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01-12-2014 | Research | Uitgave 1/2014 Open Access

Journal of Foot and Ankle Research 1/2014

Variation in the location of the shoe sole flexion point influences plantar loading patterns during gait

Journal of Foot and Ankle Research > Uitgave 1/2014
Babette C van der Zwaard, Benedicte Vanwanseele, Fred Holtkamp, Henriëtte E van der Horst, Petra JM Elders, Hylton B Menz
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Electronic supplementary material

The online version of this article (doi:10.​1186/​1757-1146-7-20) contains supplementary material, which is available to authorized users.

Competing interests

HBM is Editor-in-Chief of Journal of Foot and Ankle Research. It is journal policy that editors are removed from the peer review and editorial decision making processes for papers they have co-authored. The other authors declare that they have no competing interests.

Authors’ contribution

BvdZ was responsible for data-collection and wrote the manuscript. BV and HM assisted with the data evaluation and statistical analysis. BV and HM commented on several drafts of the manuscript. FH, HvdH and PE commented on the first and last draft of the manuscript. All authors have read and approved the final manuscript.



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.


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.


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.


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.

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