Foot function has long been considered to predispose individuals to musculoskeletal injury (16). Specifically, foot pronation has been associated with conditions, such as plantar fasciitis (15,29) and Achilles tendinopathy (25). More proximally, foot pronation may also play a role in the etiology of medial tibial stress syndrome and patellofemoral pain syndrome (6,27). The reduction of foot pronation is therefore an attractive target to potentially prevent injury or aid the clinical management of these conditions.
Aberrations in foot function in people with flat-arched feet, such as excessive pronation, present as eversion of the calcaneus, abduction of the forefoot, and a lowered medial longitudinal arch. This can alter the stresses and strains acting on intrinsic foot structures (11,14), alter the distribution of load acting on the plantar surface of the foot (5), and increase demand on intrinsic foot muscles that regulate arch deformation (18). The reduction of foot pronation (“antipronation”) is a component of the proposed mechanism of action of taping and foot orthoses (9,23) and is of clinical interest for the management of individuals with flat-arched feet.
Interventions, such as foot taping and foot orthoses, are commonly used clinically under the assumption that they can modify foot biomechanics, particularly reducing foot pronation. Despite much attention given to their biomechanical effects, the mechanisms by which they exert their effects are still not well understood. Although they have been demonstrated to have broad ranging effects on the kinematic, kinetic, and neurophysiological components of foot function, the alteration of foot kinematics sits at the cornerstone of their proposed mechanism of action (9,23). However, despite this kinematic paradigm being used by most clinicians in practice, there is still no evidence to suggest that the outcome of taping the foot can be used to predict the biomechanical response an individual will have with the use of foot orthoses.
With the exception of highly invasive bone-pin studies that are not routinely applicable (21,33), numerous previous three-dimensional (3D) gait analysis studies investigating the effects of foot orthoses and taping have relied on markers applied on the surface of the shoe (4), which is not representative of foot motion inside the shoe (1). Other studies have removed portions of the shoe to gain access to the foot surface which may affect its structural integrity and may modify how the shoe interacts with the foot orthosis (8,31). Many studies have also measured foot kinematics during barefoot walking, which is not reflective of how these devices are used in clinical practice (4). Use of a noninvasive multisegment approach capable of describing the kinematics of the foot inside footwear would allow insight into how these devices exert their effects in clinically relevant conditions.
Therefore, the aim of this study was to determine the immediate effect of foot taping and foot orthoses on in-shoe multisegment foot kinematics in participants with flat-arched feet during walking. Second, we also aimed to determine if the biomechanical responses within the foot to taping and foot orthoses are related. Because of the proposed mechanism of action of these devices, we hypothesized that they would reduce hindfoot eversion and increase external inversion moment; reduce deformation of the midfoot and medial longitudinal arch and increase peak dorsiflexion of the hallux.
Twenty-one healthy adults (n = 21) were recruited from a student group of the university via advertisements placed on notice boards. To be eligible, individuals had to be between 18 and 30 yr and have a flat-arched foot posture (a navicular height normalized to foot length [NNHt] of < 0.21) because these people are most likely to benefit from antipronation interventions. These cutoff values were determined from a previously developed foot-screening protocol for distinguishing between normal and flat-arched feet (26). An a priori sample size calculation based on previous research for hindfoot kinematics indicated that 17 participants were required to detect and effect size of f = 0.33 between conditions with 80% power and a significance level of 0.05 (17). Exclusion criteria included a history of neurological or neuromuscular conditions affecting walking gait; history of lower limb fracture; lower limb surgery within the last 6 months; any musculoskeletal injury within the last 6 months requiring an absence of greater than 1 wk from sport or work; current pain in the lower limbs or any known allergies to sports tape. Individuals were also ineligible if they identified that they had any current bacterial, fungal, or viral skin infections of the feet because footwear was worn without socks during data collection. Ethical approval for this study was granted from the local human research ethics committee, and all participants gave written informed consent before their involvement.
