Pressure Analysis of the Foot in Gait

By Steven J. Levitz, D.P.M. and Ellen Sobel, Ph.D., D.P.M.

Drs. Levitz and Sobel are professors in the Department of Orthopedics, NYCPM.

Objectives
Human feet have most often been described in the medical
literature as semirigid bases functioning to provide an attitude of After reading this continuing
education article, the podiatric
stable static support for the entire erect body. This theoretical physician should be able to:
concept, however, does not correlate with what we evaluate
clinically. 1) Understand the temporal
components of the walking cycle.

When adults stand for prolonged periods at a time, common 2) Understand the importance of
subjective symptoms can result in a feeling of overall fatigue or quantifying peak pressures and
location.
produce actual intrinsic foot discomfort. When intrinsic foot
discomfort is associated with prolonged standing, many 3) Recognize the benefits of
pressure analysis documentation
theoretical models can be attributed to explain the etiology of the in the diabetic neuropathic foot.
symptoms. The model we favor is the one in which the
unremitting tension from relaxed standing will eventually result 4) Evaluate the therapeutic
modalities that we offer to unload
in tension deformity of the plantar structures. The plantar the plantar surface of the foot.
structures most commonly symptomatic are the plantar fascia,
spring ligament, and, less frequently, the posterior tibial tendon.

Another model, which has been suggested, is vascular congestion, theoretically due to
prolonged standing. This model is based on the concept that the venous system is
inhibited from proper function when not walking. Therefore, the muscular pump, which
aids the deep veins to return blood up to the body, is not active. The veins become
engorged and transudate leaks out into the interstitial spaces increasing the pressures
within the foot and leg. The increased volume of interstitial fluid inhibits normal arterial
blood flow into the foot, and the entire leg/foot vascular system becomes inefficient. This
changes the properties of the fluid environment, which bathes the nerves, fascia,
ligaments and tendons. Whichever model is correct, it is far less tiring to walk, run, jump,
or dance on normally functioning feet than it is to stand.

It is apparent that the human foot has evolved as a dynamic functional structure in which
it participates as the adapter, compensator, and regulator of gait in respect to the ground.
The foot should be evaluated clinically as an integral part of the locomotor system, and
not as a static support structure.

Human gait is unique, evolving a characteristic bipedal, orthograde, habitual type of

locomotion. This method of locomotion imposes gross similarities in the manner in
which all of us walk. However, each of us exhibits minor individual differences that
allow us to be recognized by a friend or relative even from a distance. The causes of these
individual characteristics of locomotion are many. We all differ somewhat in the length
and distribution of mass of the various segments of the body, which must be moved by
muscles of varying fiber length.

Furthermore, individual differences occur in the position of joint axes, with resultant
minor variations in lever arms. These and many other such factors combine to establish in
each of us an individual walking pattern. Efficient gait results from the integration of
many components. Mean values of one single morphological observation are of little
clinical value. The clinician should be alert to the morphological variations that occur
within the population, but it is more important to understand the functional
interrelationships among the various components.

This is particularly true when observing the foot, where anatomic variations are
extensive. If mean values are the only bases of comparison, it becomes difficult to
explain why some feet function adequately and asymptomatically, even though their
measurements deviate significantly from the mean, whereas others function
symptomatically, even though their measurements fall well within the mean. It seems
clinically reasonable to use mean values only to provide a mathematical reference for
estimating the extent of deviations from these means. Therefore the major emphasis
should be placed on functional interrelationships and not on descriptive anatomy.

Human locomotion is a learned process; it does not develop as the result of an inborn
reflex. The result of this learning process is the integration of numerous
neuromusculoskeletal mechanisms, with gross similarities and individual variations into
an efficiently functioning manner of walking. Once a person has learned to walk and has
attained maximum growth, a built-in physiologic regulatory mechanism compensates for
varying activities, terrain, and shoe style.

