Darren J. Stefanyshyn

Shoe inserts and orthotics for sport and physical activities.

The purposes of this paper were to discuss the perceived benefits of inserts and orthotics for sport activities and to propose a new concept for inserts and orthotics. There is evidence that inserts or orthotics reduce or prevent movement-related injuries. However, there is limited knowledge about the specific functioning an orthotic or insert provides. The same orthotic or insert is often proposed for different problems. Changes in skeletal movement due to inserts or orthotics seem to be small and not systematic. Based on the results of a study using bone pins, one may question the idea that a major function of orthotics or inserts consists in aligning the skeleton. Impact cushioning with shoe inserts or orthotics is typically below 10%. Such small reductions might not be important for injury reduction. It has been suggested that changes in material properties might produce adjustments in the muscular response of the locomotor system. The foot has various sensors to detect input signals with subject specific thresholds. Subjects with similar sensitivity threshold levels seem to respond in their movement pattern in a similar way. Comfort is an important variable. From a biomechanical point of view, comfort may be related to fit, additional stabilizing muscle work, fatigue, and damping of soft tissue vibrations. Based on the presented evidence, the concept of minimizing muscle work is proposed when using orthotics or inserts. A force signal acts as an input variable on the shoe. The shoe sole acts as a first filter, the insert or orthotic as a second filter, the plantar surface of the foot as a third filter for the force input signal. The filtered information is transferred to the central nervous system that provides a subject specific dynamic response. The subject performs the movement for the task at hand. For a given movement task, the skeleton has a preferred path. If an intervention supports/counteracts the preferred movement path, muscle activity can/must be reduced/increased. Based on this concept, an optimal insert or orthotic would reduce muscle activity, feel comfortable, and should increase performance.

Relation between running injury and static lower limb alignment in recreational runners

Objectives: To determine if measurements of static lower limb alignment are related to lower limb injury in recreational runners. Methods: Static lower limb alignment was prospectively measured in 87 recreational runners. They were observed for the following six months for any running related musculoskeletal injuries of the lower limb. Injuries were defined according to six types: R1, R2, and R3 injuries caused a reduction in running mileage for one day, two to seven days, or more than seven days respectively; S1, S2, and S3 injuries caused stoppage of running for one day, two to seven days, or more than seven days respectively. Results: At least one lower limb injury was suffered by 79% of the runners during the observation period. When the data for all runners were pooled, 95% confidence intervals calculated for the differences in the measurements of lower limb alignment between the injured and non-injured runners suggested that there were no differences. However, when only runners diagnosed with patellofemoral pain syndrome (n = 6) were compared with non-injured runners, differences were found in right ankle dorsiflexion (0.3 to 6.1), right knee genu varum (−0.9 to −0.3), and left forefoot varus (−0.5 to −0.4). Conclusions: In recreational runners, there is no evidence that static biomechanical alignment measurements of the lower limbs are related to lower limb injury except patellofemoral pain syndrome. However, the effect of static lower limb alignment may be injury specific.

Foot orthotics affect lower extremity kinematics and kinetics during running.

OBJECTIVE To quantify the effects of posting and custom-molding of foot orthotics on lower extremity kinematics and kinetics during running. DESIGN Repeated measures.Background. Several kinematic and kinetic factors have been suggested to increase a runners risk for injuries. It has been speculated that foot orthotics can be used to reduce injury related complaints or even prevent running injuries by affecting these factors. METHODS Twenty one volunteers participated in this study. Kinematic and kinetic variables obtained during overground running for medial posting, custom-molding, and the combination of medial posting and custom-molding of foot orthotics were compared to a control condition. Repeated measures ANOVA and student t-tests were used to detect significant differences (alpha=0.05). RESULTS Posting of foot orthotics reduced maximum foot eversion and ankle inversion moment and increased vertical loading rate and maximum knee external rotation moment (P<0.05). Molding and posting and molding reduced vertical loading rate and ankle inversion moment and increased maximum foot inversion and maximum knee external rotation moment (P<0.05). CONCLUSIONS The effects of posting and molding of foot orthotics are extremely different and when combining posting and molding, the effects of molding appear to be dominant. It yet remains to be determined whether posting or molding is more beneficial with respect to overuse running injuries. RELEVANCE The potential of foot orthotics for reducing pain and injuries is convincing. The current study provides valuable information about the role of specific structural components of foot orthotics and contributes to the knowledge about the mechanism underlying the effect of foot orthotics in running.

