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Article

Static Foot Hyperpronation Monitoring in Asymptomatic Young Individuals During Level and Sloped Gait Using an Instrumented Treadmill

by
Natalia Kamitsou
,
Ioannis Kafetzakis
and
Dimitris Mandalidis
*
Sports Physical Therapy Laboratory, Department of Physical Education and Sports Science, School of Physical Education and Sports Science, National and Kapodistrian University of Athens, Ethnikis Antistasis 41, 17237 Athens, Greece
*
Author to whom correspondence should be addressed.
Appl. Sci. 2025, 15(6), 3209; https://doi.org/10.3390/app15063209
Submission received: 19 February 2025 / Revised: 11 March 2025 / Accepted: 12 March 2025 / Published: 15 March 2025
(This article belongs to the Section Applied Biosciences and Bioengineering)
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Abstract

:
Foot hyperpronation is a common anatomical misalignment that may contribute to the development of both localized and distant musculoskeletal overuse injuries. Advancements in modern technology may enable the detection of biomechanical changes in dynamic conditions that cannot be captured through conventional foot alignment assessments. This study aimed to investigate potential differences in spatiotemporal, dynamic, and center of pressure (COP)-related gait parameters, between individuals with foot hyperpronation (n = 21) and those with a neutral foot type (n = 21) under various walking conditions, using an instrumented treadmill. These conditions included walking downhill at −20% slope at 3.5 km·h−1, and at −10% slope at 5.0 km·h−1, level (0%) at 5.0 km·h−1, and uphill at +10% slope at 3.5 km·h−1 and +20% slope at 2.5 km·h−1, each lasting five minutes. The results showed no significant differences in stride length and time, foot rotation, step width, cadence, or gait phase durations between the two groups. However, individuals with hyperpronated feet exhibited a more forward and mediolaterally displaced COP, higher vertical ground reaction forces (vGRFs) at the midfoot, and lower vGRFs at the lateral forefoot. Instrumented treadmills enable clinicians and sports scientists to detect specific traits in individuals with foot hyperpronation, which would otherwise go undetected through static assessments.

