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Effects of medial and lateral orthoses on kinetics and tibiocalcaneal kinematics in male runners

Posted on December 31, 2017 | Comments Off on Effects of medial and lateral orthoses on kinetics and tibiocalcaneal kinematics in male runners

by Jonathan Sinclair1*

The Foot and Ankle Online Journal 10 (4): 1

Background: The aim of the current investigation was to examine the effects of foot orthotic devices with a 5° medial and lateral wedge on kinetics and tibiocalcaneal kinematics during the stance phase of running.
Material and methods: Twelve male participants ran over a force platform at 4.0 m/s in three different conditions (5° medial orthotic, 5° lateral orthotic and no-orthotic). Tibiocalcaneal kinematics were collected using an 8 camera motion capture system and axial tibial accelerations were obtained via an accelerometer mounted to the distal tibia. Biomechanical differences between orthotic conditions were examined using one-way repeated measures of analysis of variance (ANOVA).
Results: The results showed that no differences (P>0.05) in kinetics/tibial accelerations were evident between orthotic conditions. However, it was revealed that the medial orthotic significantly (P<0.05) reduced peak ankle eversion and relative tibial internal rotation range of motion (-10.75 & 4.98°) in relation to the lateral (-14.11 & 6.14°) and no-orthotic (-12.37 & 7.47°) conditions.
Conclusions: The findings from this study indicate, therefore, that medial orthoses may be effective in attenuating tibiocalcaneal kinematic risk factors linked to the etiology of chronic pathologies in runners.

Keywords: running, biomechanics, orthoses, kinetics, kinematics

ISSN 1941-6806
doi: 10.3827/faoj.2017.1004.0001

1 – Center for Applied Sport Exercise and Nutritional Sciences, School of Sport and Wellbeing, Faculty of Health & Wellbeing, University of Central Lancashire, Preston, Lancashire, PR1 2HE.
* – Corresponding author: jksinclair@uclan.ac.uk

Distance running is associated with a significant number of physiological and psychological benefits [1]. However, epidemiological analyses have demonstrated that pathologies of a chronic nature are extremely common in both recreational and competitive runners [2] and as many as 80% of runners will experience a chronic injury as a consequence of their training over a one-year period [2].

Given the high incidence of chronic pathologies in runners, a range of strategies have been investigated and implemented in clinical research in an attempt to mitigate the risk of injury in runners. Foot orthoses are very popular devices that are used extensively by runners [3]. It has been proposed that foot orthoses may be able to attenuate the parameters linked to the etiology of injury in runners, thus they have been cited as a mechanism by which injuries can be prophylactically avoided and also retrospectively treated [4]. The majority of research investigating the biomechanical effects of foot orthoses during running has examined either impact loading or rearfoot eversion parameters which have been linked to the etiology of running injuries. Sinclair et al, [5] showed that an off the shelf orthotic device significantly reduced vertical rates of loading and axial tibial accelerations, but did not alter the magnitude of rearfoot eversion. Butler et al, [6] examined three-dimensional (3D) kinematic/ kinetic data alongside axial tibial accelerations during running, using dual-purpose and a rigid orthoses. Their findings revealed that none of the experimental parameters were differed significantly between the different orthotic conditions.  Laughton et al, [7] showed that foot orthoses significantly reduced the loading rate of the vertical ground reaction force but did not significantly influence rearfoot eversion parameters. Dixon, [8] examined the influence of off the shelf foot orthoses placed inside an military boot on kinetic and 3D kinematic parameters during running. The findings from this investigation revealed that the orthotic device significantly reduced the vertical rate of loading, but no alterations in ankle eversion were reported.

Further to this, because the mechanics of the foot alter the kinetics/kinematics of the proximal lower extremity joints, biomechanical control of the foot with in-shoe orthotic wedges has wide-ranging applications for the treatment of a variety chronic lower extremity conditions. Different combinations of wedges or posts have therefore been used in clinical practice/ research to treat a multitude of chronic pathologies [9]. Both valgus (lateral) and varus (medial) orthoses have been proposed as potentially important low-cost devices for the conservative management of chronic pathologies [10].

Lateral orthoses are utilized extensively in order to reduce the loads experienced by the medial tibiofemoral compartment [10]. Lateral orthoses cause the center of pressure to shift medially thereby moving the medial-lateral ground reaction force vector closer to the knee joint center [11]. This serves to reduce the magnitude of the knee adduction moment which is indicative of compressive loading of the medial aspect of the tibiofemoral joint and its progressive degeneration [12]. Kakihana et al, investigated the biomechanical effects of lateral wedge orthoses on knee joint moments during gait in elderly participants with and without knee osteoarthritis [13]. The lateral wedge significantly reduced the knee adduction moment in both groups when compared with no wedge. Butler et al, examined the effects of a laterally wedged foot orthosis on knee mechanics in patients with medial knee osteoarthritis [14]. The laterally wedged orthotic device significantly reduced the peak adduction moment and also the knee adduction excursion from heel strike to peak adduction compared to the non-wedged device. Kakihana et al, examined the kinematic and kinetic effects of a lateral wedge insole on knee joint mechanics during gait in healthy adults [15]. The wedged insole significantly reduced the knee adduction moment during gait in comparison to the no-wedge condition, although no changes in knee kinematics were evident.

