Wen-Ming Chen

Effects of internal stress concentrations in plantar soft-tissue—A preliminary three-dimensional finite element analysis

It has been hypothesized that diabetic foot ulceration might be internally initiated. This study established a three-dimensional and nonlinear finite element model of a human foot complex with comprehensive skeletal and soft-tissue components. The model was validated by experimental data of subject-specific barefoot plantar pressure measurements. The feasibility of the model to predict the 3D, internal, plantar soft-tissue deformation and stress was evaluated. The preliminary results indicate that large von Mises stress occurs where plantar soft-tissue contacts with geometrically irregular bony structures, thus internal stress distribution within the plantar soft-tissue was dramatically influenced by bony prominences due to stress concentration. At the forefoot part, an average stress magnification factor of 3.01 was quantified. The lateral sesamoid bone associated to the 1st MTH showed the largest effect of stress concentration. The modeling approach presented provides a possible way to explore the complexity of the mechanical environment inside the plantar soft-tissue.

Role of gastrocnemius–soleus muscle in forefoot force transmission at heel rise — A 3D finite element analysis

The functions of the gastrocnemius-soleus (G-S) complex and other plantar flexor muscles are to stabilize and control major bony joints, as well as to provide primary coordination of the foot during the stance phase of gait. Geometric positioning of the foot and transferring of plantar loads can be adversely affected when muscular control is abnormal (e.g., equinus contracture). Although manipulation of the G-S muscle complex by surgical intervention (e.g., tendo-Achilles lengthening) is believed to be effective in restoring normal plantar load transfer in the foot, there is lack of quantitative data supporting that notion. Thus, the objective of this study is to formulate a three-dimensional musculoskeletal finite element model of the foot to quantify the precise role of the G-S complex in terms of biomechanical response of the foot. The model established corresponds to a muscle-demanding posture during heel rise, with simulated activation of major extrinsic plantar flexors. In the baseline (reference) case, required muscle forces were determined from what would be necessary to generate the targeted resultant ground reaction forces. The predicted plantar load transfer through the forefoot plantar surface, as indicated by plantar pressure distribution, was verified by comparison with experimental observations. This baseline model served as a reference for subsequent parametric analysis, where muscle forces applied by the G-S complex were decreased in a step-wise manner. Adaptive changes of the foot mechanism, in terms of internal joint configurations and plantar stress distributions, in response to altered muscular loads were analyzed. Movements of the ankle and metatarsophalangeal joints, as well as forefoot plantar pressure peaks and pressure distribution under the metatarsal heads (MTHs), were all found to be extremely sensitive to reduction in the muscle load in the G-S complex. A 40% reduction in G-S muscle stabilization can result in dorsal-directed rotations of 8.81° at the ankle, and a decreased metatarsophalangeal joint extension of 4.65°. The resulting peak pressure reductions at individual MTHs, however, may be site-specific and possibly dependent on foot structure, such as intrinsic alignment of the metatarsals. The relationships between muscular control, internal joint movements, and plantar load distributions are envisaged to have important clinical implications on tendo-Achilles lengthening procedures, and to provide surgeons with an understanding of the underlying mechanism for relieving forefoot pressure in diabetic patients suffering from ankle equinus contracture.

A novel gait platform to measure isolated plantar metatarsal forces during walking

A new gait platform described in this report allows an isolated measurement of the vertical and shear forces under an individual metatarsal head during barefoot walking. The apparatus incorporated a customized tactile force sensor and a high-speed camera system, which enabled easy identification of a single anatomical landmark at the forefoots plantar surface that is in contact with the sensor throughout stance. After calibration, the measured peak forces under the 2nd MTH showed variability of 3.7%, 9.2%, and 8.9% in vertical, anterior-posterior, and medial-lateral directions, respectively. The device therefore provides information about the magnitude and timing of such local metatarsal forces, and has been shown to be of significant research and clinical interest. Its ability to achieve this with a high degree of accuracy ensures its potential as a valuable research tool.