1. Introduction

Close kinetic chain foot hyper—or over—pronation refers to a common misalignment of the foot characterized by an excessive inward rolling of the foot, often accompanied by a flattening of the medial arch during weight-bearing activities [1]. This misalignment primarily affects the subtalar joint, the main site of normal pronation [2], and influences all joints distal and proximal to it, as the foot, according to the regional interdependence model is part of an interconnected skeletal system of muscles, tendons, and fascia, linking distant body regions [3]. Foot hyperpronation is typically associated with altered movements of joints located centrally to the subtalar joint, including internal rotation of the tibia, femur, and pelvis as well as anterior pelvic tilt, while distally, it is linked to hallux valgus [4,5,6]. These biomechanical changes increase stress within the joints of the lower extremity kinetic chain and related structures, often causing musculoskeletal pain due to excessive strain on the surrounding tissues. Ultimately, these changes may predispose individuals to overuse injuries such as plantar fasciitis, shin splints, and knee pain [6,7,8,9,10], exacerbating functional impairments and reducing mobility. Improper positioning of lower limb joints can also significantly alter walking and running patterns, compromising overall biomechanics and increasing the long-term risk of musculoskeletal pathologies such as knee osteoarthritis [11].
Assessing foot hyperpronation is a standard component of clinical evaluation for many healthcare providers, aiming to identify potential injury causes or develop preventive intervention programs. This process often includes evaluating the foot’s static posture and alignment through various methods [12], which may not be fully capable of capturing the dynamic nature of foot hyperpronation during functional activities such as gait, where movements occur as part of complex joint motion. Such challenges have been addressed through kinematic analysis methods [13,14,15,16,17], which provide accurate measurements but at the cost of being time-consuming, expensive, and requiring specialized equipment and expertise for data interpretation. In recent years, the introduction of advanced methods, such as sensor technology [18], has provided the necessary validity and reliability in gait analysis [19], comparable to more demanding techniques used in kinematic and kinetic gait analysis, especially in the field of healthcare and medicine [20]. These sensors typically form matrices embedded in insoles, mats, or platforms [18], allowing for the generation of detailed spatial maps of the vertical ground reaction forces (vGRFs) exerted across different regions of the foot during various activities. By operating at high sampling rates [21], they can simultaneously detect rapid changes in vGRFs over time during dynamic movements. Furthermore, if the experimental setup allows, they can also yield information regarding spatiotemporal gait parameters using appropriate algorithms [22]. In this context, some researchers have conducted gait analysis on individuals with hyperpronated feet by recording real-time measurements of the forces exerted by the foot, either using insoles during shod overground walking [23], or during shod and unshod walking on pressure mats [24,25]. Despite the ability to accurately analyze gait, the use of insoles and pressure mats lack the capability to control gait characteristics and present several limitations, including fitting and footwear design/type issues (for insoles), as well as space requirements (for mats). The majority of other investigators have assessed overground walking using pressure sensor networks with matrices embedded within single-foot pressure platforms [26,27,28,29]. These small-sized platforms are designed to accommodate only one foot at a time, making them suitable for dynamic activities like gait analysis, but not for running analysis. Their focus is often restricted to the stance phase of gait, omitting data from the swing phase and the complete gait cycle, and require multiple trials to analyze both feet, increasing variability in measurements. Furthermore, they can alter natural movement patterns as participants must adjust their steps to align with the plate.
By integrating sensor matrices under the running belt of treadmills, also known as instrumented treadmills, clinicians and researchers have been given the opportunity to analyze gait and movement in a manner biomechanically comparable to overground walking [30]. This approach offers detailed spatial, temporal, and dynamic data over complete gait cycles, enabling the identification of inefficiencies or asymmetries by allowing the simultaneous measurement of both steps without requiring users to adjust their natural gait. Additionally, by controlling and standardizing test condition variables such as the speed and slope of gait, this method is particularly beneficial for individuals with significant joint misalignments, such as foot hyperpronation. Locomotion on inclined surfaces at varying speeds may impose different demands on the musculoskeletal system compared to level walking, requiring postural adjustments and increased involvement of lower body muscles [31,32]. Yet, studies utilizing instrumented treadmills for gait analysis in individuals with joint misalignments, such as foot hyperpronation, are lacking, and those that do exist often conduct gait analysis on conventional treadmills, relying on pressure-sensing insoles [33] or optoelectric systems [34] for data collection.
Therefore, the aim of the current study was to analyze gait in individuals with foot hyperpronation, utilizing the benefits provided by an instrumented treadmill. By examining these characteristics, this research seeks to advance clinical and sports science practices, providing valuable insights into optimizing performance, preventing injuries, and enhancing rehabilitation.

2. Materials and Methods

2.1. Study Design

The present study is a quantitative, observational, and cross-sectional investigation of spatiotemporal parameters, ground reaction forces, and center of pressure (COP) displacements in asymptomatic individuals with statically determined foot hyperpronation during walking at different slopes and speeds.

2.2. Sample

The study included 42 healthy male (n = 22) and female students (n = 20) from the local University’s Department of Physical Education and Sport Science. Participants were selected based on their foot type, which was determined in a relaxed standing position using the Foot Posture Index-6 (FPI-6) scale. Based on this scale, participants were classified as having a neutral foot type (n = 21) if they scored less than 5, or as hyperpronated (n = 21) if they scored greater than 10. Individuals were excluded from the study if they had localized musculoskeletal issues (e.g., ankle or foot pathology), remote musculoskeletal pain (e.g., low back pain), neurological impairments (e.g., peripheral neuropathies), recent lower limb trauma within the past year, or any condition that could affect gait patterns (e.g., balance-related disorders). Additionally, participants were excluded if they had unilateral foot hyperpronation, unilateral or bilateral foot over-supination, as determined also by the FPI-6 scale, leg length discrepancy >0.5 mm, determined by measuring leg length using a standard measuring tape from the lower edge of the right and left anterior superior iliac spine to the lower edge of the corresponding medial malleolus, with the participant in the supine position [35], or trunk rotation >5° during the Adams test (indicative of idiopathic scoliosis [36] (Table 1).

