In-shoe Pressure Research Articles

Effect of rocker shoes on plantar pressure pattern in healthy female runners

Rocker profile shoes (rocker shoes) are one of the treatment options of metatarsalgia and forefoot stress fractures. The efficacy of rocker shoes in unloading the forefoot pressure has been shown in walking. In running, however, the effect of rocker shoes on forefoot pressure is unknown. Eighteen healthy female runners participated in this study. In-shoe plantar pressures were recorded during running with the standard running shoes and rocker shoes. Shoe comfort was assessed after each shoe measurement. Peak pressure (PP), maximum mean pressure (MMP) and force-time integral (FTI) were determined for seven foot areas. The effects of shoes on the different outcome variables were statistically analyzed using a linear mixed model. Running with the rocker shoes caused a significant reduction (p<0.001) in all pressure parameters in the central and lateral forefoot. FTI and MMP were also reduced by 11% and 12% in the medial forefoot while running with rocker shoes. Running with rocker shoes resulted in a significant increase in all pressure parameters at the heel region (p<0.001). Running with rocker shoes received a significant (p<0.01) lower comfort rate than running with standard running shoes. Rocker shoes might be beneficial for runners who are recovering from metatarsalgia or stress fractures of the forefoot region, as it reduces plantar pressure in the forefoot region.

A Gait Recognition System using GA-based C-SVC and Plantar Pressure

In order to conduct the gait recognition system, a wireless in-shoe wearable plantar pressure acquisition system based on ATmega16 and 8 FSR sensors was applied to data acquisition for the gaits which consist of standing, walking, jumping and going upstairs. And four volunteers (2 females and 2 males) were invited in this research to collect the pressure information. MATLAB and LIBSVM were applied to conduct all algorithms proposed by this study. Genetic Algorithm (GA) was used to set the best tuning (penalty) parameter and the best (gamma) of Gauss radial basis kernel (RBF) for C-support vector classification (C-SVC) model and the GA-based C-SVC was obtained. A dataset named ‘train-data’, containing 800 sets of pressure data was used to train the GA-based C-SVC as the algorithm of gait recognition. Finally a testing dataset containing 400 sets of pressure data was applied to test the algorithm of gait recognition called GA-based C-SVC. The accuracy of this GA-based C-SVC was 98% for standing, 91% for walking, 82% for going-upstairs and 97% for jumping. In generally speaking, a better GA-based C-SVC was obtained in this research. DOI: http://dx.doi.org/10.11591/telkomnika.v11i10.2962

Diabetic foot ulcer incidence in relation to plantar pressure magnitude and measurement location

AimsWe prospectively examined the relationship between site-specific peak plantar pressure (PPP) and ulcer risk. Researchers have previously reported associations between diabetic foot ulcer and elevated plantar foot pressure, but the effect of location-specific pressures has not been studied. MethodsDiabetic subjects (n=591) were enrolled from a single VA hospital. Five measurements of in-shoe plantar pressure were collected using F-Scan. Pressures were measured at 8 areas: heel, lateral midfoot, medial midfoot, first metatarsal, second through fourth metatarsal, fifth metatarsal, hallux, and other toes. The relationship between incident plantar foot ulcer and PPP or pressure–time integral (PTI) was assessed using Cox regression. ResultsDuring follow-up (2.4years), 47 subjects developed plantar ulcers (10 heel, 12 metatarsal, 19 hallux, 6 other). Overall mean PPP was higher for ulcer subjects (219 vs. 194kPa), but the relationship differed by site (the metatarsals with ulcers had higher pressure, while the opposite was true for the hallux and heel). A statistical analysis was not performed on the means, but hazard ratios from a Cox survival analysis were nonsignificant for PPP across all sites and when adjusted for location. However, when the metatarsals were considered separately, higher baseline PPP was significantly associated with greater ulcer risk; at other sites, this relationship was nonsignificant. Hazard ratios for all PTI data were nonsignificant. ConclusionsLocation must be considered when assessing the relationship between PPP and plantar ulceration.