The influence of medially oriented foot orthoses has also been frequently explored in biomechanical literature. Boldt et al, examined the effects of medially wedged foot orthoses on knee and hip joint mechanics during running in females with and without patellofemoral pain syndrome [16]. The findings from this study showed that the peak knee adduction moment increased and hip adduction excursion decreased significantly when wearing medially wedged foot orthoses. Sinclair et al.,  explored the effects of medial foot orthoses on patellofemoral stress during the stance phase of running using a musculoskeletal modelling approach [17]. Their findings showed that medial foot orthoses significantly reduced peak patellofemoral stress loading at this joint during running.

Although the effects of medial/lateral foot orthoses have been explored previously, they have habitually been examined during walking in pathological patients and thus their potential prophylactic effects on the kinetics and tibiocalcaneal kinematics of running have yet to be examined. Therefore, the aim of the current investigation was to examine the effects of foot orthotic devices with a 5° medial and lateral wedge on kinetics and tibiocalcaneal kinematics the during the stance phase of running. A clinical investigation of this nature may provide further insight into the potential efficacy of wedged foot orthoses for the prevention of chronic running injuries.

Methods

Participants

Twelve male runners (age 26.23 ± 5.76 years, height 1.79 ± 0.11 cm and body mass 73.22 ± 6.87 kg) volunteered to take part in this study. All runners were free from musculoskeletal pathology at the time of data collection and were not currently taking any medications. The participants provided written informed consent in accordance with the principles outlined in the Declaration of Helsinki. The procedure utilized for this investigation was approved by the University of Central Lancashire, Science, Technology, Engineering and Mathematics, ethical committee.

Orthoses

Commercially available orthotics (Slimflex Simple, High Density, Full Length, Algeos UK) were examined in the current investigation. The orthoses were made from Ethylene-vinyl acetate and had a shore A rating of 65. The orthoses were able to be modified to either a 5˚ varus or valgus configuration which spanned the full length of the device. The order that participants ran in each orthotic condition was counterbalanced.

Procedure

Participants completed five running trials at 4.0 m/s ± 5%. The participants struck an embedded piezoelectric force platform (Kistler Instruments, Model 9281CA) sampling at 1000 Hz with their right foot. Running velocity was monitored using infrared timing gates (SmartSpeed Ltd UK). The stance phase of the running cycle was delineated as the time over which > 20 N vertical force was applied to the force platform. Kinematic information was collected using an eight-camera optoelectric motion capture system with a capture frequency of 250 Hz. Synchronized kinematic and ground reaction force data were obtained using Qualisys track manager software (Qualisys Medical AB, Goteburg, Sweden).

The calibrated anatomical systems technique (CAST) was utilized to quantify tibiocalcaneal kinematics (18). To define the anatomical frames of the right foot, and shank, retroreflective markers were positioned onto the calcaneus, first and fifth metatarsal heads, medial and lateral malleoli, medial and lateral epicondyle of the femur. A carbon fiber tracking cluster was attached to the shank segment. The foot was tracked using the calcaneus, and first and fifth metatarsal markers. Static calibration trials were obtained with the participant in the anatomical position in order for the positions of the anatomical markers to be referenced in relation to the tracking clusters/markers.

Tibial accelerations were measured using an accelerometer (Biometrics ACL 300, Units 25-26 Nine Mile Point Ind. Est. Cwmfelinfach, Gwent United Kingdom) sampling at 1000 Hz. The device was attached to the tibia 0.08 m above the medial malleolus in alignment with its longitudinal axis (19). Strong adhesive tape was placed over the device and the lower leg to prevent artifact in the acceleration signal.

Processing

The running trials were digitized using Qualisys Track Manager (Qualysis, Sweden) and then exported as C3D files. Kinematic parameters were quantified using Visual 3-D software (C-Motion, USA) after the marker data was smoothed using a low-pass Butterworth 4th order zero-lag filter at a cutoff frequency of 12 Hz. Three-dimensional kinematic parameters were calculated using an XYZ cardan sequence of rotations where X represents the sagittal plane, Y represents the coronal plane and Z represents the transverse plane rotations (Sinclair et al., 2013). Trials were normalized to 100% of the stance phase then processed and averaged. In accordance with previous studies, the foot segment coordinate system was referenced to the tibial segment for ankle kinematics, whilst tibial internal rotation (TIR) was measured as a function of the tibial coordinate system in relation to the foot coordinate axes [21]. The 3-D kinematic tibiocalcaneal measures which were extracted for statistical analysis were: (1) angle at foot strike, (2) peak angle during stance and (3) relative range of motion (ROM) from footstrike to peak angle.

