{"Affiliation":[{"label":"Affiliation","value":"Medicine, Faculty of","attrs":{"lang":"en","ns":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","classmap":"vivo:EducationalProcess","property":"vivo:departmentOrSchool"},"iri":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","explain":"VIVO-ISF Ontology V1.6 Property; The department or school name within institution; Not intended to be an institution name."},{"label":"Affiliation","value":"Non UBC","attrs":{"lang":"en","ns":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","classmap":"vivo:EducationalProcess","property":"vivo:departmentOrSchool"},"iri":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","explain":"VIVO-ISF Ontology V1.6 Property; The department or school name within institution; Not intended to be an institution name."},{"label":"Affiliation","value":"Physical Therapy, Department of","attrs":{"lang":"en","ns":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","classmap":"vivo:EducationalProcess","property":"vivo:departmentOrSchool"},"iri":"http:\/\/vivoweb.org\/ontology\/core#departmentOrSchool","explain":"VIVO-ISF Ontology V1.6 Property; The department or school name within institution; Not intended to be an institution name."}],"AggregatedSourceRepository":[{"label":"Aggregated Source Repository","value":"DSpace","attrs":{"lang":"en","ns":"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider","classmap":"ore:Aggregation","property":"edm:dataProvider"},"iri":"http:\/\/www.europeana.eu\/schemas\/edm\/dataProvider","explain":"A Europeana Data Model Property; The name or identifier of the organization who contributes data indirectly to an aggregation service (e.g. Europeana)"}],"Citation":[{"label":"Citation","value":"Journal of Foot and Ankle Research. 2021 Oct 06;14(1):55","attrs":{"lang":"en","ns":"https:\/\/open.library.ubc.ca\/terms#identifierCitation","classmap":"oc:PublicationDescription","property":"oc:identifierCitation"},"iri":"https:\/\/open.library.ubc.ca\/terms#identifierCitation","explain":"UBC Open Collections Metadata Components; Local Field; Indicates a bibliographic reference for the resource if it has been previously published."}],"Contributor":[{"label":"Contributor","value":"University of British Columbia. Motion Analysis and Biofeedback Laboratory","attrs":{"lang":"en","ns":"http:\/\/purl.org\/dc\/terms\/contributor","classmap":"dpla:SourceResource","property":"dcterms:contributor"},"iri":"http:\/\/purl.org\/dc\/terms\/contributor","explain":"A Dublin Core Terms Property; An entity responsible for making contributions to the resource.; Examples of a Contributor include a person, an organization, or a service."},{"label":"Contributor","value":"University of British Columbia. Graduate Programs in Rehabilitation Science","attrs":{"lang":"en","ns":"http:\/\/purl.org\/dc\/terms\/contributor","classmap":"dpla:SourceResource","property":"dcterms:contributor"},"iri":"http:\/\/purl.org\/dc\/terms\/contributor","explain":"A Dublin Core Terms Property; An entity responsible for making contributions to the resource.; Examples of a Contributor include a person, an organization, or a service."}],"CopyrightHolder":[{"label":"Copyright Holder","value":"The Author(s)","attrs":{"lang":"en","ns":"https:\/\/open.library.ubc.ca\/terms#rightsCopyright","classmap":"oc:PublicationDescription","property":"oc:rightsCopyright"},"iri":"https:\/\/open.library.ubc.ca\/terms#rightsCopyright","explain":"UBC Open Collections Metadata Components; Local Field; Refers to the publisher or author who holds the copyright."}],"Creator":[{"label":"Creator","value":"Tse, Calvin","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/creator","classmap":"dpla:SourceResource","property":"dcterms:creator"},"iri":"http:\/\/purl.org\/dc\/terms\/creator","explain":"A Dublin Core Terms Property; An entity primarily responsible for making the resource.; Examples of a Contributor include a person, an organization, or a service."},{"label":"Creator","value":"Ryan, Michael B.","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/creator","classmap":"dpla:SourceResource","property":"dcterms:creator"},"iri":"http:\/\/purl.org\/dc\/terms\/creator","explain":"A Dublin Core Terms Property; An entity primarily responsible for making the resource.; Examples of a Contributor include a person, an organization, or a service."},{"label":"Creator","value":"Tse, Calvin","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/creator","classmap":"dpla:SourceResource","property":"dcterms:creator"},"iri":"http:\/\/purl.org\/dc\/terms\/creator","explain":"A Dublin Core Terms Property; An entity primarily responsible for making the resource.; Examples of a Contributor include a person, an organization, or a service."},{"label":"Creator","value":"Ryan, Michael B.","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/creator","classmap":"dpla:SourceResource","property":"dcterms:creator"},"iri":"http:\/\/purl.org\/dc\/terms\/creator","explain":"A Dublin Core Terms Property; An entity primarily responsible for making the resource.; Examples of a Contributor include a person, an organization, or a service."},{"label":"Creator","value":"Dien, Jason","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/creator","classmap":"dpla:SourceResource","property":"dcterms:creator"},"iri":"http:\/\/purl.org\/dc\/terms\/creator","explain":"A Dublin Core Terms Property; An entity primarily responsible for making the resource.; Examples of a Contributor include a person, an organization, or a service."},{"label":"Creator","value":"Scott, Alexander","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/creator","classmap":"dpla:SourceResource","property":"dcterms:creator"},"iri":"http:\/\/purl.org\/dc\/terms\/creator","explain":"A Dublin Core Terms Property; An entity primarily responsible for making the resource.; Examples of a Contributor include a person, an organization, or a service."},{"label":"Creator","value":"Hunt, Michael A.","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/creator","classmap":"dpla:SourceResource","property":"dcterms:creator"},"iri":"http:\/\/purl.org\/dc\/terms\/creator","explain":"A Dublin Core Terms Property; An entity primarily responsible for making the resource.; Examples of a Contributor include a person, an organization, or a service."