Interventions—foot orthoses and taping
Before data collection, all participants had plaster casts of their feet taken by an experienced podiatrist (TM) for the manufacture of customized foot orthoses. Neutral suspension plaster casts were taken in a nonweight-bearing position. Foot orthoses were manufactured using a consistent prescription protocol with features designed to reduce hindfoot pronation. The casts were corrected to a vertical hindfoot position, with a minimal medial expansion and arch height equating to weight-bearing navicular height when the foot was in neutral calcaneal stance position (13). Foot orthoses were made from 4-mm-thick polypropylene with a 350-kg·m2 density ethylene-vinyl acetate heel post and 1.5-mm multiform top cover material (Fig. 1). For consistency, all orthoses were manufactured by the same podiatrist (TM) with 10 yr experience in orthoses manufacture. Standard tape (Elastoplast®, 38 mm thickness; Beiersdorf Australasia Ltd, North Ryde, Sydney) was applied to the feet of all participants in accordance with the modified low-Dye technique described by Landorf et al. (19) with the addition of three strips proximal to the metatarsal heads to the heel (Fig. 1). A second taping technique was also used (Fig. 1). The addition of the modified tape in this study was an attempt to investigate whether a taping technique designed to replicate the effect of orthotics by providing inversion around the joint axes of the talonavicular, navicular—medial cuneiform and medial cuneirom—first metatarsal joints would have larger effects on the foot than that seen previously in the literature with low-Dye taping. All taping was applied by the same investigator (TM).
All participants underwent 3D gait analysis where their foot kinematics were quantified while walking in the four different conditions: 1) an ASICS Gel-Pulse 3 neutral running shoe (ASICS, Japan); 2) wearing the same shoes with the low-Dye taping applied to the feet; 3) wearing the same shoes with the modified taping applied; and 4) wearing the same shoes with the customized foot orthoses inserted inside.
Retroreflective surface markers (10 mm diameter) were placed on anatomical landmarks of the feet in accordance with the protocol published by Bishop et al. (2). One investigator (CB) applied all surface markers and laced-up the footwear to ensure consistency between conditions. To allow tracking markers to be placed directly on the foot, circular holes of 25-mm diameter were cut in the shoe upper and heel counter over standardized locations (see Document, Supplemental Digital Content 1, specifications for positioning of shoe windows in footwear, http://links.lww.com/MSS/A596). We previously established the validity of this method which allows unrestricted movement of the markers in athletic footwear (2). This method also ensured removal and reapplication of markers between conditions was on the same location, which was also confirmed by tracing the outline of the tracking marker bases on the foot. It must be stated that the application of tape to the foot in this study provided a unique challenge in terms of identification of marker placement. Where tape was to be applied over or near a marker location, the tape was applied in a manner so that at least one quarter of the original marker tracing was visible on the skin. This ensured the marker could still be placed in the exact same location as the other nontape conditions. Further, because the taping tape was adhered securely to the skin, it was not considered to pose a threat to increased skin movement artefact. Test–retest reliability of the variables of interest in this study was established by conducting the same data collection and analysis protocol on two separate days in 30 healthy adults, with intraclass correlation coefficient ranging from 0.722 to 0.896 (see Table, Supplemental Digital Content 2, repeatability of biomechanical variables, http://links.lww.com/MSS/A597).
Trajectories of surface markers were acquired with 12 Vicon cameras at 100 Hz (MX-F20; Vicon Metrics, UK). Ground reaction force data were collected with two Kistler force platforms at 400 Hz (9281B; Kistler Instrument Corp, Switzerland). Walking speed was monitored with two infrared photocell timing gates (Speed Light V2, Swift Performance Equipment, Queensland, Australia). Each participant’s preferred walking speed was determined during three practice trials, and all subsequent trials in the four conditions were required to be within 10% of this target speed. Five walking trials were recorded in each condition. The order of testing was randomized, and a 10-min washout period was implemented between each testing condition.