An instrumented tissue tester for measuring soft tissue property under the metatarsal heads in relation to metatarsophalangeal joint angle

Identification of the localized mechanical response of the plantar soft tissue pads underneath the metatarsal heads (i.e., sub-MTH pad) to external loading is key to understand and predict how it functions in a gait cycle. The mechanical response depends on various parameters, such as the external load (direction and rate), the sub-MTH tissue properties (anisotropy and viscoelasticity), and the configuration of the metatarsophalangeal (MTP) joint overlying the tissue. In this study, an instrument-driven tissue tester that incorporates a portable motorized indentor within a special foot positioning apparatus was developed for realistic in vivo mechanical characterization (i.e. tissue stiffness and force relaxation behavior) of the local sub-MTH pad with the MTP joint configured at various dorsiflexion angles associated with gait. The tester yields consistent results for tests on the 2nd sub-MTH pad. Measurement errors for the initial stiffness (for indentation depths ≤ 1 mm), end-point stiffness, and percentage force relaxation were less than 0.084 N/mm, 0.133 N/mm, and 0.127%, respectively, across all test configurations. The end-point tissue stiffness, which increased by 104.2% due to a 50° MTP joint dorsiflexion, also agreed with a previous investigation. In vivo tissues force relaxation was shown to be pronounced (avg. = 8.1%), even for a short holding-time interval. The proposed technique to facilitate study of the dependence of the local sub-MTH pad and tissue response on the MTP joint angle might be preferable to methods that focus solely on measurement of tissue property because under physiologic conditions the sub-MTH pad elasticity may vary in gait, to adapt to drastically changing mechanical demands in the sub-MTH region of the terminal stance-phase, where MTP joint dorsiflexion occurs.

Explicit finite element modelling of heel pad mechanics in running: inclusion of body dynamics and application of physiological impact loads

Many heel pathologies including plantar heel pain may result from micro tears/trauma in the subcutaneous tissues, in which internal tissue deformation/stresses within the heel pad play an important role. Previously, many finite element models have been proposed to evaluate stresses inside the heel pad, but the majority of these models only focus on static loading boundary conditions. This study explored a dynamics modelling approach to the heel pad subjected to realistic impact loads during running. In this model, the inertial property and action of the body are described by a lumped parameter model, while the heel/shoe interactions are modelled using a viscoelastic heel pad model with contact properties. The impact force pattern, dynamic heel pad deformation and stress states predicted by the model were compared with published experimental data. Further parametrical studies revealed the model responses, in terms of internal stresses in the skin and fatty tissue, change nonlinearly when body dynamics changes. A reduction in foots touchdown velocity resulted in a less severe impact landing and stress relief inside the heel pad, for example peak von-Mises stress in fatty tissue, was reduced by 11.3%. Applications of the model may be extendable to perform iterative analyses to further understand the complex relationships between body dynamics and stress distributions in the soft tissue of heel pad during running. This may open new opportunities to study the mechanical aetiology of plantar heel pain in runners.

Plantar pressure relief under the metatarsal heads – Therapeutic insole design using three-dimensional finite element model of the foot

Therapeutic footwear with specially-made insoles is often used in people with diabetes and rheumatoid arthritis to relieve ulcer risks and pain due to high pressures from areas beneath bony prominences of the foot, in particular to the metatarsal heads (MTHs). In a three-dimensional finite element study of the foot and footwear with sensitivity analysis, effects of geometrical variations of a therapeutic insole, in terms of insole thicknesses and metatarsal pad (MP) placements, on local peak plantar pressure under MTHs and stress/strain states within various forefoot tissues, were determined. A validated musculoskeletal finite element model of the human foot was employed. Analyses were performed in a simulated muscle-demanding instant in gait. For many design combinations, increasing insole thicknesses consistently reduce peak pressures and internal tissue strain under MTHs, but the effects reach a plateau when insole becomes very thick (e.g., a value of 12.7mm or greater). Altering MP placements, however, showed a proximally- and a distally-placed MP could result in reverse effects on MTH pressure-relief. The unsuccessful outcome due to a distally-placed MP may attribute to the way it interacts with plantar tissue (e.g., plantar fascia) adjacent to the MTH. A uniform pattern of tissue compression under metatarsal shaft is necessary for a most favorable pressure-relief under MTHs. The designated functions of an insole design can best be achieved when the insole is very thick, and when the MP can achieve a uniform tissue compression pattern adjacent to the MTH.