KINEMATICS OF HUMAN LOCOMOTION

Kinematics is concerned only with motion, and does not consider muscle function and
forces. Walking is more than merely placing one foot in front of the other. During the
walking cycle all major segments of the body are in motion with displacements that can
be accurately described.

Vertical Body Displacements

The normal rhythmic upward and downward displacement of the body during walking is
familiar to everyone, and is observed from a side view by seeing an individual's head
bobbing up and down. These displacements with in the vertical plane are a necessary
concomitant of bipedal locomotion. When the legs are separated, as during transmission
of the body weight from one leg to the other (double weight support), the distance
between the trunk and the floor must be less than when it passes over a relatively
extended leg, as during midstance. Since the nature of bipedal locomotion demands these
vertical oscillations of the body, they should occur in a smooth sinusoidal manner for the
conservation of energy.
The center of gravity of the body should move in a smooth sinusoidal path, with the
amplitude of displacement being approximately 4 to 5 cm. Although movements of the
pelvis and hip modify the amplitude of the sinusoidal curve, the knee, ankle, and foot are
particularly involved in converting what would be a series of intersecting arcs into a
smooth, sinusoidal curve. This conversion requires both precise and simultaneous
motions in the knee, ankle, and foot.

The center of gravity of the body reaches its maximum elevation immediately after
passage over the weight-bearing leg, then begins to fall. This fall must be stopped at the
termination of the swing phase of the other leg as the heel strikes the ground. Actually the
falling center of gravity of the body is smoothly decelerated, because relative shortening
of the leg occurs at the time of impact against a gradually increasing resistance. The knee
flexes against a gradual contraction of the quadriceps muscle and the ankle plantar flexes
against the resisting anterior crural muscles. After the foot-flat position is reached, further
shortening is achieved by pronation of the foot.

After decelerating to zero, the center of gravity must now evenly accelerate upward to
advance over the opposite leg. The kinetics (the study of motion, acceleration, or rate of
change) is complex, but the kinematics is simple. The leg is relatively elongated as a
result of extension of the knee, plantar flexion of the ankle, and supination of the foot.
Heel lift is the major component contributing to upward acceleration of the center of
gravity at this time.

Horizontal Body Displacements

In addition to vertical displacements of the body, a series of axial rotational movements

occur that can be observed within the horizontal plane. These horizontal rotations of the
pelvis and the shoulder girdle are familiar to all clinicians who observe gait. Similar
horizontal rotations occur in the femoral and tibial segments of the extremities.

The tibias rotate about their long axes, internally during swing phase and into the first
part of stance phase and externally during the latter part of stance. This motion continues
until the toes leave the ground; the degree of these rotations is subject to marked
individual variations. The largest amount of this rotation occurs when the foot is firmly
placed on the floor.. For these movements to occur, a mechanism must exist in the foot
that permits the rotations but offers resistance to them of such magnitude that they are
transmitted through the foot to the floor and are recorded on a force plate as torques.

Lateral Body Displacements

When a person is walking, the body does not remain precisely in the plane of progression
but oscillates slightly from side to side to keep the center of gravity approximately over
the weight-bearing foot. Everyone has experienced this lateral shift of the body walking
in tandem with a companion. If one gets out of step with the other, their bodies are likely
to bump. The body is shifted slightly over the weight-bearing leg with each step;
therefore a total lateral displacement of the body of approximately 4 to 5 cm occurs from
side to side with each complete stride. This lateral displacement can be increased by
walking with the feet more widely separated, and decreased by keeping the feet close to
the line of progression. Normally the presence of the adult tibiofemoral angle (carrying
angle) of 6-12 degrees (slight genu valgum) permits the tibia to remain essentially
vertical and the feet close together while the femurs diverge to articulate with the pelvis.
Again the lateral displacement of the body is through a smooth sinusoidal pathway.

The slower an individual walks, the less movement of the center of gravity and the less
the recorded force. Conversely, the faster the gait, the greater the movement of the center
of gravity and the larger the force.