Effects of shoe sole hardness on plantar pressure and comfort in older people with forefoot pain

Plantar forefoot pain is common in older people and is related to increased peak pressures under the foot during gait. Variations in the hardness of the shoe sole may therefore influence both the magnitude of loading under the foot and the perceived comfort of the shoe in this population. The aim of this investigation was to determine the effect of varying shoe sole hardness on plantar pressures and comfort in older people with forefoot pain. In-shoe plantar pressures under the forefoot, midfoot and rearfoot were recorded from 35 older people (mean age 73.2, SD 4.5 years) with current or previous forefoot pain using the pedar-X® system. Participants walked at their normal comfortable speed along an 8m walkway in shoes with three different levels of sole hardness: soft (Shore A25), medium (Shore A40) and hard (Shore A58). Shoe comfort was measured on a 100mm visual analogue scale. There were statistically significant differences in peak pressure of between 5% and 23% across the forefoot, midfoot and rearfoot (p<0.01). The hard-soled shoe registered the highest peak pressures and the soft-soled shoe the lowest peak pressures. However, no differences in comfort scores across the three shoe conditions were observed. These findings demonstrate that as shoe sole hardness increases, plantar pressure increases, however this does not appear to have a significant effect on shoe comfort.

Plantar Pressures, Plantar Forces, and Their Influence on the Pathogenesis of Diabetic Foot Ulcers

Clinical recommendations for the prevention and healing of diabetic foot ulcers (DFUs) are somewhat clear. However, assessment and quantification of the mechanical stress responsible for DFU remain complex. Different pressure variables have been described in the literature to better understand plantar tissue stress exposure. This article reviews the role of pressure and shear forces in the pathogenesis of plantar DFU. We performed systematic searches of the PubMed and Embase databases, completed by a manual search of the selected studies. From 535 potentially relevant references, 70 studies were included in the full-text review. Variables of plantar mechanical stress relate to vertical pressure, shear stress, and temporality of loading. At this time, in-shoe peak plantar pressure (PPP) is the only reliable variable that can be used to prevent DFU. Although it is a poor predictor of in-shoe PPP, barefoot PPP seems complementary and may be more suitable when evaluating patients with diabetes mellitus and peripheral neuropathy who seem noncompliant with footwear. An in-shoe PPP threshold value of 200 kPa has been suggested to prevent DFU. Other variables, such as peak pressure gradient and peak maximal subsurface shear stress and its depth, seem to be of additional utility. To better assess the at-risk foot and to prevent ulceration, the practitioner should integrate quantitative models of dynamic foot plantar pressures, such as in-shoe and barefoot PPPs, with the regular clinical screening examination. Prospective studies are needed to evaluate causality between other variables of mechanical stress and DFUs.

Effect of overground vs treadmill running on plantar pressure: Influence of fatigue

The differences produced when running on a treadmill vs overground may call into question the use and validity of the treadmill as a piece of equipment commonly used in research, training, and rehabilitation.The aim of the present study was to analyze under pre/post fatigue conditions the effect of treadmill vs overground on plantar pressures. Twenty-seven recreational runners (17 men and 10 women) ran on a treadmill and overground at two speeds: S1=3.33m/s and S2=4.00m/s, before and after a fatigue protocol consisting of a 30-min run at 85% of their individual maximal aerobic speed (MAS). Contact time (CT in seconds), peak pressure (PP in kPa), and relative load (RL in %) were analyzed under nine foot zones of the left foot using an in-shoe plantar pressure device.A two-way repeated measures ANOVA showed that running on a treadmill increases CT (7.70% S1 and 9.91% S2), modifies the pressure distribution and reduces PP (25.98% S1 and 31.76% S2), especially under the heel, medial metatarsals, and hallux, compared to running overground. Moreover, on both surfaces, fatigue (S2) led to a reduced stride frequency (2.78%) and reduced PP on the lateral heel and hallux (15.96% and 16.35%, respectively), and (S1) increased relative load on the medial arch (9.53%). There was no significant interaction between the two factors analyzed (surface and fatigue). Therefore, the aforementioned surface effect, which occurs independently of the fatigue state, should be taken into account when interpreting the results of studies that use the treadmill in their experimental protocols, and when prescribing physical exercise on a treadmill.