2.3. Testing Procedure

Volunteers visited the department’s physical therapy facilities on two separate occasions. During the first visit, anthropometric measurements, including body mass and height, were recorded. Additionally, a comprehensive musculoskeletal assessment was conducted to identify any characteristics that might render participants ineligible for the study. The musculoskeletal assessment included evaluations of leg length [37], ankle dorsiflexion range of motion bilaterally with the weight-bearing lunge test [38], and assessments for scoliosis [36].
Volunteers who were deemed eligible for participation in the study were required to visit the facilities for a second session, during which they performed treadmill walking in random order at a 0% slope (level) at 5.0 km·h−1 (1.39 m·s−1), uphill slopes of +10% and +20% at 3.5 km·h−1 (0.97 m·s−1) and 2.5 km·h−1 (0.69 m·s−1), respectively, and downhill slopes of −10% and −20% at 5.0 kg·h−1 (1.39 m·s−1) and 3.5 kg·h−1 (0.97 m·s−1), respectively. The variation in speeds between conditions reflected natural adaptations in walking speed to the slope of the terrain as determined by Tobler [39,40]. Each walking condition lasted 5 min, with data collected during the final 4 min to allow participants accommodate to the respective conditions. Before testing, participants completed a 7 min familiarization session at a speed of 5.0 km·h−1 on a level treadmill surface to become familiar with the treadmill equipment [41]. A 5 min rest was allowed after the familiarization session, and 5 min breaks were provided between walking conditions to prevent fatigue. However, additional rest was given if a participant’s heart rate, monitored using a Polar H10 heart rate monitor (Polar Electro, Kempele, Finland), exceeded 60% of their maximum heart rate (HRmax = [220 − age] × 0.6) prior to the start of each walking condition. This threshold was consistent with the literature suggesting that such intensity levels are associated with high-demand activities and reduced postural control [42], which could potentially affect normal walking performance, particularly in conditions of extreme incline or decline on the treadmill. Participants were instructed to wear comfortable sportswear and walk unshod with fitted socks to reduce friction between the plantar surface and the treadmill belt. They were also advised to avoid strenuous physical activity prior to testing.

2.4. Instrumentation

Walking conditions were performed using an instrumented treadmill (Pluto® Med, h/p/cosmos® Sports & Medical GmbH, Nussdorf–Traunstein, Germany). The treadmill featured a walking surface measuring 150 cm (L) × 50 cm (W) and was equipped with a platform embedded beneath the surface. This platform contained a matrix of 7168 capacitive pressure sensors (FDM-THPL-M-3i, Zebris Medical GmbH, Isny, Germany) that are arranged in columns and lines running closely next to each other and distributed across an area of 108.4 cm (L) × 46.4 cm (W) (resolution of 1.4 sensors·cm−2). The instrumented treadmill featured a speed range of up to 18.0 km·h−1 for uphill walking and up to 5.0 km·h−1 for downhill walking. Its surface supported slope adjustments between 0.1% and 20.0%. Forward belt motion facilitated walking on level and uphill slopes, while reverse belt motion enabled downhill walking. The treadmill was connected to a desktop computer, enabling real-time data transfer as well as storage for subsequent processing and analysis. Additionally, the software provided by the manufacturer enabled remote adjustment and control of the parameters used in the research protocol. The system recorded data at a frequency of 240 Hz. The sensor’s threshold was preset by the manufacturer at 1 N·cm−2.

