title: A clinically applicable non-invasive method to quantitatively assess the visco-hyperelastic properties of human heel pad, implications for assessing the risk of mechanical trauma.
abstract: Pathological conditions such as diabetic foot and plantar heel pain are associated with changes in the mechanical properties of plantar soft tissue. However, the causes and implications of these changes are not yet fully understood. This is mainly because accurate assessment of the mechanical properties of plantar soft tissue in the clinic remains extremely challenging.
  
  
  
  To develop a clinically viable non-invasive method of assessing the mechanical properties of the heel pad. Furthermore the effect of non-linear mechanical behaviour of the heel pad on its ability to uniformly distribute foot-ground contact loads in light of the effect of overloading is also investigated.
  
  
  
  An automated custom device for ultrasound indentation was developed along with custom algorithms for the automated subject-specific modeling of heel pad. Non-time-dependent and time-dependent material properties were inverse engineered from results from quasi-static indentation and stress relaxation test respectively. The validity of the calculated coefficients was assessed for five healthy participants. The implications of altered mechanical properties on the heel pad's ability to uniformly distribute plantar loading were also investigated in a parametric analysis.
  
  
  
  The subject-specific heel pad models with coefficients calculated based on quasi-static indentation and stress relaxation were able to accurately simulate dynamic indentation. Average error in the predicted forces for maximum deformation was only 6.6±4.0%. When the inverse engineered coefficients were used to simulate the first instance of heel strike the error in terms of peak plantar pressure was 27%. The parametric analysis indicated that the heel pad's ability to uniformly distribute plantar loads is influenced both by its overall deformability and by its stress-strain behaviour. When overall deformability stays constant, changes in stress/strain behaviour leading to a more "linear" mechanical behaviour appear to improve the heel pad's ability to uniformly distribute plantar loading.
  
  
  
  The developed technique can accurately assess the visco-hyperelastic behaviour of heel pad. It was observed that specific change in stress-strain behaviour can enhance/weaken the heel pad's ability to uniformly distribute plantar loading that will increase/decrease the risk for overloading and trauma.
authors.affiliation: Faculty of Health Sciences, Staffordshire University, Stoke-on-Trent, UK. Electronic address: sara.behforootan@research.staffs.ac.uk.
authors.forename: Sara
authors.initials: S
authors.lastname: Behforootan
authors.affiliation: Faculty of Health Sciences, Staffordshire University, Stoke-on-Trent, UK.
authors.forename: Panagiotis E
authors.initials: PE
authors.lastname: Chatzistergos
authors.affiliation: Faculty of Health Sciences, Staffordshire University, Stoke-on-Trent, UK.
authors.forename: Nachiappan
authors.initials: N
authors.lastname: Chockalingam
authors.affiliation: Faculty of Health Sciences, Staffordshire University, Stoke-on-Trent, UK.
authors.forename: Roozbeh
authors.initials: R
authors.lastname: Naemi
mesh_terms: D001696:Biomechanical Phenomena; D004548:Elasticity; D020342:Finite Element Analysis; D006365:Heel / Q000502:physiology*; D006801:Humans; D008954:Models, Biological; D013314:Stress, Mechanical; D016474:Weight-Bearing
keywords: Diabetic foot; Finite element analysis; Inverse engineering; Plantar pressure; Soft tissue injuries; Ultrasonography; Ultrasound indentation