University of Malaya

Faculty of Engineering
KUEP 3130: Biomechanics of Orthotics
Session 2015/2016, Semester I

Assignment:
Biomechanical Analysis using Kinovea

Students:

HARMONY TAN SHI LE

KED130002

NURUL AFNIZAH BINTI ZAKARIAH

KED130012

Lecturer:

DR. NUR AZAH BINTI HAMZAID

KUEP3130 | 2015/2016(1)

Harmony, S. L. Tan, Nurul Afnizah Zakariah

Effect of total contact insoles to treat flexible pes planus using 2D analysis
Harmony, S. L. Tan, Nurul Afnizah Zakariah
Department of Biomedical Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia

Abstract
Flexible pes planus is a common foot deformity that presents as a lower medial longitudinal
arch (MLA). Foot orthoses, namely total contact insoles (TCIs), are most popular treatments for
flexible pes planus. In this study, we will determine resultant biomechanical gait changes
caused by TCIs by investigating the effect on three kinematic parameters: step length, sagittal
knee angle, and hindfoot angle. Through 2D kinematic motion analysis using Kinovea and
MATLAB, it was found that TCIs increase step length, increase knee flexion during midstance,
and reduce hindfoot valgus during loading response.
Keywords: Pes planus, Flat foot, Total contact insole, Foot orthosis, Orthotics, Kinematics, Gait
Introduction
Pes planus is an umbrella term
encompassing foot shapes with
visually lowered medial longitudinal
arch (MLA) (Shibuya, Jupiter, Ciliberti,
VanBuren, & Fontaine, 2010). It is
often associated with rearfoot
eversion (hindfoot valgum) and other
physical anomalies as the result of a
domino effect starting from the foot to
the ankle and on to more proximal
joints because of the foots ultimate
function in weight transmission and
ambulation. Abnormal weight bearing
Figure 1: Medial longitudinal arch with
caused by pes planus strains the
supporting ligaments and bones
structures and tissues, increasing the
risk for problems or pain. The bony architecture of the MLA is made up of the calcaneus, talus,
navicular, medial cuneiform, intermediate cuneiform, lateral cuneiform, and metatarsals I
through III. The arched structure formed by these bones creates a space for the soft, elastic
tissues that give the foot its ability to function as a walking base. In quiet standing, the foot
balances the body by providing a supply (flexible) but stable platform that adapts to the
surface of the ground. During walking, the foot absorbs shock in the impact of the foot with the
ground, but more importantly, the plantar aponeurosis acts as a spring that assists in forward
propulsion through the Windlass mechanism. In pes planus, the keystone of the MLA i.e. the
talus bone is lowered, which can result in abnormal gait and transmission of asymmetrical
forces into the pelvis and spine. Additionally, the medial side of the plantar surface of the foot
is fallen, and depending on the severity of the deformity, may be touching the ground, resulting
in abnormal distribution of pressure on the sole of the foot during gait.
Flat foot or pes planus is a common condition that affects approximately 6% of the U.S.
population (IPMA, 2014); 46% of people suffering from pes planus seek medical attention from
podiatrists each year. Its prevalence among the world population has given pes planus its