2.5. Measurement Outcomes

Gait analysis was conducted based on spatial parameters, including stride length, step width, and foot rotation (i.e., the angle between the longitudinal axis of the foot and the direction of walking), as well as temporal parameters such as stride time and cadence. Cross-group comparisons were performed after normalizing the data by calculating dimensionless numbers for stride length ( l ^ ), stride time ( t ^ ), and cadence ( f ^ ), using Hof’s scaling method, where the average leg length of both legs was used as the constant ( l 0 ) [43]. Stride length was normalized as l ^ = l l 0 , stride time as t ^ = t l 0 / g , and cadence as f ^ = f g / l 0 , where l, t, and f represented the participant’s stride length, stride time, and cadence, respectively, recorded under each walking condition [43]. The average length of both legs was also used to normalize step width, which was expressed as a percentage of leg length, similar to the approach used in a previous study that utilized stature as a constant [13]. The duration of the stance phase and its sub-phases—load response, midstance, and pre-swing—as well as the swing phase of gait were assessed and reported as percentages of the total gait cycle duration. The stance and swing phases refer to the periods within a gait cycle when the foot is in contact with the ground and when it is not, respectively. The load response corresponded to the period between the initial ground contact and the lifting of the contralateral leg. Mid-stance is the period in which the contralateral leg swings in the air and the body’s center of gravity is transported over the loaded foot. The pre-swing includes the period within a gait cycle whose beginning is defined by the heel strike of the contralateral side of the body and whose end is defined by toe-off of the side of the body under consideration [44].
The anteroposterior and mediolateral location of COP was identified as the intersection point on the cyclogram—a diagram created by connecting the COP trajectories from the forefoot of one side to the rearfoot of the contralateral side during selected gait cycles over time [44].
Additionally, the maximum vGRFs exerted on seven distinct plantar surface regions of the foot were recorded across all walking conditions. These functional regions were identified by the system’s dedicated software using predefined segmentation methods [45]. These methods integrate geometric proportions and dynamic pressure distribution across the plantar surface, along with customizable analysis settings, to ensure consistency in data interpretation. Geometric segmentation divides the foot into predefined zones based on its length and width proportions, while dynamic pressure-based segmentation allows for the automatic detection of high-pressure areas, adjusting region boundaries in response to shifts in the CoP, maximum load points, and gait phases. The regions, along with the proposed approximate anatomical structures that correspond to them (acknowledging that their boundaries are not always clearly defined), are delineated as follows: (i) the rearfoot, covering the posterior 30% of the foot and subdivided into medial and lateral regions corresponding to the heel; (ii) the midfoot, comprising the central 30% of the foot, aligning with the medial longitudinal arch; and (iii) the forefoot, covering the anterior 40% of the foot, which is further divided into two equal parts: the anterior half, corresponding anatomically to the toes, and the posterior half, which is subdivided vertically into three regions—the medial, central, and lateral forefoot regions—corresponding to the 1st, 2nd–3rd, and 4th–5th metatarsals, respectively (Figure 1) [44,46].
Results were reported as averages for the measured variables derived from all steps taken across each gait condition. For variables involving both limbs (e.g., duration of gait phases, vGRFs), the average value of the right and left limbs was used for statistical analysis.

2.6. Reliability Study

The reliability of spatial, temporal, and dynamic gait parameters as well as the location of COP, was assessed in a subset of 22 participants from the original sample of 42 by repeating the measurements one week after the initial testing under identical gait conditions. Intraclass Correlation Coefficients (ICC 3, k) were used to quantify reliability, employing a two-way mixed-effects model to evaluate absolute agreement across sessions [47]. ICC values > 0.5 indicated poor reliability, those between 0.5 and 0.75 suggested moderate reliability, values from 0.75 to 0.9 represented good reliability, and values < 0.9 reflected excellent reliability [47].
The ICC values for absolute agreement across all walking conditions were good to excellent, ranging from 0.76 to 0.99 for the spatial variables, 0.76 to 0.97 for the temporal variables, 0.77 to 0.98 for the duration of gait phases, 0.78 to 0.96 for the location of COP, and 0.91 to 1.00 for the vGRFs exerted on various plantar regions of the foot.

2.7. Statistical Analysis

The normality of the data distribution was assessed using the Shapiro–Wilk test and by visually inspecting Q-Q and box plot graphs. Differences between the two groups regarding anthropometric measurements were assessed using independent samples t-tests. Differences in spatiotemporal parameters and gait phase durations between groups (hyperpronated vs. neutral foot type, between-subject factor) and walking conditions (slope/speed condition, within-subject factor), as well as the group-by-walking condition interaction, were assessed using a mixed-design two-way ANOVA. A mixed-design ANOVA also was used to assess differences in vGRFs between groups and plantar foot regions (LRF vs. MRF vs. MID vs. LFF vs. IFF vs. MFF vs. TOES), as well as the group-by-plantar foot region interaction. The sphericity of the data was determined based on Mauchly’s test, where a significant Greenhouse–Geisser correction was used. Pairwise comparisons were performed using the Bonferroni adjustment. The statistical analysis of the data was performed with SPSS 29.0 (IBM Corp, Armonk, NY, USA), while the significance level was set at the level of p ≤ 0.05.