Knee Angular Impulse as a Predictor of Patellofemoral Pain in Runners

Background Identification of mechanical factors associated with patellofemoral pain, the most prevalent running injury, is necessary to help in injury prevention, but unfortunately they remain elusive. Hypothesis Runners who develop patellofemoral pain have increased knee joint angular impulse in the frontal plane. Study Design Case control study; Level of evidence, 3. Methods A retrospective study compared knee abduction impulses of 20 patellofemoral pain patients with those of 20 asymptomatic patients. A second prospective study quantified knee angular impulses during the stance phase of running of 80 runners at the beginning of the summer running season. Epidemiologic data were then collected, recording the type and severity of injury of these runners during a 6-month running period. Results The patellofemoral pain patients in the retrospective study had significantly higher (P =. 026) knee abduction impulses (17.0 ± 8.5 Nms) than did the asymptomatic patients (12.5 ± 5.5 Nms). Six patients developed patellofemoral pain during the prospective study. The prospective data showed that patients who developed patellofemoral pain had significantly higher (P =. 042) knee abduction impulses (9.2 ± 3.7 Nms) than did matched patients who remained uninjured (4.7 ± 3.5 Nms). Conclusion The data indicate that increased knee abduction impulses should be deemed risk factors that play a role in the development of patellofemoral pain in runners. Clinical Relevance Footwear and running style can influence knee angular impulse, and the appropriate manipulation of these variables may play a preventive role for patients who are predisposed to patellofemoral pain.

Development of a reliable method to assess footwear comfort during running.

The purposes of this study were: (a) to determine whether subjects are able to distinguish between differences in footwear with respect to footwear comfort; and (b) to determine how reliably footwear comfort can be assessed using a visual analogue scale (VAS) and a protocol including a control condition during running. Intraclass correlation coefficients (ICCs) between comfort ratings for repeated conditions were high (ICC = 0.799). Differences in comfort ratings between the insert conditions were significant. A paired t-test revealed a significant difference in overall comfort ratings for the control insert when tested after the soft insert compared to when tested after the hard insert (P = 0.008). The results of this study showed that VASs provide a reliable measure to assess footwear comfort during running under the conditions that: (a) a control condition is included; and (b) the average comfort rating of sessions 4-6 is used.

Relationship between footwear comfort of shoe inserts and anthropometric and sensory factors

PURPOSE The purposes of this study were (a) to determine lower extremity anthropometric and sensory factors that are related to differences in comfort perception of shoe inserts with varying shape and material and (b) to investigate whether shoe inserts that improve comfort decrease injury frequency in a military population. METHODS 206 military personnel volunteered for this study. The shoe inserts varied in arch and heel cup shape, hardness, and elasticity in the heel and forefoot regions. A no insert condition was included as the control condition. Measured subject characteristics included foot shape, foot and leg alignment, and tactile and vibration sensitivity of the plantar surface of the foot. Footwear comfort was assessed using a visual analog scale. Injury frequency was evaluated with a questionnaire. The statistical analyses included Students t-tests for repeated measures, ANOVA (within subjects), MANOVA (within insert combinations), and chi-square tests. RESULTS The average comfort ratings for all shoe inserts were significantly higher than the average comfort rating for the control condition. The incidence of stress fractures and pain at different locations was reduced by 1.5-13.4% for the insert compared with the control group. Foot arch height, foot and leg alignment, and foot sensitivity were significantly related to differences in comfort ratings for the hard/soft, the viscous/elastic, and the high arch/low arch insert combinations. CONCLUSIONS Shoe inserts of different shape and material that are comfortable are able to decrease injury frequency. The results of this study showed that subject specific characteristics influence comfort perception of shoe inserts.

Kinematic Changes After Fusion and Total Replacement of the Ankle Part 1: Range of Motion