The in vivo plantar soft tissue mechanical property under the metatarsal head: implications of tissues׳ joint-angle dependent response in foot finite element modeling.

Material properties of the plantar soft tissue have not been well quantified in vivo (i.e., from life subjects) nor for areas other than the heel pad. This study explored an in vivo investigation of the plantar soft tissue material behavior under the metatarsal head (MTH). We used a novel device collecting indentation data at controlled metatarsophalangeal joint angles. Combined with inverse analysis, tissues׳ joint-angle dependent material properties were identified. The results showed that the soft tissue under MTH exhibited joint-angle dependent material responses, and the computed parameters using the Ogden material model were 51.3% and 30.9% larger in the dorsiflexed than in the neutral positions, respectively. Using derived parameters in subject-specific foot finite element models revealed only those models that used tissues׳ joint-dependent responses could reproduce the known plantar pressure pattern under the MTH. It is suggested that, to further improve specificity of the personalized foot finite element models, quantitative mechanical properties of the tissue inclusive of the effects of metatarsophalangeal joint dorsiflexion are needed.

Biomechanical influence of footwear with double rocker/wedged outsole profile on lower extremity

underneath an individual MTH. A key advantage of the proposed device is the integration of a portable indentor with a special foot positioning apparatus; this facilitates convenient investigation of the dependence of the local sub-MTH pad and tissue responses on MTP joint angle. This could prove preferable to studies that focus on measurement of tissue property in isolation (Garcia et al. 2008), because the sub-MTH pad may vary its elasticity under physiologic gait conditions, as it adapts to drastically changing mechanical demands at the sub-MTH region in the terminal stance-phase, where MTP joint dorsiflexion occurs. The device developed is a stepping stone to subsequent exploration of (joint-angle-dependent) tissue property as an indicator of disease states and risks, such as ulcer formation at the MTH region in neuropathic diabetic feet.

Investigation of Plantar Barefoot Pressure and Soft-tissue Internal Stress: A Three-Dimensional Finite Element Analysis

Mechanical loading acting on the foot plantar soft-tissue in the form of focal stress plays a central pathogenic role in the onset of diabetic neuropathic ulcers. Current instruments which merely allow superficial estimate of plantar loading acting on the foot, severely limit the scope of many biomechanical/clinical studies on this issue. Recent studies have suggested that peak plantar pressure may be only 65% specific for the development of ulceration. These limitations are at least partially due to surface pressures not being representative of the complex mechanical stress developed inside the subcutaneous plantar soft-tissue, which are potentially more relevant for tissue breakdown. This study established a threedimensional and nonlinear finite element model of a human foot complex with comprehensive skeletal and soft-tissue components capable of predicting both the external and internal stresses and deformations of the foot. The model was validated by experimental data of subject-specific plantar foot pressure measures. The stress analysis indicated the internal stresses doses were site-dependent and the observation found a change between 1.5 to 4.5 times the external stresses on the foot plantar surface. In the forefoot, peak external stress was found in the medial region (the first metatarsal heads). Peak internal stress, however, was shifted to the lateral forefoot region (the fourth and fifth metatarsal heads). It suggested that the normal protective plantar soft-tissue has the potential to redistribute the plantar load such that the internal peak stress can have a significantly different location than the external. The results yielded insights into the internal loading conditions of the plantar soft-tissue, which is important in enhancing our knowledge on the causes of foot ulceration and related stressinduced tissue breakdown in diabetic foot.

Strategies towards rapid generation of forefoot model incorporating realistic geometry of metatarsals encapsulated into lumped soft tissues for personalized finite element analysis

Abstract Use of finite element (FE) foot model as a clinical diagnostics tool is likely to improve the specificity of foot injury predictions in the diabetic population. Here we proposed a novel workflow for rapid construction of foot FE model incorporating realistic geometry of metatarsals encapsulated into lumped forefoot’s soft tissues. Custom algorithms were implemented to perform unsupervised segmentation and mesh generation to directly convert CT data into a usable FE model. The automatically generated model provided higher efficiency and comparable numerical accuracy when compared to the model constructed using a traditional solid-based mesh process. The entire procedure uses MATLAB as the main platform, and makes the present approach attractive for creating personalized foot models to be used in clinical studies.