The tibial acceleration signal was filtered using a 60 Hz Butterworth zero lag 4th order low pass filter to prevent any resonance effects on the acceleration signal. Peak tibial acceleration (g) was defined as the highest positive axial acceleration peak measured during the stance phase. Average tibial acceleration slope (g/s) was quantified by dividing peak tibial acceleration by the time taken from footstrike to peak tibial acceleration and instantaneous tibial acceleration slope (g/s) was quantified as the maximum increase in acceleration between frequency intervals. From the force platform all parameters were normalized by dividing the net values by body weight. Instantaneous loading rate (BW/s) was calculated as the maximum increase in vertical force between adjacent data points.

Statistical analyses

Means, standard deviations and 95 % confidence intervals were calculated for each outcome measure for all orthotic conditions. Differences in kinetic and tibiocalcaneal kinematic parameters between orthoses were examined using one-way repeated measures ANOVAs, with significance accepted at the P≤0.05 level. Effect sizes were calculated using partial eta2 (pη2). Post-hoc pairwise comparisons were conducted on all significant main effects. The data was screened for normality using a Shapiro-Wilk which confirmed that the normality assumption was met. All statistical actions were conducted using SPSS v23.0 (SPSS Inc., Chicago, USA).

Results

Tables 1-3 and Figure 1 present differences in kinetics and tibiocalcaneal kinematics as a function of the different orthoses. The results indicate that the experimental orthoses significantly affected orthoses tibiocalcaneal kinematic parameters.

Medial Lateral No-orthotic
Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper)
Coronal plane (+ = inversion & – = eversion)
 Angle at footstrike (°) -3.98 5.65 -7.57 -0.39 -3.77 5.64 -7.35 -0.19 -0.66 5.91 -4.41 3.09
 Peak eversion (°) -10.75 5.7 -14.38 -7.13 -14.11 6.48 -18.22 -9.99 -12.37 5.43 -15.82 -8.92
 Relative ROM (°) 6.77 2.78 5.00 8.54 10.34 3.44 8.15 12.53 11.71 3.26 9.64 13.78
Transverse plane (+ = external & – = internal)
 Angle at footstrike (°) -11.78 2.72 -13.51 -10.05 -15.01 2.81 -16.80 -13.22 -14.41 2.97 -16.29 -12.52
 Peak rotation (°) -6.80 3.10 -8.78 -4.83 -5.6 3.94 -8.10 -3.09 -5.05 3.33 -7.17 -2.93
 Relative ROM (°) 4.97 0.86 4.43 5.52 9.41 1.33 8.56 10.26 9.35 1.44 8.44 10.27

Table 1 Ankle kinematics (mean, SD & 95% CI) in the coronal and transverse planes as a function of the different orthotic conditions.

Medial Lateral No-orthotic
Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper)
Transverse plane (+ =  internal & – =external)
 Angle at footstrike (°) 8.57 3.16 6.56 10.57 9.74 4.01 7.20 12.29 6.51 3.98 3.98 9.04
 Peak TIR (°) 13.54 4.28 10.82 16.27 15.89 5.65 12.30 19.48 13.98 4.58 11.07 16.89
 Relative ROM (°) 4.98 2.68 3.28 6.68 6.14 3.54 3.89 8.39 7.47 3.75 5.09 9.85

Table 2 Tibial internal rotation parameters (mean, SD & 95% CI) as a function of the different orthotic conditions.

Medial Lateral No-orthotic
Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper) Mean SD 95% CI (Lower) 95% CI (Upper)
Peak tibial acceleration (g) 9.83 4.50 6.98 12.69 9.97 4.88 6.87 13.07 9.41 4.76 6.38 12.44
Average tibial acceleration slope (g/s) 362.73 196.31 238.01 487.46 367.37 219.63 227.83 506.91 369.52 257.85 205.69 533.35
Instantaneous tibial acceleration slope (g/s) 866.20 459.40 574.31 1158.09 867.71 554.16 515.61 1219.81 776.85 529.86 440.20 1113.51
Instantaneous load rate (BW/s) 156.17 58.72 118.86 193.48 161.77 71.57 116.30 207.25 134.49 44.62 106.14 162.84

Table 3 Kinetic and tibial acceleration parameters (mean, SD & 95% CI) as a function of the different orthotic conditions.

Figure 1 Tibiocalcaneal kinematics as a function of the different orthotic conditions; a= ankle coronal plane angle, b= ankle transverse plane angle & c = tibial internal rotation, (black = lateral, dash = medial & grey = no-orthotic), (IN = inversion, EXT = external & INT = internal).

Kinetics and tibial accelerations

No significant (P>0.05) differences in kinetics/tibial acceleration parameters were observed between orthotic conditions.