3. Results

3.1. Spatial Parameters

Statistical analysis revealed no significant main effect of foot type on normalized stride length and step width, as well as foot rotation. Additionally, the interaction between foot type and walking condition was non-significant for these gait spatial parameters indicating similar responses of foot types across walking conditions (p > 0.05).
However, a significant main effect of walking condition was observed for normalized stride length (F = 747.566, p < 0.001, partial η2 = 0.949), and step width (F = 50.985, p < 0.001, partial η2 = 0.560), as well as for foot rotation (F = 44.417, p < 0.001, partial η2 = 0.526), regardless of foot type. Stride length was shorter during both downhill and uphill walking conditions compared to level walking. In general, step width was greatest during downhill walking, followed by uphill walking, and level walking. In contrast, foot rotation was greater during uphill compared to level and downhill walking. These findings suggest that walking conditions influenced these gait parameters consistently across both groups (please refer to Figure 2 and Figure 3 for pairwise comparisons).

3.2. Temporal Parameters

No significant differences were observed between individuals with hyperpronated and neutral foot types regarding normalized stride time and cadence. Furthermore, the interaction between foot type and walking conditions for these parameters was non-significant.
Statistical analysis revealed significant differences across walking conditions for stride time (F = 512.850, p < 0.001, partial η2 = 0.928) and cadence (F = 755.967, p < 0.001, partial η2 = 0.950), irrespective of foot type. More specifically, stride time was greater during uphill walking conditions compared to level and downhill walking conditions, while cadence was greater during downhill walking conditions compared to level and uphill walking conditions (please refer to Figure 4 for pairwise comparisons).

3.3. Gait Phase Analysis

Statistical analysis revealed no significant differences between individuals with hyperpronated and neutral foot types for the duration of the stance, load response, mid-stance, pre-swing, and swing phases. Similarly, the interaction between foot type and floor inclination was non-significant for the duration of these gait phases.
However, significant differences were observed between walking conditions for the stance phase (F = 638.945, p < 0.001, partial η2 = 0.941), load response (F = 638.216, p < 0.001, η2 = 0.941), mid-stance (F = 638.130, p < 0.001, η2 = 0.941), pre-swing (F = 638.216, p < 0.001, η2 = 0.941), and swing phase (F = 638.945, p < 0.001, partial η2 = 0.941), irrespective of foot type (please refer to Table 2 for pairwise comparisons).

3.4. Anteroposterior and Mediolateral Locations of COP

Statistical analysis revealed a significant main effect only related to walking conditions for both the anteroposterior (F = 113.587, p ≤ 0.001, partial η2 = 0.740) and mediolateral (F = 15.838, p ≤ 0.01, partial η2 = 0.284) locations of COP, irrespective of foot type. Additionally, the interaction between foot type and walking condition was significant for both the anteroposterior (F = 3.779, p ≤ 0.05, partial η2 = 0.086) and mediolateral (F = 6.715, p ≤ 0.001, partial η2 = 0.144) locations of COP. In general, the COP in individuals with a hyperpronated foot type was projected more anteriorly compared to individuals with a neutral foot type in most walking conditions, with the greatest projection observed during uphill walking (please refer to Figure 5 for pairwise comparisons).