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status as one of the major types of foot deformities that plague both children and adults. There
are two main forms of pes planus, rigid and flexible. The World Health Organisation defines
rigid pes planus as a congenital, rigid or spastic deformity of the foot, and flexible pes planus as
an acquired joint disorder resulting in a valgus foot deformity (WHO, 2010). Unlike its rigid
counterpart, in flexible pes planus the MLA is present until weight is applied to the sole of the
foot, at which time the arch disappears. The best way to differentiate between rigid and flexible
is by asking the patient to perform the toe-raise test; if an individual has flexible pes planus, the
MLA will reappear when standing on tip toe. Rigid pes planus affects less than 1% of the
population and leads to significant pain and disability, but can only be effectively treated with
surgery (Luhmann, Rich, & Schoenecker, 2000). On the other hand, flexible pes planus affects a
significantly higher number of individuals, with reports varying between 2-23% of the U.S.
adult population (Shibuya et al., 2010). However, intervention methods in practice today for
treating flexible pes planus remain unclear and are frequently subjected to debate (Leung, Mak,
& Evans, 1998). This is primarily because there are many different causes of flexible pes
planus, and as of yet, no specific etiology has been agreed upon by experts. The current
approach to treating flexible pes planus is principally with foot orthoses.
Kirby (1997) defines a foot orthosis (FO) as an in-shoe medical device which is designed to alter
the magnitudes and temporal patterns of the reaction forces acting on the plantar aspect of the
foot in order to allow more normal foot and lower extremity function and to decrease pathologic
loading forces on the structural components of the foot and lower extremity during
weightbearing activities. This definition justifies the development and implementation of
different designs of functional FOs (rigid or semirigid) and accomodative FOs (soft) in pes
planus treatments by podiatrists and orthotists alike over the years. While there are many
different types of FOs used to treat pes planus, for instance the Australian favourite modified
Root device (Landorf, Keenan, & Rushworth, 2001), the FO most commonly prescribed
nowadays is the total contact insole (TCI). In fact, TCIs are not just prescribed for pes planus
and its equally popular counterpart pes cavus, but a multitude of medical conditions that are
related to foot deformities such as leprosy (Tang, Chen, Lin, et al., 2015), partial foot
amputations due to diabetes (El-Hilaly, Elshazly, & Amer, 2013), and knee osteoarthritis
(Arnold, 2015). The vast potential of TCIs in treating a variety of physical ailments is a popular
subject of research, but there are not many studies that investigate how TCIs affect pes planus
using motion analysis. The only notable study on the matter at present is (Tang, Chen, Wu, et
al., 2015), who evaluated the effect of TCI with forefoot medial posting in patients with flexible
pes planus. They found that the aforementioned insole design significantly reduced excessive
valgus movement of the rearfoot, and decreased peak pressures under the toe, lateral
metatarsal, lateral foot and heel areas. Hence, (Tang, Chen, Wu, et al., 2015) concluded that the
TCI with forefoot medial posting is an effective orthotic device for rearfoot motion control,
plantar pressure reduction and re-distribution in patients with flexible pes planus. In our
study, we will see if the TCI does indeed reduce or correct hindfoot valgum in flexible pes
planus, and take it one step further by looking at the step length and sagittal knee angle i.e.
reduction in genu recurvatum. In gait analysis, step length is one of the five attributes of
normal walking, therefore it is a suitable parameter for investigating the effectiveness of TCIs
as a treatment. As to the reason for taking genu recurvatum as a parameter, (Quanbeck, Greer,
& Wilkins, 2013) states that pes planus is often a sign of joint hypermobility, which can be an
indication of more serious disorders such as Ehlers-Danlos syndrome and osteogenesis
imperfecta, conditions that frequently present with genu recurvatum. Similarly, (Kosashvili,
Fridman, Backstein, Safir, & Ziv, 2008) proved that moderate and severe pes planus is
associated with nearly double the rate of anterior knee pain, a symptom of genu recurvatum.

KUEP3130 | 2015/2016(1)

Harmony, S. L. Tan, Nurul Afnizah Zakariah

Methods
Participant

In this research project, we focused on the effect of total contact insoles on the biomechanics of
one single patient. The subject is a healthy, fit, physically active 33-year-old Chinese female
with flexible pes planus. The subject is an outpatient from University Malaya Medical Centre
(UMMC).

Terminology

The main purpose of this research is to determine the effect of total contact insoles on the
biomechanics of walking gait of a flexible pes planus case. Generally, insoles is an orthotic
device which is use to help patient with various foot deformities such as pes planus, pes cavus
and bunion. Parameters used to analyse the biomechanics gait of pes planus patient are as
follows:

Step length
Sagittal knee angle
Frontal hindfoot angle

Procedure (Data collection)

All procedures were explained to the subject and a consent form was filled by the subject in
approval to participate in this research project for data collection. The experiment was
conducted in UMMC, BioApps SDN. BHD. Before video recording, a few markers were placed on
the subjects left and right legs using body plasters (see Appendix). The markers are located on
the hip joint (greater trochanter), knee joint (tibial plateau), ankle joint (apex of lateral
malleolus) and hindfoot midline (vertical line along the Achilles tendon), and are used as
reference points in the 2D video analysis. Two cameras are used to record the subjects gait in
sagittal and frontal planes. Videos of the subject in walking were recorded in two conditions,
with and without insole. In both conditions, the subject wore socks, to eliminate the effect of
wearing socks in the data analysis. After one practice trial for the subject to understand the
process of data collection, we recorded three trials of the subject in walking. For measuring the
step length, the measurement is calibrated according to the length of the floor tiles of the
enclosed gaiting training room used for the video recording.