}],"DateAvailable":[{"label":"Date Available","value":"2021-10-29T18:19:53Z","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/issued","classmap":"edm:WebResource","property":"dcterms:issued"},"iri":"http:\/\/purl.org\/dc\/terms\/issued","explain":"A Dublin Core Terms Property; Date of formal issuance (e.g., publication) of the resource."}],"DateIssued":[{"label":"Date Issued","value":"2021-10-06","attrs":{"lang":"","ns":"http:\/\/purl.org\/dc\/terms\/issued","classmap":"oc:SourceResource","property":"dcterms:issued"},"iri":"http:\/\/purl.org\/dc\/terms\/issued","explain":"A Dublin Core Terms Property; Date of formal issuance (e.g., publication) of the resource."}],"Description":[{"label":"Description","value":"Background\r\n                Lateral wedge insoles (LWI), standalone or with medial arch support (supported-LWI), have been thoroughly investigated for their effects on modifying gait biomechanics for people with knee osteoarthritis. However, plantar pressure distribution between these insole types has not been investigated and could provide insight towards insole prescription with concomitant foot symptoms taken into consideration.\r\n              \r\n              \r\n                Methods\r\n                In a sample of healthy individuals (n\u2009=\u200940), in-shoe plantar pressure was measured during walking with LWI, with or without medial arch support (variable- and uniform-stiffness designs), and a flat control insole condition. Pressure data from the plantar surface of the foot were divided into seven regions: medial\/lateral rearfoot, midfoot, medial\/central\/lateral forefoot, hallux. Plantar pressure outcomes assessed were the medial-lateral pressure index (MLPI) for the whole foot, and the peak pressure, pressure-time integral (PTI), and contact area in each plantar region. Comfort in each insole condition was rated as a change relative to the flat control insole condition. Repeated-measures analyses of variance were calculated to compare the plantar pressure outcomes between insole conditions.\r\n              \r\n              \r\n                Results\r\n                Regionally, medial rearfoot and forefoot pressure were reduced by all wedged insoles, with the variable-stiffness supported-wedge showing greater reductions than the standalone wedge. Lateral rearfoot and forefoot pressure were reduced by both supported-LWI, but unchanged by the standalone wedge. In the midfoot, the standalone wedge maintained pressure but reduced regional contact area, while both supported-LWI increased midfoot pressure and contact area. All LWI increased the MLPI, indicating a lateral shift in plantar pressure distribution throughout the weightbearing phase of gait. Comfort ratings were not significantly different between insole conditions.\r\n              \r\n              \r\n                Conclusions\r\n                Regional differences in plantar pressure may help determine an appropriate lateral wedge insole variation to avoid exacerbation of concomitant foot symptoms by minimizing pressure in symptomatic regions. Lateral shifts in plantar pressure distribution were observed in all laterally wedged conditions, including one supported-LWI that was previously shown to be biomechanically ineffective for modifying knee joint load distribution. Thus, shifts in foot centre of pressure may not be a primary mechanism by which LWI can modify knee joint load distribution for people with knee osteoarthritis.","attrs":{"lang":"en","ns":"http:\/\/purl.org\/dc\/terms\/description","classmap":"dpla:SourceResource","property":"dcterms:description"},"iri":"http:\/\/purl.org\/dc\/terms\/description","explain":"A Dublin Core Terms Property; An account of the resource.; Description may include but is not limited to: an abstract, a table of contents, a graphical representation, or a free-text account of the resource."}],"DigitalResourceOriginalRecord":[{"label":"Digital Resource Original Record","value":"https:\/\/circle.library.ubc.ca\/rest\/handle\/2429\/80128?expand=metadata","attrs":{"lang":"en","ns":"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO","classmap":"ore:Aggregation","property":"edm:aggregatedCHO"},"iri":"http:\/\/www.europeana.eu\/schemas\/edm\/aggregatedCHO","explain":"A Europeana Data Model Property; The identifier of the source object, e.g. the Mona Lisa itself. This could be a full linked open date URI or an internal identifier"}],"FullText":[{"label":"Full Text","value":"RESEARCH Open AccessAn exploration of changes in plantarpressure distributions during walking withstandalone and supported lateral wedgeinsole designsCalvin T. F. Tse1,2,3, Michael B. Ryan3,4, Jason Dien1, Alex Scott5 and Michael A. Hunt1,5*AbstractBackground: Lateral wedge insoles (LWI), standalone or with medial arch support (supported-LWI), have beenthoroughly investigated for their effects on modifying gait biomechanics for people with knee osteoarthritis.However, plantar pressure distribution between these insole types has not been investigated and could provideinsight towards insole prescription with concomitant foot symptoms taken into consideration.Methods: In a sample of healthy individuals (n = 40), in-shoe plantar pressure was measured during walking withLWI, with or without medial arch support (variable- and uniform-stiffness designs), and a flat control insolecondition. Pressure data from the plantar surface of the foot were divided into seven regions: medial\/lateralrearfoot, midfoot, medial\/central\/lateral forefoot, hallux. Plantar pressure outcomes assessed were the medial-lateralpressure index (MLPI) for the whole foot, and the peak pressure, pressure-time integral (PTI), and contact area ineach plantar region. Comfort in each insole condition was rated as a change relative to the flat control insolecondition. Repeated-measures analyses of variance were calculated to compare the plantar pressure outcomesbetween insole conditions.Results: Regionally, medial rearfoot and forefoot pressure were reduced by all wedged insoles, with the variable-stiffness supported-wedge showing greater reductions than the standalone wedge. Lateral rearfoot and forefootpressure were reduced by both supported-LWI, but unchanged by the standalone wedge. In the midfoot, thestandalone wedge maintained pressure but reduced regional contact area, while both supported-LWI increasedmidfoot pressure and contact area. All LWI increased the MLPI, indicating a lateral shift in plantar pressuredistribution throughout the weightbearing phase of gait. Comfort ratings were not significantly different betweeninsole conditions.