Data were processed in Visual3D (v 4.0; C-Motion Inc.) where marker trajectories were filtered at 7 Hz and GRF signals at 25 Hz with a zero-lag, fourth-order, low-pass Butterworth filter. Local coordinate systems for each segment were defined according to the published protocol (2) (see Figures, Supplemental Digital Content 3, foot–shoe model and coordinate system definitions, http://links.lww.com/MSS/A598). The following segments were defined in the four segment kinematic model: shank (tibia and fibula); hindfoot; midfoot/forefoot, and hallux. Joint angles were computed following the joint coordinate system (12), with an X–Y–Z order of rotations between the shank and hindfoot (“ankle joint”), midfoot/forefoot and hindfoot (“tarsometatarsal joint”), and hallux and midfoot/forefoot (“first metatarsophalangeal joint” [MTPJ]). Rotation about the x-axis was defined as dorsiflexion (+)/plantarflexion (−), around the y-axis as inversion (+)/eversion (−) and about the z-axis as abduction (+)/adduction (−). All joints were constrained to three degrees of freedom using a global optimisation procedure (22) and the hallux which was modelled as a one degree of freedom hinge. Joint moments were computed using inverse dynamics, resolved in the distal segment coordinate system, and normalized to body mass (N·m·kg−1). Data were time normalized to 0% to 100% of the stance phase (initial contact to toe-off), with these gait events defined from the GRF data with a threshold of 20 N. Because of the proposed mechanism of action of taping and foot orthoses in reducing foot pronation, the analysis was limited to a core set of variables which were extracted: peak hindfoot eversion and eversion ROM, time to peak hindfoot eversion, the peak external hindfoot inversion moment, peak tarsometatarsal dorsiflexion, and peak first MTPJ dorsiflexion.
Descriptive statistics for the variables of interest were computed (mean of the five walking trials per participant). A general linear mixed regression model (fixed effect, condition; random effect, subjects) with post hoc sequential Bonferroni adjusted t-tests was used to determine differences in means between conditions. Linear regression was used to test the ability of both baseline and change scores in the biomechanical variables of interest to predict the corresponding response to foot orthoses. Each regression model included only one biomechanical variable of interest at any one time, avoiding the issue of high collinearity of multiple predictor variables. Histograms of the model residuals were plotted to check for an approximate normal distribution, and the residuals were also plotted against the predicted values and checked to confirm that the residual variance was constant across observations as well as to assess for any outliers (3). There were no instances of violation of these checks to warrant data transformation. P values less than 0.05 were considered statistically significant. Data analysis was performed in SPSS (v20, IBM). Of the 21 participants who completed data collection, three had less than five successful walking trials in each condition; therefore, 18 participants were included in the analysis.
General anthropometrics and foot posture
The physical characteristics and foot posture of participants are displayed in Table 1. Mean values for NNHt were similar to other studies of participants with flat-arched feet using the same protocol (10,26).
Walking speed was consistent between conditions (1.42 SD, 0.08 m·s−1; 1.41 SD, 0.07 m·s−1; 1.42 SD, 0.07 m·s−1; 1.41 SD, 0.07 m·s−1; P = 0.126).
Kinematics and kinetics
There was a small but statistically significant increase in peak hindfoot eversion in the foot orthoses condition compared with the neutral shoe (−7.8° vs −6.8°, P = 0.04; Table 2); however, foot orthoses delayed the timing of peak eversion compared with the neutral shoe (44% stance vs 39%, P = 0.002; Fig. 2A). There were no significant differences in hindfoot ROM between the shoe, taping, and foot orthoses conditions.
Dorsiflexion across the midfoot/forefoot was reduced with the low-Dye taping (34.1° vs 36.5°, P = <0.001; Table 2) and modified taping (31.0° vs 36.5°, P = <0.001), but not with the foot orthoses (Fig. 2C). The low-Dye taping, modified taping, and foot orthoses increased peak dorsiflexion of the first MTPJ (54.9° vs 53.4°, P = 0.023; 54.9 vs 53.4, P = <0.001; 56.6° vs 53.4°, P = <0.001, respectively) Fig. 2D). Neither the taping tape nor foot orthoses altered the external inversion hindfoot moment (P > 0.05) (Fig. 2B).