The effects of focused-rigidity casts on forefoot plantar pressures: a pilot investigation

To establish if focused rigidity casts (FRCs) reduce forefoot pressures in healthy participants, and to examine the effects of FRCs on contact area, contact pressure, peak pressure and force–time integral on the forefoot and the plantar pressures of the whole foot in participants with differing foot posture. Thirty-one healthy participants were recruited from a convenience sample of university staff and students. This study employed a repeated measures design, where walking in FRCs was compared with a control (canvas shoe). An in-shoe pressure measuring system was used to record changes in plantar pressure and the foot posture index was used to record foot posture. A statistically significant reduction in contact pressure (p ≤ 0.000; n=31) and peak pressures(p ≤ 0.002; n=31) was observed in the forefoot. A statistically significant reduction in contact area and contact pressure over the whole foot and rear foot when participants wore the FRC was also found. The greatest decrease occurred in participants with a supinated foot posture while the least occurred in participants with a pronated foot posture. An increase in peak pressure was found in the mid foot for participants with a normal and supinated foot postures when the FRC was worn. The results suggest that FRCs are an effective way of reducing forefoot pressures when compared with the control shoe. FRC’s work by redistributing pressure away from the forefoot to the area of increased rigidity beneath the cast.

Changes in Dynamic Plantar Pressure During Loaded Gait

Lower extremity overuse injuries are detrimental to military readiness. Extremes of arch height and heavy loads carried by military personnel are associated with increased risk for overuse injury. Little is known regarding the impact of load carriage on plantar pressure distributions during gait. The objective of this study was to determine how load carriage affects plantar pressure distributions during gait in individuals with varying arch types. A cross-sectional, repeated-measures design was used for the study. The study was performed at a research laboratory at Fort Sam Houston, Texas. Service members who were healthy and weighing ≥70 kg were enrolled in the study. The participants (97 men, 18 women; mean age=31.3 years, SD=5.6; mean weight=86.0 kg, SD=11.0) were categorized as having high-, normal-, or low-arched feet on the basis of published cutoff values for the arch height index. Plantar pressure measurements were obtained with the use of an in-shoe pressure measurement system while participants wore combat boots and walked on a treadmill under 3 loaded conditions (uniform, 20-kg load, and 40-kg load). Maximal force (MaxF) and force-time integral (FTI) were assessed with the use of a 9-sector mask to represent regions of the foot. A 3 × 3 repeated-measures analysis of variance was used for analysis across the levels of load and arch type. A significant interaction existed between arch type and load for MaxF and FTI in the medial midfoot, with greater force in low-arched feet. In the medial forefoot, MaxF and FTI were greatest in high-arched feet across all load conditions. In the great toe region, low-arched and normally arched feet had greater MaxF and FTI. The relative distribution of FTI increased proportionately in all regions of the foot regardless of arch type for all load conditions. The influence of fatigue, greater loads, and different walking speeds was not assessed. Regardless of arch type, increases in load did not alter the relative distribution of force over the plantar foot during gait. Participants with high-arched feet had greater force in the medial forefoot region, whereas those with normally arched or low-arched feet had greater force in the great toe region, regardless of load. These differences in force distribution may demonstrate different strategies to generate a rigid lever during toe-off.

Foot Center of Pressure Trajectory Alteration by Biomechanical Manipulation of Shoe Design

Footwear-generated biomechanical manipulations have been shown to alter lower limb kinetics. It has been suggested that this is due to altered trajectory of the foot's center of pressure (COP), conveying a shift in location of the ground reaction force and modifying moments and forces acting on proximal body segments. However, past studies have focused on qualitative association between footwear design and the COP locus. Moreover, this association was calculated via indirect analysis. The purpose of the present study was to directly examine and quantify the correlation between measured footwear biomechanical manipulation and the location of the COP trajectory during gait. A novel biomechanical device allowing flexible positioning of 2 convex-shaped elements attached to its sole was utilized. A total of 20 healthy male adults underwent direct in-shoe pressure measurements while walking with the device set at 7 mediolateral configurations. COP data were collected during gait and analyzed with respect to different stance subphases. COP location significantly correlated with a shift of the elements medially or laterally. The linear model describing this correlation was found to be statistically significant. There was significant correlation between the plantar orientation of the shoe device configuration and the COP. Changes in COP trajectory may be valuable in patients suffering from multiple foot disorders elevating pressure on the foot. Accurate COP control could aid in the manipulation of the forces acting on the proximal joints during gait. In addition, these findings may have implications in the field of biomechanical apparatus design and practice.