\u00a9 The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you giveappropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate ifchanges were made. The images or other third party material in this article are included in the article's Creative Commonslicence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commonslicence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtainpermission directly from the copyright holder. To view a copy of this licence, visit http:\/\/creativecommons.org\/licenses\/by\/4.0\/.The Creative Commons Public Domain Dedication waiver (http:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/) applies to thedata made available in this article, unless otherwise stated in a credit line to the data.* Correspondence: michael.hunt@ubc.ca1Motion Analysis and Biofeedback Laboratory, University of British Columbia,Vancouver, BC, Canada5Department of Physical Therapy, University of British Columbia, Vancouver,BC, CanadaFull list of author information is available at the end of the articleTse et al. Journal of Foot and Ankle Research           (2021) 14:55 https:\/\/doi.org\/10.1186\/s13047-021-00493-5Conclusions: Regional differences in plantar pressure may help determine an appropriate lateral wedge insolevariation to avoid exacerbation of concomitant foot symptoms by minimizing pressure in symptomatic regions.Lateral shifts in plantar pressure distribution were observed in all laterally wedged conditions, including onesupported-LWI that was previously shown to be biomechanically ineffective for modifying knee joint loaddistribution. Thus, shifts in foot centre of pressure may not be a primary mechanism by which LWI can modify kneejoint load distribution for people with knee osteoarthritis.Keywords: Plantar pressure, Pressure distribution, Lateral wedge insole, Supported lateral wedgeBackgroundShoe-worn lateral wedge insoles (LWI) are simple toolsused to modify gait biomechanics in people with medialtibiofemoral osteoarthritis (knee OA). In this clinicalpopulation, conservative biomechanical interventionstypically target reductions in magnitudes of the knee ad-duction moment (KAM), a surrogate of knee load distri-bution linked to structural [1, 2] and clinical worseningof knee OA [3]. LWI, as standalone insoles or combinedwith medial arch supports (supported-LWI), have beenthoroughly investigated for their effect on the KAM,with a recent systematic review and meta-analysisreporting 5\u201310% reductions across various outcomes ofthe KAM during walking with various LWI designs [4].As a foot-based intervention, evaluating LWI for theireffects on modifying plantar pressure distribution wouldhelp inform other clinically-relevant features, such as re-gional loading and comfort.There is growing interest in concomitant foot andankle symptoms and their link to clinical features ofknee OA. Recent analyses of the Osteoarthritis Initiativedatabase have highlighted relationships between symp-tomatic knee OA and concomitant foot and ankle symp-toms, defined as pain, aching, or stiffness for more thanhalf of the days in the past 30 days [5\u20137]. Patients withknee OA and concomitant foot symptoms have exhib-ited poorer outcomes of overall health and physicalfunction at baseline [5], and a higher risk of worseningknee pain in the subsequent 4 years [7], compared toknee OA patients without concomitant foot symptoms.Further, in individuals at risk of developing knee OA,but asymptomatic and without radiographic signs atbaseline, the presence of foot and ankle symptoms in-creased the likelihood of developing knee pain andradiographic signs of OA over 4 subsequent years [6]. Aconsistent effect of LWI is increased ankle eversion andexternal eversion moment demands [4, 8, 9], withgreater angles of wedging also negatively affecting self-reported comfort [10, 11]. Supported-LWI have beenshown to be effective at minimizing ankle eversion ef-fects, while still reducing the KAM [8, 9, 12], and maybe preferred over a standalone LWI [13]. Consideringthe clinical concerns of concomitant foot symptoms inknee OA and that multiple LWI options havedemonstrated biomechanical efficacy, selecting an insolefor patients to avoid exacerbation of existing foot symp-toms appears to be paramount.Evaluations of pressure distribution underfoot withLWI have primarily reported lateral shifts in the centreof pressure (CoP) [9, 14, 15]. Lateralization of CoP is hy-pothesized to reduce the KAM by shifting the medially-oriented ground reaction force to shorten the frontalplane moment arm between the reaction force vectorand the knee joint. Shifts in CoP may not be a reliablemechanism of KAM reduction, however, since medialshifts in CoP have also been found to reduce the KAM,as seen with medial thrust gait [16] and laterally-wedgedfootwear (wedged externally on the outsole) [17]. Inves-tigations of KAM reduction often report CoP measuredby floor-mounted force platforms, which provide high fi-delity kinetic information about the interface betweenfootwear and the ground, necessary for calculating jointmoments. In comparison, flexible in-shoe pressure sen-sors provide a less expensive and portable method ofmeasuring pressure between the plantar foot surface andthe insole, in particular those with non-planar designs.With a method for plantar pressure assessment that isfeasible for clinical settings, relevant information aboutthe foot-insole interface could inform insole prescriptionwhen concomitant foot symptoms are present.Assessments of regional plantar pressure