports Med
foot compared to more rigid components which 1983; 11: 127-31
decrease the loading time. Finally, the methods 19 Scholl WM. The Human Foot. Foot Specialist Publishing
presented in this paper will be useful in evaluating co. 1931
20 Snider MF, Clancy WG, McBeath AA. Plantar fascial
future designs of longitudinal arch support mechanisms release for chronic plantar fasciitis in runners. Am J Sports
for orthoses as well as athletic shoes. Med 1983; 11: 215-19
21 Torg JS. Athletic footwear and orthotic appliances. Clin
Sports Med 1982; 1: 157-75
Acknowledgements
22 Torg JS, Pavlov H, Torg E. Overuse injuries in sport. The
The authors wish to thank Dr Steve Verhulst, Division foot. Clin Sports Med 1987; 6: 291-320
of Statistics and Consulting, Southern Illinois University 23 Hicks JH. The foot as a support. Acta Anat. 1955;25:
34-45
School of Medicine, for his assistance with the data 24 Hicks JH. The three weight bearing mechanisms of the
analysis. We also acknowledge Dr John N Bergmann of foot. In: Evans FG, ed. Biomechanical Studies of the
Bergmann Orthotic Laboratories for his consultation Musculo-skeletal System). Charles C. Thomas,
with the laser digitization of the foot orthoses, and Springfield, IL, 1961; 161-91
25 Sarrafian SK. Functional characteristics of the foot and
Franklin Veer for his assistance with the data analysis.
plantar aponeurosis under tibiotalar loading, Foot Ankle
This study was supported by a Central Research 1987; 8: 4- 18
Committee Award from Southern Illinois University 26 Wright DG, Rennels BS. A study of the elastic properties
School of Medicine, and by a grant from the Pedorthic of plantar fascia. J Bone Joint Surg 1964; 46: 482-92
Footwear Association Research Foundation. 27 Kogler GF, Solomonidis SE, Paul JF. In vitro method for
quantifying the effectiveness of the longitudinal arch
support mechanism of a foot orthosis. Clin Biomech 1995;
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28 Schuster RO. Neutral plantar impression cast-method
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1044(as quoted by N&p? R.ssoc 1982; 72: 600- 605

THE VOLVO AWARDS


FOR LOW MCK PAIN
RESEARCH 1997
In order to encourage research in low back pain, the Volvo Company of Giiteborg, Sweden, again this year
has sponsored three prizes of US$9000 each. Awards will be made competitively on the basis of scientific
merit in one or more of the following areas:

I. Clinical studies
2. Bioengineering studies
1 Studies in other basic science areas

Papers submitted for the contest must contain original material, not previously published or submitted for
publication. Multiple authorship is acceptable. The manuscripts, in the English language, should be in
the form of a complete report, including original illustrations (please note: marked with names!); not
exceeding 30 typewritten pages -- references and tables included; double-spaced; typed text should not be
smallerthan 10 points; and in a form suitable for submission as an original paper (not thesis) to a scientific
journal. Ethics committee approval is necessary for all animal studies as well as controlled clinical studies.
One original and 5 copies of each paper in full - including illustrations - must reach the address given
below not later than 2 December 1996. Accordingly, articles sent by Fax will not be accepted. Do not forget
to give a complete correspondence address with telephone number and Fax number.
One of the authors should be prepared, at his own expense, to come to Singapore at the time of the
meeting of the International Society for the Study of the Lumbar Spine, 2-6 June 1997, to present
the paper and to receive the award.
The board of referees will be chaired by the undersigned and will contain members from the fields of
clinical medicine, bioengineering and biochemistry.
Please direct all correspondence to:

Professor Alf Nachemson


Department of Orthopaedics
Sahlgren Hospital
S-413 45 Giiteborg
Sweden

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