title: Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait.
abstract: BACKGROUND
  Several footwear design characteristics are known to have detrimental effects on the foot. However, one characteristic that has received relatively little attention is the point where the sole flexes in the sagittal plane. Several footwear assessment forms assume that this should ideally be located directly under the metarsophalangeal joints (MTPJs), but this has not been directly evaluated. The aim of this study was therefore to assess the influence on plantar loading of different locations of the shoe sole flexion point.
  
  
  METHODS
  Twenty-one asymptomatic females with normal foot posture participated. Standardised shoes were incised directly underneath the metatarsophalangeal joints, proximal to the MTPJs or underneath the midfoot. The participants walked in a randomised sequence of the three shoes whilst plantar loading patterns were obtained using the Pedar® in-shoe pressure measurement system. The foot was divided into nine anatomically important masks, and peak pressure (PP), contact time (CT) and pressure time integral (PTI) were determined. A ratio of PP and PTI between MTPJ2-3/MTPJ1 was also calculated.
  
  
  RESULTS
  Wearing the shoe with the sole flexion point located proximal to the MTPJs resulted in increased PP under MTPJ 4-5 (6.2%) and decreased PP under the medial midfoot compared to the sub-MTPJ flexion point (-8.4%). Wearing the shoe with the sole flexion point located under the midfoot resulted in decreased PP, CT and PTI in the medial and lateral hindfoot (PP: -4.2% and -5.1%, CT: -3.4% and -6.6%, PTI: -6.9% and -5.7%) and medial midfoot (PP: -5.9% CT: -2.9% PTI: -12.2%) compared to the other two shoes.
  
  
  CONCLUSIONS
  The findings of this study indicate that the location of the sole flexion point of the shoe influences plantar loading patterns during gait. Specifically, shoes with a sole flexion point located under the midfoot significantly decrease the magnitude and duration of loading under the midfoot and hindfoot, which may be indicative of an earlier heel lift.
authors.affiliation: EMGO + Institute for health and care research, department of general practice and elderly care medicine, VU University Medical Centre, Postbus 7057, 1007 MB Amsterdam, The Netherlands. b.vanderzwaard@vumc.nl.
authors.forename: Babette C
authors.initials: BC
authors.lastname: van der Zwaard
authors.forename: Benedicte
authors.initials: B
authors.lastname: Vanwanseele
authors.forename: Fred
authors.initials: F
authors.lastname: Holtkamp
authors.forename: Henriëtte E
authors.initials: HE
authors.lastname: van der Horst
authors.forename: Petra Jm
authors.initials: PJ
authors.lastname: Elders
authors.forename: Hylton B
authors.initials: HB
authors.lastname: Menz