BIOMECHANICS OF WEIGHT BEARING

The vertical force curve demonstrates an initial spike against the ground, after which the
force declines. This initial spike is the reaction of the heel against the ground. The shoe
material can alter the magnitude of the spike: a softer heel will result in a smaller initial
spike, and a harder heel in a larger spike. When the first peak occurs, which is 10 percent
to 15 percent greater than body weight it is caused by the upward acceleration of the
body's center of gravity. This is followed by a dip in which the weight against the ground
is approximately 20 percent less than body weight. This dip occurs because after the
initial force has been exerted to raise the center of gravity the stance foot is unloaded as
the center of gravity reaches the top of its trajectory before starting to fall. A second peak,
again 10 percent to 15 percent greater than body weight, is caused by the falling of the
center of gravity, after which the force rapidly declines to zero at toe-off and subsequent
weight transfer to the opposite limb

Shear Forces

Fore shear represents the initial braking of the body at the time of heel strike, and occurs
because the center of gravity is behind the foot at the time of heel strike. After the center
of gravity has passed in front of the weight bearing foot an aft shear is noted. The aft
shear reaches a maximum as the opposite limb strikes the ground at 50 percent of the
walking cycle, at which time a fore shear is noted. The magnitude of the fore-aft shear,
however, is only about 10 percent to 15 percent of body weight.

Medial shear forces are exerted toward the midline at the time of heel strike, after which
there is a persistent lateral shear until opposite heel strike at 50 percent of the cycle, when
the medial shear occurs again. Following heel strike there is an internal torque that
reaches a maximum at the time of foot flat, after which there is a progressive external
torque that reaches a maximum just prior to toe-off. This torque corresponds to the
inward and outward rotation of the lower extremity.

Another way of visualizing the force against the ground is to observe the movement of
the center of pressure. The movement of the center of pressure along the bottom of the
foot follows a consistent pattern in a normal person.
The center of pressure moves rapidly along the bottom of the foot following heel strike
until it reaches the metatarsal area, where it dwells about half of the stance phase, then
passes distally to the great toe. A greater appreciation of the movement of the center of
pressure is observed in a patient with rheumatoid arthritis who has a hallux valgus
deformity with painful metatarsalgia. In this circumstance the center of pressure remains
in the posterior aspect of the foot, avoiding the painful metatarsal area, then rapidly
passes over the metatarsal heads along the middle of the foot, compared with weight
bearing under the great toe in the normal foot. In a study carried out in patients with
amputation of the great toe, the center of pressure passed in a more lateral direction.

Although the movement of the center of pressure presents a visualization of the

movement of the center of gravity, it represents an average of pressure against the
ground. New techniques and computerization, have demonstrated graphically the
distribution of forces on the plantar aspect of the foot in such a way that a more
quantitative visual concept of the weight-bearing pattern on the plantar aspect of the foot
is obtained. This new type of representation again demonstrates how rapidly the pressure
leaves the heel and dwells in the metatarsal region. It further demonstrates the importance
of the toes in weight bearing in the last 30 percent of the stance phase of walking.

Further quantification and localization of plantar forces utilizing various types of pressure
platforms and in-shoe transducers allow further insight into the pressure distribution on
the plantar aspect of the foot in gait. During the propulsive phase of gait, approximately
80 percent of the population demonstrate a peak plantar pressure either under the hallux,
first metatarsal or 2nd metatarsal. Clinical correlations using these pressure
measurements have been established with respect to various clinical problems. In the
diabetic neuropathic foot, areas of ulceration correlate well with the areas demonstrating
maximum vertical and shear forces. The weight-bearing pattern in these patients tends to
shift from the medial to the lateral border of the forefoot, and the load taken by the toes is
reduced.