Tibiocalcaneal kinematics

In the coronal plane a significant main effect (F (2, 22) = 25.58, P<0.05, pη2 = 0.70) was found for the magnitude of peak eversion. Post-hoc pairwise comparisons showed that peak eversion was significantly larger in the lateral in relation to the medial (P=0.0000007) and no-orthotic (P=0.01) conditions. In addition, it was also revealed that peak eversion was significantly greater in the no-orthotic (P=0.008) in comparison to the medial orthotic condition. In addition, a significant main effect (F (2, 22) = 25.58, P<0.05, pη2 = 0.74) was noted for relative eversion ROM. Post-hoc pairwise comparisons showed that relative eversion ROM was significantly larger in the lateral (P=0.0000006) and no-orthotic (P=0.00001) in relation to the medial condition.

In the transverse plane a significant main effect (F (2, 22) = 116.11, P<0.05, pη2 = 0.91) was noted for relative transverse plane ankle ROM. Post-hoc pairwise comparisons showed that relative transverse plane ankle ROM was significantly larger in the lateral (P=0.0000001) and no-orthotic (P=0.0000008) in relation to the medial condition.

In addition, a significant main effect (F (2, 22) = 5.99, P<0.05, pη2 = 0.36) was found for the magnitude of peak TIR. Post-hoc pairwise comparisons showed that peak TIR was significantly larger in the lateral in relation to the medial (P=0.007) and no-orthotic (P=0.025) conditions. Finally, a significant main effect (F (2, 22) = 7.55, P<0.05, pη2 = 0.41) was noted for relative TIR ROM. Post-hoc pairwise comparisons showed that relative TIR ROM was significantly larger in the lateral (P=0.04) and no-orthotic (P=0.007) in relation to the medial condition.

Discussion

The aim of the current investigation was to examine the effects of foot orthotic devices with a 5° medial and lateral wedge on kinetics and tibiocalcaneal kinematics the during the stance phase of running. This is, to the authors’ knowledge, the first investigation to concurrently examine the influence of different orthotic wedge configurations on the biomechanics of running. An investigation of this nature may, therefore, provide further insight into the potential prophylactic efficacy of wedged foot orthoses for the prevention of chronic running injuries.

The current study importantly confirmed that no significant differences in impact loading or axial tibial accelerations were evident as a function of the experimental orthotic conditions. This observation opposes those of Sinclair et al., Laughton et al. and Dixon, who demonstrated that foot orthoses significantly reduced the magnitude of axial impact loading during the stance phase of running [5,7,8]. However, the findings are in agreement with those noted by Butler et al,  who similarly observed that the magnitude of axial impact loading did not differ significantly whilst wearing rigid orthoses [6]. Although not all of the aforementioned investigations have published hardness ratings, at a shore A grade of 65 it is likely that the orthoses examined in the current explanation were more rigid than those utilized by Sinclair et al., Laughton et al. and Dixon [5,7,8]. It is proposed that the divergence between investigations relates to differences in hardness characteristics of the experimental orthoses. The magnitude of impact loading is governed by the rate of change in momentum of the decelerating limb as the foot strikes the ground [22]; as such, it appears that the orthoses examined in this analysis were not sufficiently compliant to provide any reduction in impact loading.

Of further importance to the current investigation is that the medial orthoses significantly reduced eversion and TIR parameters in relation to the lateral and no-orthotic conditions. It is likely that this observation relates to the mechanical properties of the medial wedge which is designed specifically to rotate the foot segment into a more inverted position. This finding has potential clinical significance as excessive rearfoot eversion and associated TIR parameters are implicated in the etiology of a number of overuse injuries such as tibial stress syndrome, plantar fasciitis, patellofemoral syndrome and iliotibial band syndrome [23-25]. This observation therefore suggests that medial orthoses may be important for the prophylactic attenuation of chronic running related to excessive eversion/ TIR.

The findings from the current study importantly show that whilst lateral orthoses are effective in attenuating pain symptoms [9] and reducing the magnitude of the external knee adduction moment [13-15] in patients with medial compartment tibiofemoral osteoarthritis, they may concurrently place runners at risk from chronic pathologies distinct from the medial aspect of the tibiofemoral joint. It appears based on the findings from the current investigation that caution should be exercised when prescribing lateral wedge orthoses without a thorough assessment of the runners’ individual characteristics.  

A limitation, in relation to the current investigation, is that only the acute effects of the wedged insoles were examined. Therefore, although the medial orthoses appear to prophylactically attenuate tibiocalcaneal risk factors linked to the etiology of injuries, it is currently unknown whether this will prevent or delay the initiation of injury symptoms. Furthermore, the duration over which the orthoses would need to be utilized in order to mediate a clinically meaningful change in patients is also not currently known. A longitudinal examination of medial/lateral orthoses in runners would therefore be of practical and clinical relevance in the future. A further potential limitation is that only male runners were examined as part of the current investigation. Females are known to exhibit distinct tibiocalcaneal kinematics when compared to male recreational runners, with females being associated with significantly greater eversion and TIR parameters compared to males [26]. Furthermore, females are renowned for being at increased risk from tibiofemoral joint degeneration in comparison to males [27], and experimental findings have shown that degeneration may also be more prominent at different anatomical aspects of the knee in females in relation to males [28]. This suggests that the requirements of females, in terms of wedged orthotic intervention, may differ from those of male runners, thus it would be prudent for future biomechanical investigations to repeat the current study using a female sample.