Background: The purpose of this study was to determine how closely the present designs of ankle prostheses mimic the unique requirements of the foot and ankle. The three-dimensional range of motion (ROM) of the ankle joint complex, before and after ankle arthrodesis and after implantation of three currently used total ankle prostheses, was investigated. Methods: The three-dimensional ROM was determined in six fresh-frozen cadaver leg specimens using a 6-df device with an axial load of 200 N and a four-camera high-speed video system. A moment of 100 Nm was applied to the footplate to determine the ROM in the sagittal (dorsiflexion and plantarflexion) and frontal (inversion and eversion) planes. The same moment was applied to the tibia to determine the ROM for the internal and external tibial rotation. The measurements were performed for the normal ankle, the fused ankle, and the AGILITY, HINTEGRA, and S.T.A.R. prostheses. Results: Compared to the normal condition, the ROM for dorsiflexion and plantarflexion was changed for all surgical interventions. The changes were highest for the ankle arthrodesis. The changes due to the prostheses were significantly less than the changes due to ankle arthrodesis. Compared to the normal condition, the total ROM for inversion/eversion was slightly decreased by the fused ankle and not changed by the three-component prostheses (HINTEGRA, S.T.A.R.). However, the ROM for inversion/eversion was significantly higher for the two-component prosthesis, AGILITY. The ROM for internal and external tibial rotation was not altered by the AGILITY and HINTEGRA ankle, but it was significantly reduced by the ankle arthrodesis. S.T.A.R. showed a significant shift of the total ROM toward internal tibial rotation. Conclusions: The three tested ankle joint prostheses changed the ROM of the ankle joint complex less than ankle fusion did. Total ankle prostheses were shown to replicate normal joint ROM closely. However, ankle arthrodesis was found to reduce the ROM substantially in all three planes: the sagittal, frontal, and horizontal planes. Clinical Implications: With respect to the ROM, total ankle replacement changes the natural ankle joint condition less than ankle arthrodesis, which reduces the ROM in all three planes and might increase stress in adjacent structures. The prosthesis that replicated the normal ankle joint ROM best was the one with the most anatomical design.

Influence of midsole bending stiffness on joint energy and jump height performance

PURPOSE A substantial amount of rotational energy is lost at the metatarsophalangeal joint during running and jumping. We hypothesized that the lost energy could be decreased by increasing the bending stiffness of shoe midsoles. The purposes of this investigation were to determine the influence of stiff shoe midsoles on changes in lower extremity joint power during running and jumping and to determine the influence of stiff shoe midsoles on vertical jump performance. METHODS Carbon fiber plates were inserted into shoe midsoles and data were collected on five subjects during running and vertical jumping. RESULTS The data showed that energy generation and absorption at each of the ankle, knee, and hip joints was not influenced by the stiffness of the shoe midsole. The stiff shoes with the carbon fiber plates did not increase the amount of energy stored and reused at the metatarsophalangeal joint; however, they reduced the amount of energy lost at this joint during both running and jumping. Vertical jump height was significantly higher (average, 1.7 cm for a group of 25 subjects) while wearing the stiff shoes. CONCLUSIONS Increasing the bending stiffness of the metatarsophalangeal joint reduced the amount of energy lost at that joint and resulted in a corresponding improvement of performance.

Mechanical energy contribution of the metatarsophalangeal joint to running and sprinting

Despite the fact that a number of studies have investigated lower extremity energy generation during locomotion, the influence of the metatarsophalangeal (MP) joint remained unknown. The purpose of this study was to determine the relative contribution of the MP joint to the total mechanical energy in running and sprinting. A sagittal plane analysis was performed on data collected from 10 trained male athletes (five runners and five sprinters). The MP moment was assumed to be negligible until the ground reaction force acted distal to the joint. During running, once the ground reaction force crossed the MP joint, the MP moment was plantarflexor for the remainder of ground contact with average peak values of 59.9 Nm. The MP joint moment was plantarflexor throughout the stance phase for sprinting with average peak values of 112.4 Nm. Since the MP joint was dorsiflexing throughout the majority of the stance phase the joint absorbed large amounts of energy, on average 20.9 J during running and 47.8 J during sprinting. A lack of plantarflexion of the MP joint resulted in a lack of energy generation during take-off. Thus, the energy that was absorbed at the joint was dissipated in the shoe and foot structures.

The effect of material characteristics of shoe soles on muscle activation and energy aspects during running

The purposes of this study were (a) to determine group and individual differences in oxygen consumption during heel-toe running and (b) to quantify the differences in EMG activity for selected muscle groups of the lower extremities when running in shoes with different mechanical heel characteristics. Twenty male runners performed heel-toe running using two shoe conditions, one with a mainly elastic and a visco-elastic heel. Oxygen consumption was quantified during steady state runs of 6 min duration, running slightly above the aerobic threshold providing four pairs of oxygen consumption results for comparison. Muscle activity was quantified using bipolar surface EMG measurements from the tibialis anterior, medial gastrocnemius, vastus medialis and the hamstrings muscle groups. EMG data were sampled for 5 s every minute for the 6 min providing 30 trials. EMG data were compared for the different conditions using an ANOVA (alpha=0.05). The findings of this study showed that changes in the heel material characteristics of running shoes were associated with (a) subject specific changes in oxygen consumption and (b) subject and muscle specific changes in the intensities of muscle activation before heel strike in the lower extremities. It is suggested that further study of these phenomena will help understand many aspects of human locomotion, including work, performance, fatigue and possible injuries.