The rheumatoid foot demonstrates findings similar to those of the neuropathic foot. After
a hindfoot fusion, greater contact force at heel strike has been observed. This could be
due to the inability of the calcaneus to move into a valgus position after heel strike. The
alterations in weight bearing about the hallux have demonstrated that in hallux valgus
there is decreased weight bearing of the first and second toes associated with an increased
transfer of weight to the lateral metatarsals. Similar findings have been demonstrated
after a Keller resection-type arthroplasty.

Although floor reactions are important in demonstrating the totality of the forces
transmitted through the foot, they give little information concerning the movements of
the various articulations of the foot and ankle or about the activity of the muscles
controlling these movements. Continuous geometric recordings and electromyographic
studies are required to indicate joint motion and phasic activity of the intrinsic and
extrinsic muscles. From the moment of heel strike to the instant of toe-off, floor
reactions, joint motions, and muscular actions change constantly. The walking cycle will
be reviewed to reinforce your understanding.
WALKING CYCLE

The walking cycle consists of the stance phase and the swing phase of the same leg. The
mean walking or gait cycle is based upon a mean time of 1 second. This is the mean time
that it takes to travel forward from one heel strike to the same heel strike again. This
walking or gait cycle begins at 0 percent and ends at 100 percent. The stance phase
usually consumes about 62 percent of the cycle or 0.62 seconds, and the swing phase 38
percent of the cycle or 0.38 seconds. The stance phase is further divided into a period of
initial double limb support (heel contact with toe off) from (0 percent to 12 percent) in
which both feet are on the ground, followed by a period of single limb support from (12
percent to 50 percent) and a terminal or second period of double limb support( toe off
with heel contact) from (50 percent to 62 percent), after which the swing phase begins.

The initiation of the walking cycle is heel strike which is 0 percent, being followed by
foot flat which is observed by 7 percent of the cycle, opposite toe-off at 12 percent, heel
rise beginning at 34 percent as the swing leg passes the stance foot, and opposite heel
strike at 50 percent of the cycle.

In a patient with spasticity, the initial heel strike may be toe contact, and foot flat may not
occur by 7 percent of the cycle. Heel rise may be premature if spasticity or a contracture
is present, or delayed in the case of weakness of the gastrocnemius-soleus muscle group.

The walking cycle being one of continuous motion is difficult to describe in its entirety
because so many events occur simultaneously. However, a reasonably accurate summary
of the events can be presented if the stance phase is divided into three stages.

Stage One: Heel Strike to Flat Foot

Stage one occurs during approximately the first 15 percent of the walking cycle. The
center of gravity of the body is decelerated by ground contact, then immediately
accelerated upward to carry it over the extending lower extremity. The body's impact and
shift of the center of gravity account for a vertical floor reaction that exceeds body weight
by 15 percent to 25 percent. The ankle joint undergoes rapid plantar flexion until foot
flat, at 7 percent of the cycle, after which dorsiflexion begins .The plantar flexion is under
the control of the anterior compartment muscles, which undergo an eccentric contraction
to prevent foot slap. The posterior calf muscles all are electrically silent, as are the
intrinsic muscles in the sole of the foot There is no muscular response in those muscles
usually considered important in supporting the longitudinal arch of the foot.

At this time the foot is being loaded with the weight of the body, and flattening of the
longitudinal arch occurs. Gait analysis during walking reveals rapid eversion of the
calcaneus and flattening of the longitudinal arch as a result of the impact of the body
weight. This flattening of the arch originates in the subtalar joint and reaches a maximum
during this interval .The pronation that occurs at initial ground contact is a passive
mechanism, and the amount of motion appears to depend entirely on the configuration of
the articulating surfaces, their capsular attachments, and ligamentous support. No
significant muscle function appears to play a role in restricting this motion at initial
ground contact.

Because of the relationship of the leg to the foot, which occurs through the subtalar joint,
the eversion of the calcaneus is translated proximally into inward rotation that is
transmitted across the ankle joint into the lower extremity. Distally this eversion
theoretically unlocks the transverse tarsal joint . The main thrust of what occurs during
the first interval is that of absorption and dissipation of the forces generated by the foot
striking the ground.