In conclusion, despite the fact that the biomechanical effects of wedged foot orthoses have been examined previously, current knowledge with regards to the effects of medial and lateral orthoses on the kinetics and tibiocalcaneal kinematics of running have yet to be explored. This study adds to the current literature in the field of biomechanics by giving a comprehensive comparative examination of kinetic and tibiocalcaneal kinematic parameters during the stance phase of running whilst wearing medial and lateral orthoses. The current investigation importantly showed that medial orthoses significantly attenuated eversion and TIR parameters in relation to the lateral and no-orthotic conditions. The findings from this study indicate therefore that medial orthoses may be effective in attenuating tibiocalcaneal kinematic risk factors linked to the etiology of chronic pathologies in runners.

References

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  2. van Gent, B.R., Siem, D.D., van Middelkoop, M., van Os, T.A., Bierma-Zeinstra, S.S., Koes, B.B. (2007). Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. British Journal of Sports Medicine. 41, 469-480.
  3. McMillan, A., Payne, C. (2008). Effect of foot orthoses on lower extremity kinetics during running: a systematic literature review. Journal of Foot and Ankle Research. 13, 1-13.
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  5. Sinclair, J., Isherwood, J., Taylor, P.J. (2014). Effects of foot orthoses on kinetics and tibiocalcaneal kinematics in recreational runners. Foot and Ankle Online Journal, 7, 3-11.
  6. Butler, R. J., Davis, I. M., Laughton, C. M., Hughes, M. (2003). Dual-function foot orthosis: effect on shock and control of rearfoot motion. Foot & ankle international, 24, 410-414.
  7. Laughton, C. A., Davis, I. M., Hamill, J. (2003). Effect of strike pattern and orthotic intervention on tibial shock during running. Journal of Applied Biomechanics, 19, 153-168.
  8. Dixon, S.J. (2007). Influence of a commercially available orthotic device on rearfoot eversion and vertical ground reaction force when running in military footwear. Military medicine, 172, 446-450.
  9. Parkes, M. J., Maricar, N., Lunt, M., LaValley, M. P., Jones, R. K., Segal, N. A., Felson, D. T. (2013). Lateral wedge insoles as a conservative treatment for pain in patients with medial knee osteoarthritis: a meta-analysis. JAMA, 310, 722-730.
  10. Reilly, K. A., Barker, K. L., Shamley, D. (2006). A systematic review of lateral wedge orthotics-how useful are they in the management of medial compartment osteoarthritis?. The Knee, 13, 177-183.
  11. Rafiaee, M., Karimi, M. T. (2012). The effects of various kinds of lateral wedge insoles on performance of individuals with knee joint osteoarthritis. International Journal of Preventive Medicine, 3, 693-698.
  12. Birmingham, T.B., Hunt, M.A., Jones, I.C., Jenkyn, T.R., Giffin, J.R. (2007). Test–retest reliability of the peak knee adduction moment during walking in patients with medial compartment knee osteoarthritis. Arthritis Care & Research. 57, 1012-1017.
  13. Kakihana, W., Torii, S., Akai, M., Nakazawa, K., Fukano, M., Naito, K. (2005). Effect of a lateral wedge on joint moments during gait in subjects with recurrent ankle sprain. American Journal of Physical Medicine & Rehabilitation, 84, 858-864.
  14. Butler, R. J., Marchesi, S., Royer, T., Davis, I. S. (2007). The effect of a subject‐specific amount of lateral wedge on knee mechanics in patients with medial knee osteoarthritis. Journal of Orthopaedic Research, 25, 1121-1127.
  15. Kakihana, W., Akai, M., Yamasaki, N., Takashima, T., Nakazawa, K. (2004). Changes of joint moments in the gait of normal subjects wearing laterally wedged insoles. American Journal of Physical Medicine & Rehabilitation, 83, 273-278.
  16. Boldt, A.R., Willson, J.D., Barrios, J.A., Kernozek, T.W. (2013). Effects of medially wedged foot orthoses on knee and hip joint running mechanics in females with and without patellofemoral pain syndrome. Journal of Applied Biomechanics. 29, 68-77.
  17. Sinclair, J., Vincent, H., Selfe, J., Atkins, S., Taylor, P.J., Richards, J. (2015). Effects of foot orthoses on patellofemoral load in recreational runners. Foot and Ankle Online Journal, 8, 5-12.
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  21. Eslami, M., Begon, M., Farahpour, N., Allard, P. (200). Forefoot–rearfoot coupling patterns and tibial internal rotation during stance phase of barefoot versus shod running. Clinical Biomechanics, 22, 74-80.
  22. Whittle, M.W. (1999). Generation and attenuation of transient impulsive forces beneath the foot: a review. Gait & posture, 10, 264-267.
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  24. Lee, S.Y., Hertel, J., Lee, S.C. (2010). Rearfoot eversion has indirect effects on plantar fascia tension by changing the amount of arch collapse. The Foot, 20, 64-70.
  25. Barton, C. J., Levinger, P., Menz, H. B., Webster, K. E. (2009). Kinematic gait characteristics associated with patellofemoral pain syndrome: a systematic review. Gait & posture, 30, 405-416.
  26. Sinclair, J., Taylor, P. J. (2014). Sex differences in tibiocalcaneal kinematics. Human Movement, 15, 105-109.
  27. Hame, S.L., Alexander, R.A. (2013). Knee osteoarthritis in women. Current Reviews in Musculoskeletal Medicine. 6, 182-187.
  28. Hanna, F.S., Teichtahl, A.J., Wluka, A.E., Wang, Y., Urquhart, D.M., English, D.R., Cicuttini, F.M. (2009). Women have increased rates of cartilage loss and progression of cartilage defects at the knee than men: a gender study of adults without clinical knee osteoarthritis. Menopause. 16, 666-670.