Video analysis (Data extraction)

The chosen biomechanical parameters were analysed using Kinovea. Kinovea is a software used
in 2D video analyses to observe, compare and measure biomechanics of motions. From
Kinovea, parameters such as step length, knee angle (sagittal plane) and hindfoot angle (frontal
plane) were obtained. For step length, the distance (horizontal displacement) between two
corresponding points of contact of the foot with the ground is measured using Kinoveas
distance measurement feature, as shown in Figures 2 and 3. For knee angle, the tracking
pathway feature is used at three points (hip, knee, ankle) as shown in Figure 4, from which the
raw 2D position values (x and y coordinates with time) are exported into an Excel spreadsheet
(.xml). Similarly for the hindfoot angle, the tracking pathway feature is used at two points, a
distal point and a proximal point on the body marker placed on the hindfoot midline, as shown
in Figure 7. The x-y values are also exported to Excel.

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Harmony, S. L. Tan, Nurul Afnizah Zakariah

Data analysis (Processing and visualisation)

The raw x-y coordinate values against time are imported into MATLAB. MATLAB is a high-level
technical computing language and interactive environment for numerical computation,
visualization, and programming. Three different MATLAB scripts (.m) were written to perform
the following computations respectively (see Appendix):

Calculate the angle between three points (hip, knee, ankle) with the vertex at the ankle
marker, forming the knee angle.
Calculate the angle between two points; distal point (x1, y1) and proximal point (x2, y2)
of the hindfoot midline marker. The hindfoot angle is formed by the angle between a
horizontal vector from (x1, y1) to (x1+1, y1) and the vector from (x1, y1) to (x2, y2).
Plot graphs using the data values obtained for the knee angle and hindfoot angle against
time.

Results
Step Length

Figure 2: Step lengths without insole (barefoot with socks)

Figure 3: Step lengths with insole (shoes with socks)

Table 1 shows the step lengths of the subject in walking with and without the total contact
insole over the course of three trials, from which the average values are calculated.
Table 1

1st
Right side
Left side

74.55
73.37

Right side
Left side

81.79
71.04

Step length (cm)

3rd
Without insole
74.56
68.91
77.26
74.23
With insole
77.90
79.10
79.40
78.50
2nd

Avg.
72.67
74.95
79.60
76.31

Knee angle

In Figures 5 and 6, the knee angle in degrees is plotted against time for the stance phase only
i.e. from initial contact (heel strike) at 0s to preswing (toe off), generated using MATLAB. Zero
degrees (0) is full extension at the knee joint, while positive degree values are knee flexion
angles.

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Harmony, S. L. Tan, Nurul Afnizah Zakariah

Figure 4: Example tracking pathway for three markers in measuring knee angle

Figure 5: Sagittal knee angular kinematics for the right side in stance phase

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Harmony, S. L. Tan, Nurul Afnizah Zakariah

Figure 6: Sagittal knee angular kinematics for the left side in stance phase

Hindfoot angle

Figure 7: Example of tracking pathway for two markers in measuring hindfoot angle
In Figures 9 and 10, the hindfoot angle in degrees is plotted against time for the stance phase only
i.e. from initial contact (heel strike) at 0s to terminal stance (heel off), generated using MATLAB.
90 is when the hindfoot midline is perpendicular to the ground; degree values above 90 are
hindfoot valgus angles (rearfoot eversion), while degree values below 90 are hindfoot varus
angles (rearfoot inversion).