Stage Two: Flat Foot Just Prior to Heel Off

Stage two, or the single leg support phase extends from 15 percent to 50 percent of the
walking cycle. During this interval the center of gravity of the body passes over the
weight-bearing leg at about 35 percent of the cycle, after which it commences to fall.
Force plate recordings show that the foot is supporting less than actual body weight. The
load on the foot may be as low as 70 percent to 80 percent of actual body weight.

The ankle joint is undergoing progressive dorsiflexion, reaching its peak at 40 percent of
the walking cycle. This is when the force across the ankle joint has reached a maximum
4.5 times body weight. Heel rise begins at 34 percent of the gait cycle and precedes the
onset of plantar flexion, which begins at 40 percent.

During stage two, important functional changes occur in both foot and leg, which are the
results of muscular action. The triceps surae, peroneals, tibialis posterior, long toe
flexors, and intrinsic muscles in the sole of the foot demonstrate electrical activity .The
activity in the intrinsic muscles of the normal foot begin at 30 percent of the cycle,
whereas in flatfoot activity they begin earlier at 15 percent of the cycle. The posterior calf
musculature is functioning to control the forward movement of the tibia over the fixed
foot, which permits the contralateral limb to increase its step length.

The mean linear distance from heel strike of one foot to heel strike of the same foot is
approximately 39 inches this is called the stride length. The linear distance from heel
contact of one foot to heel contact of the opposite (contra lateral) foot is called the step
length. Step lengths are not symmetrical and vary from side to side depending on
structural and functional limb length differences.

Subtalar joint motion demonstrates progressive inversion in flatfoot at the beginning of

this period, and in a normal foot at about 30 percent of the cycle. The inversion is brought
about by multiple factors, and precisely which plays the greatest role is unclear. The
factors occurring above the subtalar joint consist of the external rotation of the lower
extremity brought about by the swinging contralateral limb, its transmittal to the stance
limb as an external rotation torque, its transmittal across the ankle joint, and its
translation by the subtalar joint into inversion. Inversion of the subtalar joint is passed
distally into the foot, realigning the transverse tarsal articulation. The progressive
inversion rearranges the skeletal components of the foot, which theoretically transforms
the flexible midfoot into a rigid structure. During this interval full body weight is not
borne on the foot.

Stage Three: Heel Off to Toe Off

Heel off to toe off constitutes the last of the stance phase and extends from 40 percent to
62 percent of the walking cycle. Force plate recordings demonstrate an increase in the
percentage of body weight as a result of the falling of the center of gravity at the
beginning of this interval; the load on the foot again exceeds body weight by
approximately 20 percent. The vertical floor reaction promptly falls to zero during this
period as the body weight is being transferred to the opposite foot.

The ankle joint demonstrates rapid plantar flexion during this interval. The flexion is
caused primarily by the concentric contraction of the posterior calf musculature, in
particular the triceps surae The plantar flexion leads to relative elongation of the
extremity. Although full plantar flexion at the ankle joint occurs during this interval,
electrical activity is observed only until 50 percent of the cycle, after which there is no
longer electrical activity in the extrinsic muscles. The remainder of ankle joint plantar
flexion occurs because of the transfer of weight from the stance leg to the contralateral
limb.

The intrinsic muscles of the foot are active until toe-off. Although the intrinsic muscles
help to stabilize the longitudinal arch, the main stabilizer is the plantar aponeurosis,
which is said to function maximally during this period as the toes are brought into
dorsiflexion and the plantar aponeurosis is wrapped around the metatarsal heads, forcing
them into plantar flexion and; theoretically ,elevating the longitudinal arch. One would
question at this point the long-term results of plantar fasciectomy if the theoretical
function of the plantar fascia was as functionally important as proposed by many
clinicians and anatomists.