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Effects of foot orthoses on kinetics and tibiocalcaneal kinematics in recreational runners

Posted on September 30, 2014 | Comments Off on Effects of foot orthoses on kinetics and tibiocalcaneal kinematics in recreational runners

by Sinclair, J1 Isherwood J1 and Taylor PJ2pdflrg

The Foot and Ankle Online Journal 7 (3): 3

Epidemiological studies analysing the prevalence of running injuries suggest that chronic injuries are a prominent complaint. Foot orthoses have been advocated for the treatment of running injuries yet the mechanism behind their effects are not well understood. This study aimed to examine the kinetics and tibiocalcaneal kinematics of running as a function of orthotic intervention. Fourteen recreational runners ran at 4.0 m.s-1. The kinetics and tibiocalcaneal kinematics of running were obtained when running with and without orthotics and contrasted using paired t-tests. The results show that tibiocalcaneal kinematics were not significantly influenced by foot orthoses. However, it was demonstrated that kinetic parameters were significantly reduced as a function of the orthotic intervention. This study supports the notion that runners who are susceptible to chronic injuries related to excessive impact forces may benefit from foot orthoses and may provide insight into the clinical efficacy of orthotic intervention.

Key words: Foot orthoses, kinetics, tibiocalcaneal, runners

ISSN 1941-6806
doi: 10.3827/faoj.2014.0703.0003

Address correspondence to: Jonathan Sinclair, Division of Sport, Exercise and Nutritional Sciences, School of Sport Tourism and Outdoors
University of Central Lancashire, Preston, Lancashire, PR1 2HE.
e-mail: Jksinclair@uclan.ac.uk

1 Division of Sport Exercise and Nutritional Sciences, University of Central Lancashire.
2 School of Psychology, University of Central Lancashire.

Epidemiological studies analysing the prevalence of running injuries suggest that chronic injuries are a prominent complaint for both recreational and competitive runners [1]. Each year approximately 19.4-79.3% of runners will experience a pathology related to running [2].

Higher levels of impact loading have been shown by previous analyses to correlate significantly with the etiology of chronic injuries such as stress fractures, osteoarthritis, plantar fasciitis, medial tibial stress syndrome, and patellofemoral pain syndrome [3,4,5,6]. In addition, etiological analyses have shown that during running excessive coronal plane eversion of the ankle and internal rotation of the tibia are linked to the generation of chronic injuries [7,8].

This motion has been associated in clinical studies with a number of different pathologies such as tibial stress syndrome, plantar fasciitis, and anterior knee pain [9,10,11,12].

Orthoses are commonly utilized for the treatment of chronic injuries in runners [13,14]. Foot orthoses are utilized in an attempt to reduce impact forces and control coronal and transverse plane motion of the foot and tibia. The efficacy of foot orthoses has been demonstrated for both the prevention and treatment of chronic pathologies [15]. However, the mechanism by which foot orthoses exert their clinical benefits is not well understood.

The aim of the current investigation was to examine the influence of orthotic intervention on the kinetics and tibiocalcaneal kinematics of running. A study of this nature may provide information regarding the clinical effectiveness of foot orthoses and offer insight into the mechanism by which orthotic intervention serves to reduce symptoms of chronic running injuries.

Methods

Participants

Fourteen male runners (age 25.22 ± 3.87 years, height 1.79 ± 0.12 m, and body mass 73.64 ± 5.34 kg) took part in the current investigation. Participants were recreational runners who trained at least 3 times per week. All runners were deemed to exhibit a rearfoot strike pattern as they exhibited first peak in their vertical ground reaction force time-curve [16]. Ethical approval was obtained from the University Ethics Committee and the procedures outlined in the declaration of Helsinki were followed.