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Harmony, S. L. Tan, Nurul Afnizah Zakariah

Figure 8: Illustration of hindfoot angle values presented in Figures 8 and 9

Figure 9: Frontal hindfoot angular kinematics for the right side in stance phase

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Harmony, S. L. Tan, Nurul Afnizah Zakariah

Figure 10: Frontal hindfoot angular kinematics for the left side in stance phase

Discussion
Step length

Based on the results obtained, when the subject is wearing the total contact insole, their step
length increases compared to without the insole. This may be connected to the fact that the
subject admitted feeling more stable and comfortable with intimate heel-cup support when
walking with the insole. On the other hand, the presence of sport shoes could also be a reason
for the increase in step length because shoes are also a type of foot orthosis that make walking
more comfortable and stable. Therefore, to make the results more comparable and conclusive,
we should ask the subject to wear shoes with and without the total contact insoles, so we can
eliminate the influence from the shoes and more accurately isolate the effects of the total
contact insoles on the subjects gait.

Knee angle

Based on the graphs in Figures 4 and 5, the subject does not actually present with knee
hypertension (genu recurvatum) in walking during stance phase. However, the subject did
reveal through subjective assessment that she has a mild case of genu recurvatum according to
the physical assessment performed by the UMMC rehab clinic doctor, aggravated by her love
for high-impact outdoor activities such as hiking. Despite not observing any hypertension
angles in the knee joint, both graphs show that the knee angles present more flexion when the
subject is wearing the insoles compared to without the insoles. This can be observed at
midstance phase, approximately 50% of stance phase, which is around the time 40-50 seconds

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on the x-axis of both graphs. The time at which midstance takes place cannot be accurately
determined The right side is more obvious than the left side; the left side only shows slight
increase in knee flexion. At midstance, the center of gravity of the body is progressing forward
anteriorly over the base of support (i.e. the feet). At the very instant of midstance, the knee is
approaching full extension, after which the knee either goes into hyperextension or flexion.
Hyperextending the knee is a passive method of locking the knee for stability using external
joint moment created by the body weight line falling anterior to the knee joint axis. On the
other hand, flexing the knee is an active method of stabilising the body as it propels forward
through internal joint moment from the hamstrings. In other words, it depends on the habit of
the subject. Perhaps because the subject is aware that she tends to hyperextend, she
consciously prevents her knee from hyperextending. Either way, the graphs conclusively show
that the knee flexes more with insoles than without. However, this may be due to the combined
effect of the sport shoes and the insoles, because all sport shoes are designed with a slight heel
height to aid in forward propulsion.

Hindfoot angle

Unlike for the graphs of knee angles, we cannot assume the hindfoot valgus or varus angles at
midstance because that is not the phase of gait at which foot pronation is maximum. Instead,
the maximum foot pronation, which then leads to hindfoot valgus angles due to pes planus, is
usually observed around loading response, as the foot transforms from a supple structure to a
rigid lever in preparation for forward propulsion midstance and heel off. Overall, the hindfoot
angle is more valgus when the subject is wearing the insoles compared to without, which is the
opposite of the intended result. However, there is a noticeable dip in the angle pattern shortly
after initial contact, presumably during loading response. This sudden fall in the graph is more
significant and occurs more quickly when the subject is wearing insoles compared to without
insoles, and is observable in both right and left sides. The right side is more noticeable and the
angle drops to varus territory, while the left side is less noticeable and the angle only drops to
90. Soon after of course, the hindfoot angles return to valgus position, which continues on for
the rest of stance phase. From this, we can conclude that the total contact insoles do indeed
reduce the hindfoot valgus angle in loading response during the phase of maximum foot
pronation, but are not successful in doing so for the rest of stance phase. Perhaps this is
because the insoles had to be grinded down to be able to fit into the subjects original shoe, and
therefore the intended medial posting designed to produce an external joint moment into
varus about the subtalar joint could not achieve its desired effect. This is a common problem
among patients prescribed with insoles, especially if the patients try to change shoes but use
the same insoles. Ideally, the idea is for the patients to use shoes with larger fit to
accommodate the insoles without compromising the thickness and shape of the insoles.