Biofeedback can reduce foot pressure to a safe level and without causing new at‐risk zones in patients with diabetes and peripheral neuropathy

Plantar pressure reduction is mandatory for diabetic foot ulcer healing. Our aim was to evaluate the impact of a new walking strategy learned by biofeedback on plantar pressure distribution under both feet in patients with diabetic peripheral neuropathy. Terminally augmented biofeedback has been used for foot off-loading training in 21 patients with diabetic peripheral sensory neuropathy. The biofeedback technique was based on a subjective estimation of performance and objective visual feedback following walking sequences. The patient was considered to have learned a new walking strategy as soon as the peak plantar pressure (PPP) under the previously defined at-risk zone was within a range of 40-80% of baseline PPP in 70% of the totality of steps and during three consecutive walking sequences. The PPP was measured by a portable in-shoe foot pressure measurement system (PEDAR(®)) at baseline (T0), directly after learning (T1) and at 10-day retention test (T2). The PPP under at-risk zones decreased significantly at T1 (165 ± 9 kPa, p < 0.0001) and T2 (167 ± 11, p = 0.001), as compared with T0 (242 ± 12 kPa) without any increase of the PPP elsewhere. At the contralateral foot (not concerned by off-loading), the PPP was slightly higher under the lateral midfoot at T1 (68 ± 8 kPa, p = 0.01) and T2 (65 ± 8 kPa, p = 0.01), as compared with T0 (58 ± 6 kPa). The foot off-loading by biofeedback leads to a safe and regular plantar pressure distribution without inducing any new 'at-risk' area under both feet.

1P1-E03 靴内部における剪断力・圧力の同時測定法の開発(看護とメカトロニクス)

1P1-E03 靴内部における剪断力・圧力の同時測定法の開発(看護とメカトロニクス)

Fifty years after Zamosky's article "Shoe modifications in lower-extremity orthotics"

The art and science of correcting foot deformities is still a mixture of tradition, skill, and the doctor's professional convictions [1]. Zamosky's 1964 article on various shoe modifications in lower-extremity orthotics starts with this observation [1]. Reflecting on 50 years of development in this field, we ask ourselves, Have the ingredients of this mixture changed? Computer-aided design and computer aided manufacturing [2] have changed the elements of the ingredient artisan However, creating a last from which shoe modifications are fabricated remains an skill, as reflected by the ongoing debate over the relatively low intra- and intercaster reliability [34]. The implicit knowledge of the skill still seems to be too complicated to translate into an explicit computer-aided skill. Other technological advancements involve new objective systems. In-shoe pressure systems show promise for analyzing the effect of shoe modifications on plantar pressure distribution [5]. Advanced gait analysis systems provide the option to analyze gait performance before and after shoe modifications [6]. Objective measurement is a new ingredient in the mixture. Patient perspective is another ingredient that can be added to Zamosky's mixture. Even when a shoe is perfectly modified, it is only effective if worn. As such, patients have an increased role in their own care compared with 50 years ago. This is reflected in studies with patient-reported outcomes as a primary outcome measure [7-8], together with a shift in practice from a product-oriented toward a patient oriented method of and providing shoes. The remaining ingredients--tradition, clinical experience, and prescribing doctor's professional convictions--are preferably balanced by reference to evidence-based guidelines. Although national protocols [9] or disorder-specific algorithms [10] can be found, an international guideline for and providing shoe modifications is an important gap in the literature. To progress from tradition and evidence-based guidelines need to be developed. Fifty years after Zamosky's article, the ingredients of his mixture for and providing shoe modifications have changed in-line with advancing technology and changes in patients' role in their own care. The evidence base in this field will continue to profit from the addition of objective measurements and patientreported outcomes, yet the lack of international guidelines is a reason for concern. …

Navicular stress fracture injury: observational use of plantar pressure measures in elite AFL footballers