Orthotic device
Commercially available orthotics (Sorbothane, shock stopper sorbo Pro; Nottinghamshire UK) were examined in the current investigation. Although the right lower extremity was selected for analysis, orthotic devices were placed inside both shoes.

Procedure

Participants completed five running trials at 4.0 m.s-1 ± 5%. The participants struck an embedded piezoelectric force platform (Kistler Instruments, Model 9281CA) sampling at 1000 Hz with their right foot [17]. Running velocity was monitored using infrared timing gates (SmartSpeed Ltd UK). The stance phase of the running cycle was delineated as the time over which > 20 N vertical force was applied to the force platform [18]. Kinematic information was collected using an eight-camera optoelectric motion capture system. Synchronised kinematic and ground reaction force data were obtained using Qualisys track manager software (Qualisys Medical AB, Goteburg, Sweden) with a capture frequency of 250 Hz.

The calibrated anatomical systems technique (CAST) was utilised to quantify tibiocalcaneal kinematics [19]. To define the anatomical frames of the right foot, and shank, retroreflective markers were positioned onto the calcaneus, first and fifth metatarsal heads, medial and lateral malleoli, medial and lateral epicondyle of the femur. A carbon fiber tracking cluster was attached to the shank segment. The foot was tracked using the calcaneus, and first and fifth metatarsal markers. Static calibration trials were obtained with the participant in the anatomical position in order for the positions of the anatomical markers to be referenced in relation to the tracking clusters/markers. Tibial accelerations were measured using an accelerometer (Biometrics ACL 300, Units 25-26 Nine Mile Point Ind. Est. Cwmfelinfach, Gwent United Kingdom) sampling at 1000 Hz. The device was attached to the tibia 0.08 m above the medial malleolus in alignment with its longitudinal axis [20]. Strong adhesive tape was placed over the device and the lower leg to prevent artifact in the acceleration signal.

Data processing

Retroreflective markers were digitized using Qualisys Track Manager in order to identify appropriate markers, and then exported as C3D files. Three-dimensional kinematics were quantified using Visual 3-D (C-Motion Inc, Germantown, MD, USA) after marker displacement data were smoothed using a low-pass Butterworth 4th order zero-lag filter at a cut off frequency of 12 Hz. Three-dimensional kinematics were calculated using an XYZ sequence of rotations. All kinematic waveforms were normalized to 100% of the stance phase, and then processed trials were averaged. Discrete three-dimensional kinematic measures from the ankle and tibia which were extracted for statistical analysis were 1) angle at footstrike, 2) angle at toe-off, 3) range of motion from footstrike to toe-off during stance, 4) peak eversion/tibial internal rotation, 5) relative range of motion (representing the angular displacement from footstrike to peak angle, 6) eversion/tibial internal rotation (EV/TIR) ratio.

Forces were reported in bodyweights (B.Ws) to allow normalization of the data among participants. From the force plate data, stance time, average loading rate, instantaneous loading rate, peak impact force, and time to peak impact were calculated. Average loading rate was calculated by dividing the impact peak magnitude by the time to the impact peak. Instantaneous loading rate was quantified as the maximum increase in vertical force between frequency intervals. The tibial acceleration signal was filtered using a 60 Hz low-pass Butterworth 4th order zero-lag filter to prevent any resonance effects on the acceleration signal. Peak tibial acceleration was defined as the highest positive acceleration peak measured during the stance phase. Average tibial acceleration slope was quantified by dividing peak tibial acceleration by the time taken from footstrike to peak tibial acceleration. The instantaneous tibial acceleration slope was quantified as the maximum increase in vertical force between frequency intervals

Table1

Table 1 Kinetic parameters (Mean and SD) obtained as a function of orthotic intervention (* = significant difference).

Fig 1

Figure 1 Tibiocalcaneal kinematics as a function of orthotic intervention (a= ankle sagittal, b= ankle coronal, c= ankle transverse, d= tibial internal rotation) (Black = no-orthotic and Grey = orthotic).

Statistical analyses

Differences in kinetics and tibiocalcaneal kinematics as a function of orthotic intervention were examined using paired samples t-tests. The alpha criterion for statistical significance was taken at the p<0.05 level [21]. Effect sizes were calculated using a Cohen’s D. All statistical analyses were conducted using SPSS 21.0 (SPSS Inc., Chicago, USA).

Results

Figure 1 and Tables 1-3 present the three-dimensional tibiocalcaneal kinematics and kinetics obtained as a function of orthotic intervention. The results indicate that kinetic parameters were significantly influenced by orthotic intervention.

Table2

Table 2 Ankle kinematic parameters (Mean and SD) obtained as a function of orthotic intervention (* = significant difference).