Suggestions for improving future studies

Throughout the duration of this experiment (in data collection, data extraction, and data
processing), we realised several limitations in terms of the equipment and software systems
used.
Firstly, the camera used was not a high speed camera, and therefore the obtained video
produced blurry images at certain snapshots during analysis. More than two cameras should
be used, all linked to each other and placed at different angles to triangulate the placement of
body markers when one of the cameras are blocked e.g. when subject walks, the hands
frequently pass over the hip joint, covering the marker from the camera view. To overcome

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this, manual checking at each frame is necessary to correct the marker placements when the
tracking feature in Kinovea runs away from the proper placement. In addition, each camera
only provides a 2D view from one angle (sagittal or frontal place respectively) with a limited
zoom range. With the focus on keeping the subjects gait as natural as possible, the subjects full
gait cycle from stance through swing are not within the camera frame. This is why we only
looked at the knee and hindfoot angles in the stance phase and not in swing phase. This can be
overcomed by using a 3D motion analysis system. Also, the time between consecutive frames
of the camera sample rate are inconsistent i.e. the time between two data points varies.
Therefore only one trial was taken measurements from for the angular kinematic
measurements, instead of an average of several trials as performed for step length. This is
because it is impossible to take the average across trials with varying frame times. In
comparing between the barefoot and insole conditions in measuring the sagittal knee angle, an
assumed time rate of 3.5s between frame samples is used to plot the separate conditions onto
the same axes because the time between frames varied between 3 to 4 seconds. For measuring
the hindfoot angle, an assumed time rate of 5.0s was using instead because the time between
frames varied between 3 to 7 seconds.
With respect to the software systems used, the angle tracking pathway feature in Kinovea is
currently only for on-the-fly analysis i.e. exporting the data values against time to a file is not
possible. To overcome this, we did not use the angle tracking feature because it has high risk of
human error in manual observation on the computer screen; instead we used the marker
tracking pathway feature placed at a few points, exported to Excel, and then imported into
MATLAB, which was then used to calculate the angle between these points.

Conclusion
From our research, we are able to prove that total contact insoles do effect the biomechanics of
the gait cycle for pes planus subjects. Wearing a total contact insole increases the subjects step
length, knee flexion angle, and reduces the hindfoot valgus angle during loading response.
However, unlike our hypothesis, overall the hindfoot angle is more valgus when the subject is
wearing the insoles compared to without, and in fact, without insoles, the subject exhibits
varus angle in the hindfoot, which is opposite to the expected result in pes planus cases.
The equipment and software used in our motion analysis were inadequate and cannot produce
results to the level of accuracy and reliability that we desire. In future studies, we hope to solve
these limitations and improve the validity and trustworthiness of our results and analysis by
using a 3D kinematic and kinetic motion analysis system like Vicon Nexus or Qualisys, instead
of 2D kinematic motion analysis.

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References
Arnold, J. B. (2015). Lateral wedge insoles for people with medial knee osteoarthritis: one size
fits all, some or none? Osteoarthritis and Cartilage. doi: 10.1016/j.joca.2015.09.016
El-Hilaly, R., Elshazly, O., & Amer, A. (2013). The role of a total contact insole in diminishing
foot pressures following partial first ray amputation in diabetic patients. The Foot,
23(1), 6-10. doi: 10.1016/j.foot.2012.10.002
IPMA. (2014). Resources for Patients: Podiatry Facts & Statistics. Retrieved from
http://www.ipma.net/?page=15
Kirby, K. A. (1997). Foot and Lower Extremity Biomechanics. A Ten Year Collection of Precision
Intricast Newsletters. Payson, Arizona: Precision Intricast, Inc.
Kosashvili, Y., Fridman, T., Backstein, D., Safir, O., & Ziv, Y. B. (2008). The Correlation between
Pes Planus and Anterior Knee or Intermittent Low Back Pain. Foot & Ankle International,
29(9), 910-913. doi: 10.3113/fai.2008.0910
Landorf, K., Keenan, A.-M., & Rushworth, L. R. (2001). Foot Orthosis Prescription Habits of
Australian and New Zealand Podiatric Physicians. Journal of the American Podiatric
Medical Association, 91(4). doi: 10.7547/87507315-91-4-174
Leung, A. K. L., Mak, A. F. T., & Evans, J. H. (1998). Biomechanical gait evaluation of the
immediate effect of orthotic treatment for flexible flat foot. Prosthetics and orthotics .
doi: 10.3109/03093649809164454
Luhmann, S. J., Rich, M. M., & Schoenecker, P. L. (2000). Painful idiopathic rigid flatfoot in
children and adolescents. Foot Ankle Int, 21, 5966.
Quanbeck, D., Greer, K., & Wilkins, K. (2013). Joint Hypermobility: Normal Variation or Cause
for Concern? A Pediatric Perspective, 22(1).
Shibuya, N., Jupiter, D. C., Ciliberti, L. J., VanBuren, V., & Fontaine, J. (2010). Characteristics of
Adult Flatfoot in the United States. The Journal of Foot and Ankle Surgery, 49(4). doi:
10.1053/j.jfas.2010.04.001
Tang, S., Chen, C., Lin, S.-C., Wu, C.-K., Chen, C.-K., & Cheng, S.-P. (2015). Reduction of plantar
pressures in leprosy patients by using custom made shoes and total contact insoles.
Clinical Neurology and Neurosurgery, 129. doi: 10.1016/S0303-8467(15)30005-6
Tang, S., Chen, C.-H., Wu, C.-K., Hong, W.-H., Chen, K.-J., & Chen, C.-K. (2015). The effects of total
contact insole with forefoot medial posting on rearfoot movement and foot pressure
distributions in patients with flexible flatfoot. Clinical Neurology and Neurosurgery, 129.
doi: 10.1016/S0303-8467(15)30004-4
WHO. (2010). ICD-10: Diseases of the musculoskeletal system and connective tissue.