Background Navicular stress fracture (NSF) is a relatively uncommon injury according to Australian Rules Football (AFL) injury surveillance data. Like all stress fractures, a disproportionate amount of compression / strain (dose) versus remodeling (response) accounts for bone breakdown. The exact mechanism of injury or anthropometric factors involved in navicular stress fracture remains largely unknown however; several authors speculate a short first metatarsal and metatarsus adductus as contributing factors. It is thought that a long second metatarsal transmits forces unevenly through the medial cuneiform creating shearing stress at the avascular central zone of the navicular. To date no prospective data is available to support these theories. Navicular stress fracture is deemed high risk due to the potential of delayed or non union and often excessive time away from activity. Methods Retrospective plantar pressure mapping of two elite AFL footballers who’d sustained NSF injury were recorded. Testing involved unshod across a floor mounted pressure sensing mat (EMED SF™, Novel Munich Germany) using a two-step method following familiarisation. Five (5) trials were performed for each foot with the averages of the middle three (3) trials used for further analyses. Subsequent testing using an in-shoe pressure mapping system, (EMED ™ Pedar,Novel Munich Germany) was performed with custom moulded foot orthoses in situ. Data from twenty (20) steps were recorded, allowing for acceleration and deceleration with the middle ten (10) steps used for further analyses. Computer software generated data for Peak Pressure across 10 masked areas (kPa), Instant to Peak Pressure (ms), Contact Area (cm 2 ), Force and Pres

Effects of Anti-Fatigue Mats on Perceived Discomfort and Weight-Shifting During Prolonged Standing

The aim of this experiment was to investigate the effects of anti-fatigue mats on perceived discomfort and behavioral responses (weight-shifting between the feet) during prolonged standing. Prolonged standing is a common requirement in the workplace and is a well-known cause of discomfort. Anti-fatigue mats have been shown to reduce discomfort resulting from standing, but no study has identified a particular mat that performs better than others or examined the relationship between discomfort and weight-shifting. Participants stood for 4 hours on four commercially available "anti-fatigue" mats and a hard surface (control condition). Subjective ratings of discomfort were measured, and in-shoe pressure was recorded and used to evaluate weight-shifting during standing. Compared to the control condition, after 4 hours of standing discomfort was reduced by three of the four mats, but discomfort ratings did not significantly differ among mats. However, significant differences among mats were found in the frequency of weight-shifting, and weight-shifting was positively correlated to discomfort. These results suggest that subjective reports of discomfort were not sufficiently sensitive to detect differences among mats for the experimental conditions tested. Behavioral responses, specifically weight-shifting between feet, may provide a more sensitive alternative to subjective reports.

Offloading effect of therapeutic footwear in patients with diabetic neuropathy at high risk for plantar foot ulceration

Custom-made therapeutic footwear is often prescribed to patients with diabetic neuropathy, foot deformity and a healed plantar foot ulcer. Offloading these feet is important to prevent ulcer recurrence. The aim was to evaluate the offloading effect of custom-made footwear in these patients. In 171 patients with diabetic neuropathy (336 feet) with foot deformity and a recently healed plantar foot ulcer, plantar pressures walking barefoot and inside new custom-made footwear were measured. At the previous ulcer location and at locations of highest barefoot pressure attributable to the deformity, in-shoe pressures were compared with non-deformed feet. The footwear was considered effective in offloading when in-shoe peak pressure at these locations was < 200 kPa. Mean in-shoe peak pressures ranged between 211 and 308 kPa in feet with forefoot deformity (vs. 191-222 kPa in non-deformed feet) and between 140 and 187 kPa in feet with midfoot deformity (vs. 112 kPa in non-deformed feet). Offloading was effective in 61% of all feet with deformity, 81% of feet with midfoot deformity, 44% of feet with forefoot deformity and 62% of previous ulcer locations. Inter-subject variability in measured in-shoe plantar pressure was large. Offloading in custom-made footwear is often not sufficiently achieved in high-risk diabetic feet with deformity. Highest offloading success rates were seen at known high-risk locations such as previous ulcer locations and Charcot feet, the lowest success rates in forefoot deformities. Together with the large inter-subject variability in pressure outcomes, this emphasizes the need for evidence-based prescription and evaluation procedures to assure adequate offloading.

Pressure‐reduction and preservation in custom‐made footwear of patients with diabetes and a history of plantar ulceration

To assess the value of using in-shoe plantar pressure analysis to improve and preserve the offloading properties of custom-made footwear in patients with diabetes. Dynamic in-shoe plantar pressures were measured in new custom-made footwear of 117 patients with diabetes, neuropathy, and a healed plantar foot ulcer. In 85 of these patients, high peak pressure locations (peak pressure > 200 kPa) were targeted for pressure reduction (goal: > 25% relief or below an absolute level of 200 kPa) by modifying the footwear. After each of a maximum three rounds of modifications, pressures were measured. In a subgroup of 32 patients, pressures were measured and, if needed, footwear was modified at 3-monthly visits for 1 year. Pressures were compared with those measured in 32 control patients who had no footwear modifications based on pressure analysis. At the previous ulcer location and the highest and second highest pressure locations, peak pressures were significantly reduced by 23%, 21% and 15%, respectively, after modification of footwear. These lowered pressures were maintained or further reduced over time and were significantly lower, by 24-28%, compared with pressures in the control group. The offloading capacity of custom-made footwear for high-risk patients can be effectively improved and preserved using in-shoe plantar pressure analysis as guidance tool for footwear modification. This provides a useful approach to obtain better offloading footwear that may reduce the risk for pressure-related diabetic foot ulcers.