3.5. Vertical Ground Reaction Forces

A two-way repeated-measures ANOVA revealed a significant main effect of the plantar foot region on vGRFs for walking condition A (F = 109.035, p < 0.001, η2 = 0.732), Β (F = 144.729, p < 0.001, η2 = 0.783), C (F = 150.539, p < 0.001, η2 = 0.790), D (F = 157.323, p < 0.001, η2 = 0.797), and E (F = 101.093, p < 0.001, η2 = 0.716). A significant interaction between the plantar foot region and foot type on vGRFs was also observed for walking condition A (F = 10.903, p < 0.001, η2 = 0.214), B (F = 12.830, p < 0.001, η2 = 0.243), C (F = 7.958, p < 0.001, η2 = 0.166), D (F = 9.134, p < 0.001, η2 = 0.186), and E (F = 6.158, p < 0.001, η2 = 0.133). Post hoc analyses using Bonferroni corrections showed that vGRFs exerted on the midfoot were significantly greater for individuals with hyperpronation compared to their counterparts with a neutral foot type in all walking conditions. Additionally, vGRFs were significantly lower on the medial and lateral forefoot in the hyperpronated foot type group compared to the neutral foot type group (see Figure 6 for pairwise comparisons). There was no significant main effect of foot type on vGRFs across all walking conditions.
Also, statistical analysis revealed significant differences in vGRFs across walking conditions for the lateral rearfoot (F = 89.337, p < 0.001, partial η2 = 0.691), medial rearfoot (F = 116.274, p < 0.001, partial η2 = 0.744), midfoot (F = 42.535, p < 0.001, partial η2 = 0.515), lateral forefoot (F = 50.956, p < 0.001, partial η2 = 0.560), inner forefoot (F = 329.992, p < 0.001, partial η2 = 0.892), medial forefoot (F = 58.094, p < 0.001, partial η2 = 0.592), and toes (F = 71.764, p < 0.001, partial η2 = 0.642), regardless of foot type.

4. Discussion

4.1. Spatiotemporal Parameters and Gait Phase Analysis

The results of the present study revealed that the spatial and temporal gait parameters, as well as the duration of gait phases during various uphill and downhill walking conditions, did not differ between individuals with hyperpronated and neutral foot types. Our findings were consistent with some of those reported in the literature. Hillstrom et al. [48] reported no significant differences in spatiotemporal gait parameters, including stride length, step length, and cadence, between asymptomatic individuals 18 and 77 years of age with planus and rectus foot types during overground walking across an instrumented mat. The differences between the two groups were also not significant for stance, swing, and double support times unless these variables were normalized by gait cycle time. In this case, stance and double support times were statistically, but not clinically, significantly different. Similarly, Farahpour et al. [49] reported no significant differences in average walking speed, stance phase, and step length between male individuals 26 years of age with hyperpronation and those with a neutral foot type, as measured using the motion analysis system during overground walking. In contrast, Rodríguez et al. [34] observed that individuals aged 18–65 with pronation greater than six on the FPI-6 scale demonstrated longer step lengths for both the right and left legs, slower ground contact times, and a reduced cadence compared to individuals with a neutral foot type. These measurements were taken during level treadmill walking at a speed of 4 km·h−1 using an optoelectric sensor system. Other studies, such as the one by Shin et al., [13] reported different gait characteristics in radiographically determined flatfoot female patients aged 52–80 years. These patients exhibited lower cadence and stride length but showed greater step width, longer step times, and a prolonged stance phase duration in the gait cycle compared to healthy controls with a neutral foot type. The measurements in this study were conducted during overground walking using a 12-camera motion analysis system. Fujishita et al. [23] using an in-shoe plantar pressure measuring system and a wearable inertial sensor found marginally statistically significant greater cadence, lower gait cycle time, and similar stance and swing phase of gait expressed as a percentage of gait cycle time between adolescent athletes with rearfoot eversion and control groups according to a leg heel angle of 7°. The differences between studies may be attributed to the multifactorial approach required to monitor gait in individuals with foot hyperpronation, as it is influenced by a combination of factors including the hyperpronation classification method (e.g., radiographic, scale-based, anthropometric [13,34,49]), the subjects’ age (young vs. older individuals [13,49]), and the gait analysis technique used (instrumented treadmill, sensor mats, optoelectric systems, and motion analysis systems [13,23,34,49]). This difficulty also may depend on whether foot hyperpronation was experimentally induced or acquired [33], and whether the subjects were symptomatic or asymptomatic [49,50].
The spatiotemporal parameters assessed in this study during both level and sloped walking may not have been influenced in the hyperpronated foot type group, as potential musculoskeletal adaptations to this misalignment may not have had sufficient time to develop, possibly due to the young age of the participants, and were therefore limited or absent. Alternatively, any existing adaptations may have compensated for the adverse effects of foot hyperpronation, preventing noticeable changes in gait parameters. In this context, several investigators have demonstrated significant differences in the peak and overall range of motion across the lower limb joints, including the forefoot, midfoot, and rearfoot joints, as well as the knee, hip, and pelvis between individuals with overpronated and neutral foot type [15,17,33,51,52]. However, the kinematic changes between groups were generally small and challenging to compare. It is possible that biomechanical deviations are not substantial enough to disrupt spatiotemporal parameters since hyperpronation primarily affects foot mechanics rather than the overall gait cycle, allowing spatial and temporal elements of gait to stay within normal ranges. Additionally, muscles that support the arch, such as the abductor hallucis [16,29], along with the flexor digitorum brevis and longus [17,53], have demonstrated hypertrophic changes in individuals with foot hyperpronation. These individuals also show increased EMG activity in the long (e.g., tibialis posterior, tibialis anterior, flexor hallucis longus), and short muscles of the foot (e.g., abductor hallucis, flexor digitorum brevis) involved in gait [54,55,56]. Such adaptations may ultimately enhance foot stability, facilitate efficient propulsion, and prevent changes in spatiotemporal gait parameters. This effect is particularly noticeable during uphill walking, where a collapsed medial foot arch in individuals with hyperpronated feet is expected to impact propulsive ability and related spatiotemporal parameters. Because uphill walking requires increased effort to propel forward while countering both higher frictional resistance during toe-off and stronger gravitational forces, compensatory muscle activation plays a key role. Increased activation of the tibialis anterior during the contact phase and the tibialis posterior during midstance and propulsion may enable individuals with foot hyperpronation to offset reduced plantar flexor moments [33], reinforce medial longitudinal arch stability, and ultimately achieve effective propulsion with gait characteristics similar to those of a neutral foot type. The same adaptive neuromuscular mechanism may also apply during downhill walking, where participants decelerated to counteract gravity-assisted propulsion and manage the increased friction demands of heel strike.
Both foot type groups also demonstrated increased outward foot rotation during uphill walking and increased step width during downhill walking compared to level walking. Individuals with hyperpronated feet showed greater, albeit non-significant, outward foot rotation compared to those with neutral feet, likely compensating for the restricted ankle dorsiflexion observed in the present study. This response may be further influenced by the increased activation of the peroneus longus and biceps femoris during uphill walking, which facilitate foot eversion, abduction, and external rotation of the tibia, helping to prevent tripping and improve foot contact for effective propulsion [57,58]. The increased step width during downhill walking was likely a response to heightened lateral instability induced by the ankle joint’s open-packed position in plantar flexion during heel strike, combined with eccentric muscle contractions and proprioceptive disturbances that occur during downhill walking [59,60,61].