distributioncould provide insight into how redistribution of plantarpressure with insoles could influence perceived symp-toms. In people experiencing foot pain from work-related prolonged standing, contoured insoles shifted re-gional peak pressures from the rearfoot to the midfoot,and reduced sensations of pain, discomfort, and fatiguecompared to not wearing the insoles [18]. A cross-sectional exploration of patients with knee OA reportedthat greater knee pain was associated with increasedmedial plantar loading and midfoot contact area duringgait [19], which suggests plantar pressure distributioncould be linked to perceived symptoms in the lower limbwith knee OA. In-shoe measured plantar pressure effectsfor varus and valgus wedged insoles [20] and externally-wedged footwear [21] have reported lateral shifts inpressure with lateral foot posting. However, the regionalplantar pressure effects have not been evaluated forTse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 2 of 11supported-LWI, nor interpreted with the intent ofinforming insole treatment amongst concomitant footsymptoms. Therefore, the aim of this study was to ex-plore the effects of standalone LWI and supported-LWIon plantar pressure distribution and perceived comfortduring gait in healthy adults.MethodsThe current investigation is a complementary analysis ofplantar pressure and comfort data obtained during gaitanalysis of various LWI designed for knee OA. A sum-mary of the joint kinematic and kinetic outcomes forthese insoles were reported in Tse et al. [12], whichfound standalone medial arch supports increased theKAM. Similar findings of increased KAM with medialarch supports have been reported [22, 23], despite Hin-man et al. [23] reporting non-significant increases in asmall sample with large variability in KAM change. Forthis reason, standalone medial arch supports were ex-cluded from the current analysis of plantar pressure out-comes. However, outcomes across all insole conditionsare reported in Appendix 1 of supplementary materials.Additionally, the current sample size was justified for de-tecting a change in KAM with LWI from the affiliatedstudy [12]. Therefore, an additional sample size justifica-tion was not conducted for the current exploratory as-sessment of plantar pressure distribution and perceivedcomfort with standalone LWI and supported-LWI.ParticipantsA convenience sample of healthy adults from the univer-sity and surrounding community were recruited via elec-tronic and print media and word of mouth. Exclusioncriteria for study participation included any history oforthotic insole use in the 12 months prior to physicalscreening, or any musculoskeletal or neurological condi-tion that impaired gait at the time of testing. Ethics ap-proval for this study was received from the institutionalClinical Research Ethics Board. All participants receivedwritten and verbal explanations of the details prior toproviding written consent for study enrolment.Orthotic insolesFour pairs of sulcus length orthotics were custom-fabricated for each participant, using three-dimensionallaser volumetric casting by a Canadian Board-CertifiedPedorthist (Fig. 1). Non-contoured insoles fabricatedfrom ethyl-vinyl acetate foam (EVA) (Shore A stiffness55) included a neutral 3 mm flat control (FLAT) and 5\u00b0lateral wedge (WEDG). Two pairs of custom contouredarch support insoles were fabricated from the volumetriccasts: (1) variable-stiffness (V-ARCH) was constructedwith plastazote foam laterally (Shore A stiffness 70) andEVA medially (Shore A stiffness 20), (2) uniform-stiffness (U-ARCH) was constructed with EVA (Shore Astiffness 55). Two supported-LWI conditions were cre-ated by affixing each custom arch support to the top ofthe WEDG: WEDG+V-ARCH and WEDG+U-ARCH.All insoles were covered with a full-length piece of neo-prene and secured into a standardized sandal during allwalking trials (Fig. 1).ProcedureAll participants were randomly assigned a study limb ofinterest and fitted with standardized sandals to matchtheir foot dimensions. The sandals had a neutral heel totoe drop, Velcro straps to secure them to the feet, andremoveable footbeds, into which orthotic insoles couldFig. 1 Insoles and standardized sandal set-up used for walking trials. A 3 mm flat control (FLAT). B 5\u00b0 lateral wedge (WEDG). C Variable-stiffnessarch support (V-ARCH). D Uniform-stiffness arch support (U-ARCH). E Example of supported lateral wedge (WEDG+V-ARCH shown). F Sandal setupwith insole, neoprene topcover, and plantar pressure sensorTse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 3 of 11be fitted. Prior to collecting data during walking in eachinsole condition, participants were encouraged to accli-mate to the insole and sandals by walking freely and re-solving any fit abnormalities. For all participants theFLAT condition was tested first, and the five remaininginsole conditions were systematically randomized with aWilliams Design to account for possible order andcarry-over effects. Walking speed was measured usingtwo commercial photoelectric timing gates placed aknown distance apart, and self-selected walked speedwas established as the mean walking speed during walk-ing trials with FLAT. Walking trials were deemed suc-cessful if the speed was within 5% of the average walkingspeed with FLAT for all other conditions, and if thestudy limb foot struck the ground completely within theboundary of a floor-embedded force platform. A mini-mum of five successful walking trials along a 10 m walk-way were recorded in each insole condition.Data collection and reductionPlantar pressure was measured bilaterally using flexibleshoe-embedded sensors (F-Scan, Tekscan, Boston, MA,USA) at 100 Hz. All sensors were trimmed to match thesandal size and secured to the neoprene topcover withdouble-side tape to ensure consistent sensor placementamong insole conditions (Fig. 1). Each sensor detectspressure as an array of sensing units, with a surface arearesolution of 0.258 cm2 per sensing unit. Only data col-lected during the stance phase of gait were processedand analyzed. For each calculated outcome, the averageof five successful walking trials was calculated to repre-sent its value in each insole condition.Pressure data recorded by each sensing unit was fil-tered using a zero-lag 4th order low-pass Butterworthfilter with a 25 Hz cut-off. For faulty sensing units thatdetected non-physiological pressure, its data were re-placed with the time-series average of its eight neigh-bouring sensing units. A semi-automated maskingprogram was used to segment the foot into seven plantarregions: hallux, forefoot (medial, central, lateral), mid-foot, rearfoot (medial, lateral) (Fig. 2). All masks werevisually checked, and any erroneous regional masks weremanually corrected. For each plantar region, a represen-tative time-series pressure signal was calculated as theFig. 