Relationships between changes in biomechanical variables with taping and foot orthoses
The final part of the analysis revealed that the biomechanical response to both taping techniques was significantly positively related to the change in biomechanical outcome when using foot orthoses. The response to low-Dye taping predicted 8%–40% of the variance in the corresponding biomechanical outcome when using foot orthoses (Table 3), with the strongest relationships evident for the calcaneal eversion ROM (R2 = 0.37; β = 0.608; 95% CI, 0.448–0.790; P < 0.001) and time to peak calcaneal eversion (R2 = 0.40; β = 0.632; 95% CI, 0.546–0.930; P < 0.001). The response to the modified taping technique was also able to explain a significant portion of the variance in all biomechanical outcomes when using foot orthoses (Table 3), with the strongest relationship evident for the peak calcaneal eversion ROM (R2 = 0.52; β = 0.721; 95% CI, 0.710–1.072; P < 0.001). Individual changes in peak calcaneal eversion and coronal plane ROM relative to the neutral shoe are presented in Figure 3.
Despite widespread clinical use of foot taping and foot orthoses to alter foot biomechanics in individuals with flat-arched feet, there is a paucity of evidence on their biomechanical effects in realistic conditions. This study has identified that both taping and foot orthoses significantly alter foot kinematics in adults with flat-arched feet, but their effects appear region specific. Foot orthoses appear most effective acting on the hindfoot, whereas the effects of taping were more confined to the midfoot and medial longitudinal arch. Both taping and foot orthoses increased peak dorsiflexion of the first MTPJ. The biomechanical responses to taping and foot orthoses in this study were also related, supporting the premise that the changes induced by taping may be used to infer the response to foot orthoses.
The identification of region specific effects of taping and foot orthoses in this study extends previous work that has been primarily confined to investigating hindfoot biomechanics (4,30). The small effect of medially posted foot orthoses on peak hindfoot eversion in this study is consistent with previous literature (34). Although the mean direction of the effect was contrary to expectations, it is unsurprising considering variation in both the direction and magnitude of effect across studies and even between individuals with similar foot posture (23,24). This is likely a reflection of the effects of individual differences in factors that regulate the complex biomechanical behaviour of the foot, such as muscle activation patterns and force generation (18), joint morphology and compliance of periarticular soft tissues. Interestingly, temporal features of hindfoot motion, such as the timing of peak eversion, was more effectively delayed with the use of foot orthoses compared to taping. Therefore, the rate of loading of medial hindfoot structures would potentially differ with the use of taping and foot orthoses. Considering the deleterious effects of increased loading rate on development of soft tissue injury (i.e., tendon), rather than just magnitude (32), the implications of this finding for the development of hindfoot pathology warrants further investigation.
The ability of taping to more effectively limit deformation of the medial arch compared with foot orthoses was a surprising finding in this study. Intuitively, from a mechanical perspective, the increased stiffness and superior load-deformation properties of an orthotic device would outweigh that imposed by the application of tape. However, taping is in direct contact with the foot for the entire gait cycle, and the neuromotor effect stemming from enhanced plantar sensory stimulation and potential changes in muscle activation patterns cannot be discounted (9). It is also plausible that individuals are more easily able to accommodate to a device with less rigidity, enhancing the kinematic effect and reducing the likelihood of the foot slipping off the lateral side of the foot orthoses. Although the size of the effects was small, they are proportionally large relative to the amount of motion occurring within the foot and were above the established standard error of measurement thresholds, increasing confidence they reflect true differences.