The anterior crurals fire at the last 5 percent of the stance phase, probably to initiate
dorsiflexion of the ankle joint immediately after toe-off. The subtalar joint continues to
invert during this interval, reaching its maximum supinated position at toe-off; probably
as the result of the limb above the foot externally rotating and the passage of this
movement across the ankle and subtalar joints to help bring about supination. The
supination, however, is enhanced by the obliquity of the ankle joint axis in accordance
with the plantar aponeurosis, and oblique metatarsal break. The talonavicular joint also is
stabilized during this period by the pressure brought to bear across this joint, by both
body weight and the intrinsic force created by the plantar aponeurosis.

MEASUREMENT OF FORCES ON THE PLANTAR FOOT SURFACES

We clinically must be able to quantitate the pressures on the plantar surface of the foot
and their relative locations. This is the main importance of such in-shoe transducers,
which can aid us to evaluate patients with peripheral neuropathy in the hope that we can
reduce peak plantar pressures while still keeping these individuals ambulatory.
All of the manufacturers of in-shoe transducers have varying designs that function on
different principles. The emphasis in this article is not to explain the physics of each in-
shoe system but to enable the clinician to evaluate the results of such examinations and
their relevance to the neuropathic foot.

The System International (SI) unit of FORCE is the Newton (1 N is the force required to
give a mass of 1 kg an acceleration of 1m.s.) and the unit of pressure is the Pascal (1 Pa
results from a force of 1N distributed over an area of 1 m2. In many research articles
values underneath the foot are measured in kilopascal (kPa) or megapascal (Mpa) ranges.
While other studies utilize other units of pressure measurements like kg.cm2 , N.cm2, or
pounds per square inch. When comparing peak plantar measurements from one program
to the next be aware of the variances in measurement units. The documentation of peak
plantar pressures in the diabetic neuropathic patient could be performed routinely with in-
shoe transducer systems in order to enhance the effectiveness of shoe and orthotic
pressure reduction.

Materials used for pressure reduction and or redistribution that have proven to be
effective are Plastazote(tm), Spenco(tm), PPT(tm) and Poron(tm). These materials can be
used in combination or laminations, and in various thicknesses to redistribute peak
pressures. The clinical importance of an in-shoe transducer system is the relative ease in
which the documentation of pressure reduction can be performed pre and post
shoe/orthotic intervention. This procedure could be performed with each shoe/orthotic
modifications/fitting in order to see if your mechanical therapy is reducing the peaks as
expected. When this protocol is instituted, individual variances can be adjusted for via the
information from the in-shoe sensor

CONCLUSION

Human gait can be best analyzed visually, when the observer is clinically experienced.
He or she cannot document peak plantar pressures unless there is some type of pressure
analysis system, which is reliable and reproducible.

Force plates are the gold standard for force analysis and can document the pressure either
bare foot or from the sole of the shoe. In-shoe systems are clinically superior for the
documentation of mechanical shoe/orthotic therapy because multiple steps can be
averaged to identify the location and quantity of the peak pressure with and without shoes
and orthoses. Therapy can be individually fine-tuned to maximize the reduction of peak
plantar pressures.

We must continue to tactfully reinforce the fact to the diabetic neuropathic patient that his
or her condition will not go away. Diabetic patients must help us care for their feet by
daily inspection and routine office checkups.

Plastazote(R) is a registered trademark of Zoteforms, Inc.

Questions

1. The theory in which the unremitting tension of static

stance results in deformity is most commonly associated
with symptoms in which structures?

A. plantar fascia and spring ligament

B. sinus tarsi and cervical ligament
C. tibialis anterior and posterior
D. peroneus longus and brevis

2. Which anatomical structure participates as the

adaptor,compensator and regulator of gait in relation to the
ground?

A. the spine
B. the quadriceps muscles
C. the tricepts surae
D. the foot

3. Which one of the following is NOT a cause of individual

locomotion characteristics?