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Appendix

Figure 11: Body plaster used a markers

(a) Sagittal plane (left side) without and with insoles

(b) Frontal plane (posterior) without and with insoles

Figure 12: Marker placement locations at the hip, knee, angle, and hindfoot

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MATLAB scripts

For calculating the angle between three points (hip, knee, ankle) with the vertex at the ankle
marker, forming the knee angle.

A0 = knee;
A1 = hip;
A2 = ankle;
for i = 1:25
P0 = A0(i,:);
P1 = A1(i,:);
P2 = A2(i,:);
rad = atan2(abs(det([P2-P0;P1-P0])),dot(P2-P0,P1-P0));
deg_tmp = rad*180/pi;
deg = 180 - deg_tmp;
ang(i) = deg;
end

For calculating the angle between two points; distal point (x1, y1) and proximal point (x2, y2)
of the hindfoot midline marker. The hindfoot angle is formed by the angle between a horizontal
vector from (x1, y1) to (x1+1, y1) and the vector from (x1, y1) to (x2, y2).

% left foot
A = Lach;
% (x1, y1)
H = Lheel; % (x2, y2)
for i = 1:12
x1 = A(i,1);
y1 = A(i,2);
x2 = H(i,1);
y2 = H(i,2);
rad = atan2(y2-y1,x2-x1);
% This will return the angle between a horizontal vector from (x1,y1) to
% (x1+1,y1) and the vector from (x1,y1) to (x2,y2)
deg_tmp1 = rad*180/pi;
deg_tmp2 = 180 + deg_tmp1;
left_deg(i) = deg_tmp2;
end
% right foot
A = Rach;
% (x1, y1)
H = Rheel; % (x2, y2)
for i = 1:13

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x1 = A(i,1);
y1 = A(i,2);
x2 = H(i,1);
y2 = H(i,2);
rad = atan2(y2-y1,x2-x1);
% This will return the angle between a horizontal vector from (x1,y1) to
% (x1+1,y1) and the vector from (x1,y1) to (x2,y2)
deg_tmp1 = rad*180/pi;
deg_tmp2 = deg_tmp1 * (-1);
right_deg(i) = deg_tmp2;
end

For plotting graphs using the data values obtained for the knee angle and hindfoot angle
against time.

figure;
% data from without insole
plot( x, y, '+r' ); % plot the original points
n = numel(x); % number of original points
xi = interp1( 1:n, x, linspace(1, n, 10*n) ); % new sample points
yi = interp1(
x, y, xi );
hold all;
plot( xi, yi ); % should be smooth between the original points
% data from with insole
plot( x, z, 'ob' ); % plot the original points
n = numel(x); % number of original points
xi = interp1( 1:n, x, linspace(1, n, 10*n) ); % new sample points
zi = interp1(
x, z, xi );
hold all;
plot( xi, zi ); % should be smooth between the original points

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