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Does Flip-Flop Style Footwear Modify Ankle Biomechanics and Foot

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Does Flip-Flop Style Footwear Modify Ankle Biomechanics and Foot View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by University of Salford Institutional Repository Does flip-flop style footwear modify ankle biomechanics and foot loading patterns? Price, C, Andrejevas, V, Findlow, AH, Graham-Smith, P and Jones, R http://dx.doi.org/10.1186/s13047-014-0040-y Title Does flip-flop style footwear modify ankle biomechanics and foot loading patterns? Authors Price, C, Andrejevas, V, Findlow, AH, Graham-Smith, P and Jones, R Type Article URL This version is available at: http://usir.salford.ac.uk/32919/ Published Date 2014 USIR is a digital collection of the research output of the University of Salford. Where copyright permits, full text material held in the repository is made freely available online and can be read, downloaded and copied for non-commercial private study or research purposes. Please check the manuscript for any further copyright restrictions. For more information, including our policy and submission procedure, please contact the Repository Team at: [email protected]. Price et al. Journal of Foot and Ankle Research 2014, 7:40 http://www.jfootankleres.com/content/7/1/40 JOURNAL OF FOOT AND ANKLE RESEARCH RESEARCH Open Access Does flip-flop style footwear modify ankle biomechanics and foot loading patterns? Carina Price1*, Vaidas Andrejevas2, Andrew H Findlow1, Philip Graham-Smith1 and Richard Jones1 Abstract Background: Flip-flops are an item of footwear, which are rubber and loosely secured across the dorsal fore-foot. These are popular in warm climates; however are widely criticised for being detrimental to foot health and potentially modifying walking gait. Contemporary alternatives exist including FitFlop, which has a wider strap positioned closer to the ankle and a thicker, ergonomic, multi-density midsole. Therefore the current study investigated gait modifications when wearing flip-flop style footwear compared to barefoot walking. Additionally walking in a flip-flop was compared to that FitFlop alternative. Methods: Testing was undertaken on 40 participants (20 male and 20 female, mean ± 1 SD age 35.2 ± 10.2 years, B.M.I 24.8 ± 4.7 kg.m−2). Kinematic, kinetic and electromyographic gait parameters were collected while participants walked through a 3D capture volume over a force plate with the lower limbs defined using retro-reflective markers. Ankle angle in swing, frontal plane motion in stance and force loading rates at initial contact were compared. Statistical analysis utilised ANOVA to compare differences between experimental conditions. Results: The flip-flop footwear conditions altered gait parameters whencomparedtobarefoot.Maximumankle dorsiflexion in swing was greater in the flip-flop (7.6 ± 2.6°, p = 0.004) and FitFlop (8.5 ± 3.4°, p < 0.001) than barefoot (6.7 ± 2.6°). Significantly higher tibialis anterior activation was measured in terminal swing in FitFlop (32.6%, p <0.001) and flip-flop (31.2%, p < 0.001) compared to barefoot. A faster heel velocity toward the floor was evident in the FitFlop (−.326 ± .068 m.s−1, p < 0.001) and flip-flop (−.342 ± .074 m.s−1, p < 0.001) compared to barefoot (−.170 ± .065 m.s−1). The FitFlop reduced frontal plane ankle peak eversion during stance (−3.5 ± 2.2°) compared to walking in the flip-flop (−4.4 ± 1.9°, p = 0.008) and barefoot (−4.3 ± 2.1°, p = 0.032). The FitFlop more effectively attenuated impact compared to the flip-flop, reducing the maximal instantaneous loading rate by 19% (p <0.001). Conclusions: Modifications to the sagittal plane ankle angle, frontal plane motion and characteristics of initial contact observed in barefoot walking occur in flip-flop footwear. The FitFlop may reduce risks traditionally associated with flip-flop footwear by reducing loading rate at heel strike and frontal plane motion at the ankle during stance. Keywords: Flip-flop, Gait, Electromyography, Loading rate Background tibialis anterior and toes have been associated with wear- Flip-flops are a popular summer shoe in the United ing flip-flop style footwear by podiatrists [3]. Flip-flops dif- Kingdom and commonly worn throughout the year in fer from standard walking footwear design due to a thin warmer climates such as America and Australasia [1,2]. sole, no medial arch support, no protection for the toes, This style of footwear is defined by having one strap being loose fitting and having no pitch from heel to toe across the dorsal fore-foot, which attaches to the foot- [4,5]. Despite these recognised potentially detrimental fea- bed between the hallux and second toe to the thin, flex- tures, the popularity of flip-flops in warm climates con- ible sole. Despite the popularity of flip-flops, heel pain tinues. Nevertheless, limited