Table3

Table 3 Tibial internal rotation parameters (Mean and SD) obtained as a function of orthotic intervention (* = significant difference).

Kinetics

The results indicate that time to impact peak was significantly longer (t (13) = 3.03, p<0.05, D = 1.82) when using orthotics compared to without orthotics. The analysis also showed that both average (t (13) = 3.63, p<0.05, D = 2.19) and instantaneous loading rate (t (13) = 2.36, p<0.05, D = 1.43) were found to be significantly reduced as a function of orthotic intervention. In terms of tibial accelerations the results indicate that time to peak tibial acceleration was significantly longer (t (13) = 2.66, p<0.05, D = 1.60) when using orthotics compared to without orthotics. The analysis also showed that both average (t (13) = 2.79, p<0.05, D = 1.68) and instantaneous tibial acceleration slope (t (13) = 2.69, p<0.05, D = 1.62) were found to be significantly reduced as a function of orthotic intervention.

Tibiocalcaneal kinematics

No significant (p>0.05) differences in tibiocalcaneal kinematics were observed.

Discussion

The aim of the current investigation was to examine the effects of orthotic intervention on the kinetics and three-dimensional tibiocalcaneal kinematics of running. This represents the first study to simultaneously investigate the kinetics and tibiocalcaneal kinematics in runners as a function of orthotic intervention.

The first key observation from the current investigation is that the temporal element of impact parameters measured using both the force platform accelerometer were significantly reduced as a function of the orthotic device. This finding concurs with those of Dixon [22] and Mundermann et al [23] who also noted reductions in the loading rate of the vertical ground reaction force as a result of orthotic intervention. This observation opposes those of Butler et al [24] and Maclean et al [25] however; who found that orthotics had no effect on impact forces during running. It is likely that this observation relates to the distinction in mechanical properties of the examined orthotics, which leads to the conclusion that orthotics cannot be considered analogous and that perhaps a systematic comparison of the many orthotic devices is warranted in biomechanical and podiatric settings.

The reduction in loading kinetics observed when orthotics were utilized may have potential clinical significance given the proposed relationship between impact loading magnitude and the aetiology of chronic running injuries [26]. It appears based on the findings from the current study that the utilization of foot orthoses has the potential to reduce the impact force parameters linked to the development of chronic injuries [26]. The mechanics behind this observation is likely to be the additional density provided by the orthotic which serves to provide an additional deceleration mechanism that increased the duration over which the impact phase occurs facilitating a reduction in loading kinetics.

A further key finding from this study is that orthotic intervention had no significant effect on tibiocalcaneal kinematics. This has particular clinical relevance in the coronal and transverse planes as excessive eversion and tibial internal rotation have been linked to the aetiology of a number of chronic pathologies in runners. This observation is somewhat surprising given that one of the primary functions of orthotic intervention is to attenuate rearfoot eversion, which opposes the observations of Bates et al [27] and Johanson et al [28], who each documented reductions in coronal and transverse plane motions when using an orthotic. This observation does concur with those of Stacoff et al [29], Nawoczenski et al [30], and Stackhouse et al [31] who also documented that orthotics did not influence rearfoot motion parameters. There are several potential mechanisms that may explain this finding. Firstly in light of the kinetics observations, the orthotic device may have been too soft to physically restrain the coronal plane motion of the ankle, meaning that despite the medial wedging the non-sagittal motion was not affected. Secondly, the medial materials in the orthotics used in the current may not have been substantial enough to elicit a change in rearfoot motion.

A potential limitation of the current investigation is that only runners who habitually utilize a rearfoot strike pattern were examined. Whilst this is a commonplace in biomechanical analyses of this nature given that the majority of runners are known to exhibit a heel-toe running style, it does mean that the effects of orthotics examined in this study cannot be generalized to non-rearfoot runners. However, it should be noted that Stackhouse et al [31] showed that foot orthoses do not differentially affect rearfoot motion in rearfoot and forefoot strike runners. Nonetheless given the wide range of commercially available orthotics that are currently available it is recommended that further consideration be given to the efficacy of orthotic intervention in runners who adopt a midfoot or forefoot strike pattern.

A further limitation is that only male runners were examined in the current investigation. Females have been shown to exhibit distinct tibiocalcaneal kinematics when compared to male recreational runners, with females being associated with significant increases in eversion and tibial internal rotation compared to males [32]. This suggests that the requirements of females in terms of orthotic intervention may differ from those of male runners. It may be prudent for the current investigation to be repeated using a female sample.

In conclusion, the current investigation provides new information describing the influence of orthotic foot inserts on the kinetics and tibiocalcaneal kinematics of running. On the basis that decreased impact loading was observed when running with orthotics, the current investigation may provide insight into the clinical efficacy of orthotic intervention. This study supports the notion that runners who are susceptible to chronic injuries related to excessive impact forces may benefit from foot orthoses.

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