PS6 - 34. The effectiveness of offloading-improved custom-made footwear on plantar foot ulcer recurrence rate in diabetic patients: a multicenter randomized controlled trial

The aim of this study was to assess the effectiveness of custom-made footwear, of which offloading is improved based on in-shoe plantar pressure analysis, in preventing plantar foot ulcer recurrence in high-risk diabetic patients.

PS6 - 31. The effect of therapeutic footwear modifications on in-shoe plantar pressures in high risk diabetic patients

Custom-made therapeutic footwear is a common treatment used to prevent ulcer recurrence in diabetic patients with neuropathy.

The effect of prefabricated and proprioceptive foot orthoses on plantar pressure distribution in patients with flexible flatfoot during walking

Previous studies have suggested that orthoses with different constructions could alter gait parameters in flexible flatfoot. However, there is less evidence about the effect of insoles with proprioceptive mechanism on plantar pressure distribution in flatfoot. To assess the effect of orthoses with different mechanisms on plantar pressure distribution in subjects with flexible flatfoot. Quasi-experimental. In total, 12 flatfoot subjects were recruited for this study. In-shoe plantar pressure in walking was measured by Pedar-X system under three conditions including wearing the shoe only, wearing the shoe with a proprioceptive insole, and wearing the shoe with a prefabricated foot insole. Using the proprioceptive insoles, maximum force was significantly reduced in medial midfoot, and plantar pressure was significantly increased in the second and third rays (0.94 ± 0.77 N/kg, 102.04 ± 28.23 kPa) compared to the shoe only condition (1.12 ± 0.88 N/kg and 109.79 ± 29.75 kPa). For the prefabricated insole, maximum force was significantly higher in midfoot area compared to the other conditions (p < 0.05). Construction of orthoses could have an effect on plantar pressure distribution in flatfeet. It might be considered that insoles with sensory stimulation alters sensory feedback of plantar surface of foot and may lead to change in plantar pressure in the flexible flatfoot. Based on the findings of this study, using orthoses with different mechanisms such as proprioceptive intervention might be a useful method in orthotic treatment. Assessing plantar pressure can also be an efficient quantitative outcome measure for clinicians in evidence-based foot orthosis prescription.

Plantar pressure and daily cumulative stress in persons affected by leprosy with current, previous and no previous foot ulceration

Not only plantar pressure but also weight-bearing activity affects accumulated mechanical stress to the foot and may be related to foot ulceration. To date, activity has not been accounted for in leprosy. The purpose was to compare barefoot pressure, in-shoe pressure and daily cumulative stress between persons affected by leprosy with and without previous or current foot ulceration.Nine persons with current plantar ulceration were compared to 15 with previous and 15 without previous ulceration. Barefoot peak pressure (EMED-X), in-shoe peak pressure (Pedar-X) and daily cumulative stress (in-shoe forefoot pressure time integral×mean daily strides (Stepwatch™ Activity Monitor)) were measured.Barefoot peak pressure was increased in persons with current and previous compared to no previous foot ulceration (mean±SD=888±222 and 763±335 vs 465±262kPa, p<0.05). In-shoe peak pressure was only increased in persons with current compared to without previous ulceration (mean±SD=412±145 vs 269±70kPa, p<0.05). Daily cumulative stress was not different between groups, although persons with current and previous foot ulceration were less active.Although barefoot peak pressure was increased in people with current and previous plantar ulceration, it did not discriminate between these groups. While in-shoe peak pressure was increased in persons with current ulceration, they were less active, resulting in no difference in daily cumulative stress. Increased in-shoe peak pressure suggests insufficient pressure reducing footwear in persons with current ulceration, highlighting the importance of pressure reducing qualities of footwear.