scientific investigation into and other conditions such as overuse injuries of the their influence on adult gait and associated pathologies has been published in peer-reviewed literature. * Correspondence: [email protected] Descriptive research is evident quantifying gait in flip- 1Centre for Health Sciences Research, University of Salford, Salford M6 6PU, UK flops, most extensively in children. Children wearing Full list of author information is available at the end of the article © 2014 Price et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Price et al. Journal of Foot and Ankle Research 2014, 7:40 Page 2 of 8 http://www.jfootankleres.com/content/7/1/40 flip-flops display a trend towards a more dorsiflexed, The current research study aims to compare barefoot everted and abducted midfoot during walking [6] and re- walking to walking in flip-flop style footwear and walk- duced hallux dorsiflexion prior to contact during walk- ing in a FitFlop; and walking in FitFlop to walking in ing and jogging [7]. Reduced eversion during midstance flip-flop to see if this contemporary footwear design of- in adults has also been demonstrated when walking in fers a potential advantage in terms of gait modifications. flip-flops, compared to barefoot [8]. Video data has been Firstly, it is hypothesised that shod conditions will in- used in an observational study of pedestrians, identifying crease ankle dorsiflexion and tibialis anterior muscle ac- a reduction in average walking speeds when walking in tivation during swing and at heel strike compared to flip-flops [2], which was attributed to a shorter stride barefoot to hold the footwear during swing. However, length compared with other footwear and confirmed in this increase in dorsiflexion is predicted to be less in Fit- a laboratory environment [9]. In addition, an experimen- Flop than flip-flop due to the size and position of the tal study using 2D gait analysis concluded that there was dorsal strap. Secondly, there is expected to be a reduc- an increase in ankle plantarflexion during swing, which tion in the frontal plane motion of the foot in the Fit- the authors hypothesised could be due to contraction of Flop condition during stance compared to both barefoot the toe flexors to keep the flip-flop on the foot due to and flip-flop due to the ergonomically profiled sole and the lack of heel-strap or full upper [9]. Contrasting these the features of the dorsal strap. Thirdly, shod conditions findings, Chard et al. [6] identified greater ankle dorsi- are expected to attenuate force loading rates at heel flexion prior to and at heel contact when walking in flip- strike compared to barefoot due to the inclusion of ma- flops compared to barefoot conditions. terial under the calcaneus; with the FitFlop predicted to Literature more specific to potential detrimental fea- have a greater reduction in loading rate compared to the tures of gait in flip-flops is uncommon and includes flip-flop due to its greater sole thickness. some methodological weaknesses. A plantar pressure study on females walking in flip-flops postulated that “gripping” with the toes occurs to hold this footwear on the foot, how- Methods ever the variable used to speculate this may not have been Participants relevant [1]. Additionally, this study referred to potential Forty participants took part in the study, twenty female benefits in terms of the shoe providing protection to the and twenty male (Table 1) recruited from the University plantar surface of the foot, reducing plantar pressures com- staff and student population. All indicated they were pared to barefoot walking due to the material. In contrast, asymptomatic i.e. had no diagnosed gait pathologies for the impact attenuation that flip-flops provide at heel strike at least three months, and gave written informed con- has been investigated by Zhang et al. [10], but no signifi- sent fulfilling the requirements of the University of cant difference in loading rates between barefoot and flip- Salford Research Ethics Panel. flops was evident. However, the parameter used in their investigation was not maximum instantaneous loading rate, which may have attributed to identified differences between Footwear conditions conditions. Describing gait in flip-flops is useful, but more Testing utilised barefoot and two footwear conditions: valuable is comparing the influence of these styles of foot- flip-flop and FitFlop (Figure 1, Table 2). The FitFlop varied wear to a relevant and available replacement. This may en- between genders as a single style does not span the size able the identification of a replacement item of footwear range of participants. These variations included the last that fulfils the same purpose, however reduces or prevents shape (used in the manufacture), the dorsal strap material the potentially detrimental gait modifications in the wearer.
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