A. length and mass of body segments

B. position of joint axes'
C. minor variations in lever arms
D. evolutionary atavistic traits

4. An efficient locomotor system results from?

A. the morphology of the foot

B. average morphology of the foot
C. functional interrelationships
D. descriptive anatomy

5. Vertical body displacement is lowest during which phase

of the gait cycle?

A. swing
B. double support
C. single support
D. heel off
6. All of the following contribute to the smoothing out of
the deceleration of center of gravity during gait except for?

A. knee flexion
B. knee extension
C. ankle plantarflexion
D. foot pronation

7. In gait the tibias rotate internally about their long axes

during?

A. heel off
B. propulsion
C. toe off
D. swing

8. With each complete stride, a total lateral displacement of

the body occurs which is approximately?

A. 4 to 5 cm
B. 4 to 5 inches
C. 4 to 5 mm
D. 4 to 5 m

9. The mean adult tibiofemoral angle is ?

A. 2-70 varus
B. 6-100 varus
C. 6-120 valgus
D. 12-150 valgus

10. The initial spike in the vertical force curve of the gait
cycle is?

A. 20% to 30% greater than body weight

B. the reaction of the heel against the ground
C. is followed by an increase in which the weight against
the ground is 20% more than body weight
D. is caused by the downward acceleration of the body's
center of gravity

11. Fore shear occurs during which phase of the gait cycle?

A. mid stance
B. toe off
C. heel contact
D. heel off

12. The center of pressure dwells about half of the stance

phase with in what part of the foot?.

A. the heel area

B. the hallux area
C. the mid foot area
D. the metatarsal area

13. During the propulsive phase of gait the mean location

of peak plantar pressure is?

A. beneath the hallux

B. beneath the 2nd metatarsal
C. beneath the 1st metatarsal
D. all of the above

14. An individual with hallux valgus will most probably

demonstrate what type of weight bearing alteration during
gait?

A. increased weight under the 1st and 2nd toes

B. decreased weight under the 1st and 2nd toes
C. increased weight on heel contact
D. decreased weight on heel contact

15. The most important reason to use in-shoe sensors as a

screening tool for the diabetic neuropathic patient is?

A. to help cure the neuropathy

B. to make foot orthoses without plaster castings
C. to regulate the blood glucose level
D. to quantitate the peak plantar pressures

16. The plantar fascia is wrapped around which structures?

A. The cuboid
B. The navicular
C. The calcaneus
D. The metatarsals

17. The System International (SI) unit of Force is?

 A. The Pascal
B. The Newton
C. The Kilogram
D. The Pound

18. Which one of the following materials would not be a

good choice for pressure reduction in the neuropathic
diabetic foot?

A. Stainless steel
B. Plastazote
C. Poron
D. PPT

19. The goal in shoe/orthotic therapy and modification for

the neuropathic diabetic patient is?

A. To increase peak plantar pressures on the forefoot

B. To increase peak plantar pressures under the hallux
C. To decrease peak plantar pressures under at risk
locations
D. To decrease peak plantar on the heel

20. The most important aspect of neuropathic diabetic care

would be?

A. By pass surgery
B. Daily inspection of feet and routine foot check ups
C. Elective foot surgery
D. Deep muscle massage

References

Coughlin, M. J. and Mann, R.A. Surgery of the Foot and Ankle Seventh Edition Volume
1, Mosby St. Louis, MO 1999.

Cavanagh, P. R., Hewit Jr, F. G., and Perry, J.E. In shoe plantar pressure measurement: a
review. The Foot. 1992; 2: 185-194.

Harris, R.I., Beath, T.. Army foot survey-an investigation of foot ailments in Canadian
soldiers: National Research Council of Canada, 1947: NRC 1574.

Inman, V.T., Ralston, H.J., and Todd, F. Human Walking; Williams & Wilkins,
Baltimore , MD, 1981.