In light of differential effects on hindfoot and medial arch motion, it was surprising to see both taping and foot orthoses increased the peak dorsiflexion of the first MTPJ. Although this result was expected in the taping conditions due to the finding of a higher medial arch (reflective of an enhanced windlass effect), it may be that in the orthotic condition, despite a reduced peak medial arch during propulsion, there was still some distal arch support, increasing the first metatarsal inclination angle resulting in the increase in peak first MTPJ dorsiflexion. It is also known that despite kinematic coupling existing between the hindfoot and first MTPJ, they are still able to act independently (7). Recent work also suggests that inherent differences in individual joint mechanics may be responsible for the variation in response to foot orthoses, such as the inability to alter motion at the subtalar joint may be accommodated instead by the ankle (21). It is evident that the complexity of how different taping techniques and foot orthoses work and factors responsible for responses in some individuals, and not others, is still yet to be fully elucidated. If we can design methods that allow us to identify features about individuals that were related to a positive response, it may then allow us to identify individuals who would benefit from foot orthotic therapy.
Clinically, foot taping is often used as a first-line intervention in the management of pathologies suspected to be related to increased tissue load associated with flat-arched feet. The biomechanical changes associated with this short-term intervention are anecdotally thought to be suggestive of that which can be achieved with foot orthoses. In this study, we identified that the biomechanical response to taping, irrespective of the variable studied, was indicative of the subsequent change elicited with foot orthoses. This was evident for taping techniques with some similar features, but also differing in the intended effect on the hindfoot and medial arch. Although caution must be taken before extrapolating these results to individuals with pathology, this suggests that inferring changes within-individuals based on their response to taping may be appropriate before considering foot orthoses in the management of individuals with flat-arched feet. It should also be noted that only up to half of the variance in biomechanical outcome achieved with foot orthoses use could be predicted based on the response to taping, indicating the influence of other unidentified factors.
To our knowledge, this is the first study to investigate the effect of foot taping techniques and customized foot orthoses on multisegment foot biomechanics in adults with flat-arched feet during realistic and clinically relevant conditions. We used a validated and purpose designed foot model to measure in-shoe foot motion, which preserves the majority of the structural integrity of footwear while allowing accurate tracking of foot motion (2). Customized foot orthoses were manufactured for each participant, enhancing the relevance for clinicians using this approach in clinical practice, but caution is advised before extrapolating these results to other types of foot orthoses with different design features. Participants in this study were symptom free, and how the immediate biomechanical effects of these interventions relate to those with pathology who often display altered gait characteristics and over a longer time-frame requires further investigation. Any future investigation may also benefit from a personalized orthotic prescription to better reflect the individual requirements of each foot. Inherent to 3D gait analysis studies, kinematic models rely on skin mounted markers and are thus susceptible to skin movement artefact (20). However, this may be partially minimized by the inclusion of realistic joint constraints (22) and knowledge that multisegment foot models are repeatable and sensitive enough to detect changes from intervention (28).
Foot orthoses and foot taping significantly alter in-shoe foot motion in adults with flat-arched feet during walking. Their effects appeared region specific with foot orthoses causing a delay in peak hindfoot eversion while taping reduced deformation of the medial longitudinal arch. The biomechanical responses to foot taping and foot orthoses were significantly related, supporting the premise that the biomechanical outcomes of foot orthoses intervention can be predicted based on the response to foot taping. However, their different effects imply that they may achieve improvements in clinical outcomes by different mechanisms, with further research required to study the relationships between biomechanical changes and symptom reduction in individuals with foot pathology.
This study was supported by a grant from the Sports Medicine Australia (SMA) Research Foundation. Footwear was kindly donated by ASICS Oceania and the authors would like to acknowledge Dr Sara Jones (University of South Australia) for procuring materials for foot orthoses manufacture. None of the study sponsors had any role in the design, conduct or analysis of the study or decision to submit for publication.
Conflict of Interest: Christopher Bishop has been a recipient of funding from ASICS Oceania (ASICS Oceania Pty Ltd, Eastern Creek, NSW, Australia) to undertake separate research. The results of this present study do not constitute endorsement by ACSM.
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FOOT ORTHOSES; GAIT; BIOMECHANICS; FOOT; THERAPY
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