2 Representative plantar pressure map during a single stance phase.The coloured box overlays demarcate the complete pressure map intomultiple plantar regions used for calculating pressure outcomes. Reddashed line between the heel centroid and second toe delineates themidline of the foot. White crosses (+) denote the trajectory of the centre ofpressure (CoP) throughout stance phase. Green dashed lines demonstratehow the time-series medial-lateral pressure index is calculated as thedistance between the CoP and the foot midline (normalized to foot width).Positive and negative MLPI indicate a CoP that is lateral and medial to thefoot midline, respectivelyTse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 4 of 11average pressure of all active sensing units within the re-gion. From the regional time-series pressure data, thediscrete outcomes extracted for analysis included: peakpressure (kPa), pressure-time integral (kPa*sec), andtime of peak pressure (% stance). The contact area ineach plantar region was calculated as the sum of activesensing units in the region multiplied by the surface areaper unit.The medial-lateral pressure index (MLPI) representsthe medial-lateral plantar pressure distribution with re-spect to the midline of the foot (heel centroid to 2ndtoe) throughout stance phase (Fig. 2). For each frame ofdata, MLPI was calculated as the perpendicular distancebetween the centre of pressure (CoP) and the midline ofthe foot, normalized to the foot width [24]. Positive andnegative values indicate a CoP that is lateral or medial tothe midline of the foot, respectively. For each walkingtrial, the mean MLPI and area under the MLPI curve(AUC) during the first and second halves of stance phasewere calculated separately.Participants rated insole comfort on a 15-point globalrating of change scale [25]. Using the FLAT insole con-dition as the reference comparator, + 7 and \u2212 7 repre-sented a change in comfort that was maximally\u201cimproved\u201d or \u201creduced\u201d, respectively. Zero representedno change in comfort (equivalent to FLAT). Followingcompletion of walking trials in all insole conditions, par-ticipants selected one insole as their most preferred.Statistical analysisNormality was evaluated via visual inspection of histo-grams and supplemented with a Shapiro-Wilk test.Homogeneity of variance was evaluated via Mauchly\u2019stest of sphericity. For discrete outcomes of MLPI, re-gional plantar pressure, and comfort change, repeatedmeasures analyses of variance were used to test for dif-ferences between four insole conditions (FLAT, WEDG,WEDG+V-ARCH, WEDG+U-ARCH). Significant maineffects of insole condition were followed-up with posthoc Tukey\u2019s HSD pairwise comparisons. Statistical cal-culations were completed with jamovi version 1.6 [26],at an alpha level of \u03b1 = 0.05.ResultsForty healthy individuals participated in the study withthe following demographic information: 23 males, 17 fe-males, mean (SD) age = 26.6 (2.9) years, height = 173.5(8.6) cm, body mass = 71.2 (12.7) kg, BMI = 23.5 (2.8)kg\/m2. The median foot posture index was = 5 (25th per-centile = 2; 75th percentile = 9). All evaluated outcomessatisfied the assumptions for normality and homogeneityof variance. The following summarizes the outcomes forthe four conditions that were statistically compared(FLAT, WEDG, WEDG+V-ARCH, and WEDG+U-ARCH). An extended summary of discrete outcomes forall insoles can be found in Appendix 1 of supplementarymaterials.Regional plantar pressureLateral regional pressureLateral rearfoot and forefoot peak pressure andpressure-time integral were decreased with WEDG+V-ARCH (p < 0.05), when compared to FLAT. WEDG+V-ARCH also had lower peak pressure and pressure-timeintegral compared to WEDG (p < 0.05). WEDG+U-ARCH reduced the peak pressure in the lateral rearfootand the pressure-time integral in lateral forefoot, com-pared to FLAT (both p < 0.05). Discrete plantar pressureoutcomes for all regions are reported in Table 1, and en-semble average curves for the lateral rearfoot and fore-foot regions are found in Fig. 3a.Contact area in the lateral rearfoot was increased withWEDG+V-ARCH and WEDG+U-ARCH compared toFLAT (p < 0.05) and WEDG (p < 0.05). Lateral forefootcontact area decreased with supported-LWI WEDG+V-ARCH and WEDG+U-ARCH compared to FLAT (p <0.05). WEDG did not significantly change contact areain the lateral rear- or forefoot compared to FLAT (p \u22650.06). Discrete contact area values for all regions are re-ported in Table 1.Medial regional pressureMedial rearfoot and forefoot peak pressure andpressure-time integral were reduced by WEDG, WEDG+V-ARCH, and WEDG+U-ARCH (all p < 0.05) whencompared to FLAT. Both supported-LWI (WEDG+V-ARCH and WEDG+U-ARCH) also reduced medial rear-foot and forefoot peak pressure and pressure-time inte-gral compared to WEDG (p < 0.05). Ensemble averagecurves for the medial rear- and forefoot regions arefound in Fig. 3b.Contact area in the medial rearfoot decreased withWEDG, compared to FLAT (p < 0.05). The WEDG+V-ARCH and WEDG+U-ARCH increased medial rearfootcontact area when compared to WEDG (p < 0.05), butwere not different from FLAT. Medial forefoot contactarea was unchanged by any insole compared to FLAT(p \u2265 0.32).Midfoot pressureMidfoot peak pressure and pressure-time integral wereunchanged with WEDG (p \u2265 0.13), and increased withWEDG+V-ARCH (p < 0.05) and WEDG+U-ARCH (p <0.05), compared to FLAT. Ensemble average curves forthe region are found in Fig. 4.Compared to FLAT, midfoot contact area was in-creased with WEDG+V-ARCH and WEDG+U-ARCH(p < 0.05), while decreased with WEDG (p < 0.05).Tse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 5 of 11Medial-lateral pressure distributionThrough early and late stance phase, all laterally-wedgedinsole conditions (WEDG, WEDG+V-ARCH, WEDG+U-ARCH) shifted the medial-lateral plantar distributionlaterally, exhibiting increased mean and AUC MLPIcompared to FLAT (p < 0.05). Discrete values of MLPIare summarized in Table 2 and their corresponding en-semble average curves for all insole conditions are foundin Fig. 5.Comfort changeRated as a change in comfort compared to FLAT, thecomfort ratings for WEDG (mean [SD] = \u2212 1.2 [2.3]),WEDG+V-ARCH (mean [SD] = \u2212 0.8 [2.3]), andWEDG+U-ARCH (mean [SD] = \u2212 0.7 [2.5]) were not sig-nificantly different from each other (p \u2265 0.58).DiscussionIn the current study we assessed plantar pressure distri-butions of healthy individuals walking with LWI andsupported-LWI compared to a flat control insole. Theregional distribution of plantar pressure differed betweeninsole conditions. WEDG reduced medial rearfoot andforefoot pressure, while maintaining lateral rearfoot andforefoot pressures compared to FLAT. Meanwhile,WEDG+V-ARCH exhibited greater reductions in medialand lateral rearfoot and forefoot pressure than WEDG,and increased midfoot pressure and contact area com-pared to FLAT. Early and late stance phase MLPI wereincreased by all wedged insole conditions, indicative of alateral shift in CoP throughout the stance phase of gait.No differences in comfort were observed between insoleconditions. In light of the redistribution of plantar pres-sure between LWI conditions, insole prescription maybe best informed by its appropriateness for pre-existingfoot symptoms. Especially in patients with concomitantknee OA and foot symptoms, clinicians incorporatinginsoles for biomechanical intervention of medial tibiofe-moral OA should consider both kinetic effects at theknee and effects on pressures in plantar regions in theirclinical decision making.A speculated mechanism by which LWI reduce theKAM is through lateralization of the foot CoP, which re-duces the frontal plane moment arm between the kneejoint and the medially-oriented ground reaction forcevector. We found the LWI and supported-LWI increasedthe mean and AUC of MLPI by 1\u20134% of foot width (~1\u20134 mm) throughout stance phase, which is in agree-ment with the lateral shifts in CoP reported by previousworks that also evaluated gait with and without LWI,but that used force platform technology [9, 14, 15].While CoP lateralization appears to be involved in KAMreduction with LWI, it is unlikely to be the primarymechanism of effect. Hinman et al. reported only a weakcorrelation (r = 0.25) between the lateral shift in CoPwith LWI and change in KAM peak [15]. In the currentstudy we also found WEDG+U-ARCH had the largestlateral shifts in CoP, but was previously reported to beineffective at reducing the KAM [12]. In a different bio-mechanical assessment of medial thrust gait, a medialshift in CoP was found to be linearly related to KAM re-duction (r = 0.40\u20130.70) [16]. Considering theseTable 1 Regional plantar pressure outcomes by insole condition, reported as mean (standard deviation)Plantar Region Pressure Outcome FLAT WEDG WEDG + V-ARCH WEDG + U-ARCHLateral Rearfoot Peak Pressure (kPa) 133.0 (24.1) 132.6 (26.0) 122.0 (22.6) a,b 126.1 (23.4) aPressure-Time Integral (kPa*sec) 30.0 (6.4) 29.0 (5.3) 26.7 (5.5) a,b 28.3 (6.9)Contact Area (cm2) 18.7 (2.3) 18.1 (2.1) 19.5 (2.2) a,b 19.9 (2.6) a,bLateral Forefoot Peak Pressure (kPa) 106.1 (31.8) 108.6 (33.3) 85.6 (26.7) a,b 100.7 (32.2)Pressure-Time Integral (kPa*sec) 30.6 (10.4) 32.4 (10.7) 22.0 (7.3) a,b 26.8 (10.1) a,bContact Area (cm2) 12.9 (2.6) 12.6 (2.3) 12.2 (2.2) a 12.3 (2.2) aMedial Rearfoot Peak Pressure (kPa) 150.3 (23.2) 131.9 (26.1) a 105.3 (27.6) a,b 99.3 (21.5) a,bPressure-Time Integral (kPa*sec) 32.9 (6.7) 26.6 (5.8) a 21.4 (6.1) a,b 20.4 (5.2) a,bContact Area (cm2) 17.5 (2.1) 16.5 (2.1) a 17.9 (2.5) b 17.9 (2.8) bMedial Forefoot Peak Pressure (kPa) 125.3 (43.0) 105.4 (39.6) a 96.9 (34.2) a,b 93.4 (37.0) a,bPressure-Time Integral (kPa*sec) 30.1 (10.3) 23.4 (8.6) a 20.2 (7.3) a,b 18.3 (7.6) a,bContact Area (cm2) 14.4 (1.8) 13.9 (2.1) 14.5 (2.6) 14.7 (2.6)Midfoot Peak Pressure (kPa) 42.8 (11.8) 45.6 (10.6) 48.1 (12.9) a 48.0 (12.9) aPressure-Time Integral (kPa*sec) 14.1 (4.6) 15.5 (4.7) 16.2 (4.8) a 16.2 (5.2) aContact Area (cm2) 34.7 (8.7) 31.8 (7.7) a 50.9 (9.3) a,b 52.8 (9.1) a,bAll values reported as mean (standard deviation)a denotes a significant difference from FLAT (p < 0.05)b denotes a significant difference from WEDG (p < 0.05)Tse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 6 of 11Fig. 3 Ensemble average of the regional plantar pressure for the (a) lateral and (b) medial rearfoot (solid lines) and forefoot (dashed lines). Thecolours representing each insole condition are as follows: FLAT (black), WEDG (green), WEDG+V-ARCH (red), WEDG+U-ARCH (yellow)Tse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 7 of 11discrepant shifts in foot CoP and KAM reduction, it ispossible lateralizing CoP with LWI is less important toreducing the KAM than other alterations occurring be-tween the foot and knee, such as frontal plane tibial in-clination or knee angle. The frontal plane kneealignment during gait has been shown to completely me-diate the relationship between ankle eversion and magni-tudes of the KAM [27], which is relevant to how LWIcan alter KAM as a foot-based biomechanical interven-tion. It is important to acknowledge our investigationmeasured CoP with flexible in-shoe sensors atop non-planar insole surfaces, which may differ from CoP mea-sured by floor-mounted force plates. Nonetheless, thevalue of in-shoe plantar pressure assessment of LWImay be more relevant to considerations regardingregional pressure changes that could impact comfort orexisting foot symptoms.The growing concern between concomitant foot andankle symptoms and poorer clinical features of knee OA[5, 7] highlights a need for LWI intervention tominimize the likelihood of generating or exacerbatingfoot symptoms. Our affiliated evaluation of the insolesfrom this study found WEDG and WEDG+V-ARCH tobe effective at KAM reduction [12]. Differences in theregional plantar pressure profiles may help inform whichof these two LWI could be more appropriate for bio-mechanical intervention in patients experiencing con-comitant foot symptoms. For example, in the WEDGcondition, peak pressure and PTI were maintained inthe lateral rearfoot and forefoot, but reduced in theTable 2 Medial-Lateral Pressure Index (MLPI) outcomes by insole conditionMLPI Outcome FLAT WEDG WEDG + V-ARCH WEDG + U-ARCHEarly Stance Mean (% foot width) 3.2 (2.9) 5.5 (2.5) a 5.8 (3.0) a 6.9 (3.0) a,bAUC (% foot width * sec) 1.0 (0.9) 1.8 (0.8) a 1.9 (1.0) a 2.3 (1.0) a,bLate Stance Mean (% foot width) \u22122.5 (5.7) 0.5 (6.0) a \u22120.4 (5.9) a 0.9 (6.2) aAUC (% foot width * sec) \u22120.8 (1.9) 0.2 (2.0) a \u22120.1 (2.0) a 0.4 (2.1) aAll values reported as mean (standard deviation)Positive (lateral) and negative (medial) values indicate the centre of pressure position relative to the midline of the foota denotes a significant difference from FLAT (p < 0.05)b denotes a significant difference from WEDG (p < 0.05)Fig. 4 Ensemble average of the regional plantar pressure for the midfoot. The colours representing each insole condition are as follows: FLAT(black), WEDG (green), WEDG+V-ARCH (red), WEDG+U-ARCH (yellow)Tse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 8 of 11medial rearfoot and forefoot, compared to FLAT. Mean-while, WEDG+V-ARCH exhibited greater reductions inthe medial and lateral rearfoot and forefoot than WEDG,with lower peak pressure and PTI (Fig. 3 & Table 1).The arch contouring and variable-stiffness design ofWEDG+V-ARCH appeared to be redistributing pressurefrom the rearfoot and forefoot into the midfoot, whichwas seen as greater midfoot peak pressure, PTI, and con-tact area compared to FLAT (Fig. 4 & Table 1). Previ-ously, increased medial and decreased lateral peak footforces during walking have been associated with greaterself-reported knee pain in symptomatic patients withknee OA [19]. As such, the observed pattern for WEDGand WEDG+V-ARCH to redistribute plantar pressurelaterally by reducing medial pressures may be relevant tothe treatment of medial knee OA. Selecting a LWI tominimize regional pressures based on patients\u2019 existingfoot symptoms may also be less likely to elicit adversereactions to insole treatment. With the pressure distri-butions reported, patients experiencing symptoms in therearfoot or forefoot may be better suited for WEDG+V-ARCH, since pressure in these affected plantar regionsare considerably lower, and less likely to exacerbatesymptoms. In contrast, patients experiencing symptomsin the midfoot region may be better suited for WEDGalone, since this insole does not significantly increasemidfoot pressure compared to FLAT. Future clinical trialwork examining this potential impact on clinical care isneeded to confirm these preliminary findings fromyoung, healthy individuals.Ratings of comfort change relative to FLAT were notsignificantly different between any of the LWI condi-tions. These insoles were tested over a period of 10\u201315min per insole condition, using a small sample (n = 40)of healthy individuals that did not use orthotic insoleshabitually. As such, it is unsurprising that average com-fort ratings for all LWI ranged between 0 (no change)and \u2212 1 on a \u2212 7 to + 7 scale. Evaluating insole comfortin healthy individuals provides foundational informationprior to use in clinical populations that could have con-comitant foot pathologies. Future research in the com-fort effects of these LWI would benefit from longerstudy durations and using cohorts of patients with kneeOA. As previously mentioned, only WEDG and WEDG+V-ARCH reduced the KAM [12]. Until we know other-wise with data from patients with knee OA, these insolescan perhaps be treated equivalently for their biomechan-ical efficacy, and the prescription of either LWI shouldprioritize minimizing regional pressures and improvingsubjective comfort.Findings from this study should be interpreted withinthe context of several limitations. Firstly, healthy adultswithout a history of orthotic use were recruited for thisexploratory study of plantar pressure changes with LWIFig. 5 Ensemble average of the medial-lateral pressure index throughout stance phase for all insole conditions. Positive and negative MLPI indicate aCoP that is lateral or medial to the foot midline, respectively. The colours representing each insole condition are as follows: FLAT (black), WEDG (green),WEDG+V-ARCH (red), WEDG+U-ARCH (yellow)Tse et al. Journal of Foot and Ankle Research           (2021) 14:55 Page 9 of 11and supported-LWI, intended for patients with kneeOA. While it is imperative future investigations be con-ducted within the target clinical population to assess theeffects on pain and other clinically-relevant outcomes,our findings did not demonstrate any immediate effectsof plantar pressure distribution or comfort that wouldpose any major risk of adverse effects with insole use. In-deed, current clinical guidelines [28] for management ofknee OA do not necessarily support the use of LWIs forknee OA \u2013 based primarily on contradictory findings ofpain improvement [29]. While any biomechanical bene-fits of these devices are generally not considered in theseguideline recommendations, our current findings doprovide new evidence that may be used in such deci-sions. Next, we used flexible in-shoe pressure sensors tomeasure plantar pressure distribution from a non-planarsurface at the foot-insole interface, which may not reflectthe CoP measured by floor-mounted force platforms orpressure mats. Indeed, floor-measured data providesCoP data necessary for evaluations of mechanisms ofKAM reduction. However, we demonstrated in-shoepressure sensors are a cost-effective method to obtainregional pressure distribution information that could in-form the insole prescription process amidst consider-ations of existing foot symptoms. Finally, while longeracclimatization periods with insoles are common forclinical practice (~ 2\u20134 weeks), the number of insoleconditions insoles that we tested prevented us fromdoing so within the current study design. However, par-ticipants were encouraged to take as long as they feltwas necessary to adjust to the sensation of each neworthotic, prior to collection of gait trials.ConclusionIn our exploration of plantar pressure in healthy adultswalking with LWI, with or without medial arch support,the data demonstrated pressure distributions that maystreamline the selection process for which type of LWIto implement for biomechanical intervention. All LWIshifted the medial-lateral distribution laterally, includingthe WEDG+U-ARCH which was previously shown to beineffective at reducing the KAM. Therefore, shifts in footCoP may not be the primary mechanism by which LWIcan reduce the KAM. Regional plantar pressure distribu-tions point towards using the WEDG+V-ARCH for indi-viduals experiencing foot symptoms in the rearfoot andforefoot, and the WEDG for individuals experiencingfoot symptoms in the midfoot. Since comfort ratings didnot differ between insole conditions, the proposed ar-rangement of LWI recommendations aims to reducepressures in the associated plantar region and minimizethe chance of exacerbating concomitant foot symptomsin patients with knee OA.AbbreviationsAUC: Area under curve; CoP: Centre of pressure; EVA: Ethyl vinyl acetatefoam; FLAT: 3 mm EVA flat control insole; KAM: Knee adduction moment;Knee OA: Medial tibiofemoral osteoarthritis; kPa: kilopascal, unit of pressure;kPa*sec: product of kilopascal and time, unit of cumulative pressure overtime; LWI: Lateral wedge insole; MLPI: Medial-lateral pressure index;PTI: Pressure-time integral; Supported-LWI: Lateral wedge insole with medialarch support; U-ARCH: Uniform-stiffness contoured arch support insole; V-ARCH: Variable-stiffness contoured arch support insole; WEDG: 5\u00b0 lateralwedge insole; WEDG+U-ARCH: Lateral wedge with uniform-stiffness con-toured arch support insole; WEDG+V-ARCH: Lateral wedge with variable-stiffness contoured arch support insoleSupplementary InformationThe online version contains supplementary material available at https:\/\/doi.org\/10.1186\/s13047-021-00493-5.Additional file 1.AcknowledgmentsThe authors would like to thank Natasha Krowchuk for assistance during thedata acquisition process.Authors\u2019 contributionsCTFT, MBR, AS, MAH contributed to the study conceptualization,methodology, and manuscript preparation (draft, review, edit). CTFT and JDwere responsible for the data acquisition, processing, and analysis. MBR andMAH acquired study funding. The authors read and approved the finalmanuscript.FundingThis study and contributing authors received funding from the NaturalSciences and Engineering Research Council of Canada, Canadian Institutes ofHealth Research, and the Michael Smith Foundation for Health Research.Pedorthic assessment services and orthotic insoles were provided by KintecFootlabs Inc.Availability of data and materialsThe datasets used and\/or analyzed during the current study are availablefrom the corresponding author on reasonable request.DeclarationsEthics approval and consent to participateThe study was approved by the University of British Columbia ClinicalResearch Ethics Board (H16\u201301793). All participants provided written andinformed consent prior to study participation.Consent for publicationNot applicable.Competing interestsAuthors CT and MR are employed by Kintec Footlabs Inc., a companyproviding orthotic services. However, these authors do not receive any directbenefit from this research that could potentially bias these study results. Theauthors declare no other professional or financial affiliations that may bepotential conflicts of interest.Author details1Motion Analysis and Biofeedback Laboratory, University of British Columbia,Vancouver, BC, Canada. 2Graduate Programs in Rehabilitation Sciences,University of British Columbia, Vancouver, BC, Canada. 3Kintec Footlabs Inc,Surrey, BC, Canada. 4Department of Biomedical Physiology and Kinesiology,Simon Fraser University, Burnaby, BC, Canada. 5Department of PhysicalTherapy, University of British Columbia, Vancouver, BC, Canada.Tse et al. 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Recommended best practice is to use a controlled vocabulary."},{"label":"Subject","value":"Supported lateral wedge","attrs":{"lang":"en","ns":"http:\/\/purl.org\/dc\/terms\/subject","classmap":"dpla:SourceResource","property":"dcterms:subject"},"iri":"http:\/\/purl.org\/dc\/terms\/subject","explain":"A Dublin Core Terms Property; The topic of the resource.; Typically, the subject will be represented using keywords, key phrases, or classification codes. Recommended best practice is to use a controlled vocabulary."}],"Title":[{"label":"Title ","value":"An exploration of changes in plantar pressure distributions during walking with standalone and supported lateral wedge insole designs","attrs":{"lang":"en","ns":"http:\/\/purl.org\/dc\/terms\/title","classmap":"dpla:SourceResource","property":"dcterms:title"},"iri":"http:\/\/purl.org\/dc\/terms\/title","explain":"A Dublin Core Terms Property; The name given to the resource."}],"Type":[{"label":"Type","value":"Text","attrs":{"lang":"en","ns":"http:\/\/purl.org\/dc\/terms\/type","classmap":"dpla:SourceResource","property":"dcterms:type"},"iri":"http:\/\/purl.org\/dc\/terms\/type","explain":"A Dublin Core Terms Property; The nature or genre of the resource.; Recommended best practice is to use a controlled vocabulary such as the DCMI Type Vocabulary [DCMITYPE]. 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Recommended best practice is to use an encoding scheme, such as the W3CDTF profile of ISO 8601 [W3CDTF].; A point or period of time associated with an event in the lifecycle of the resource.; Date may be used to express temporal information at any level of granularity. Recommended best practice is to use an encoding scheme, such as the W3CDTF profile of ISO 8601 [W3CDTF]."}]}