4.2. Anteroposterior and Mediolateral Locations of COP

Our findings demonstrated a significant interaction between foot type and walking condition for both the anteroposterior and mediolateral locations of the COP. The COP was located more anteriorly in the hyperpronated foot group across all but uphill walking at the maximum slope, compared to individuals with neutral foot type. To the best of our knowledge, no other studies have determined the COP based on a cyclograph, which involves connecting the COP trajectories from the forefoot of one side to the rearfoot of the contralateral side during selected gait cycles. Consequently, direct comparisons with previous research are not possible. However, the few available studies investigating this biomechanical feature have shown that the COP pathway of the flat feet group tends to be abnormal, moving straight from the heel to the toe without the medial shifting in the forefoot that is typically observed in individuals with a neutral foot type [27]. Other investigators have shown that increased foot pronation displaces the COP posteriorly [33], which contrasts with the findings of the present study. Our findings indicate an anterior shift in the COP in the hyperpronated foot group across most tested gait conditions, coinciding with an increased exertion of vGRFs further toward the forefoot compared to the neutral foot type group, a response that has been observed in both current and previous findings [24,26]. The forward location of the COP was further amplified during uphill walking, likely due to a more pronounced forward shift in the center of mass ahead of the foot’s center. This shift may occur as the trunk leans forward in an attempt to enhance forward propulsion relative to the center of support against gravity, counterbalancing the increased gravitational forces acting on the body during uphill walking [62,63].
The results of the present study also showed significant mediolateral displacement of the COP in individuals with hyperpronation, but not in those with neutral feet. These results are aligned with recent data reported in healthy individuals tested under similar walking conditions [64]. Such responses likely reflect the need for greater lateral adaptations to maintain balance and stability on inclined surfaces in the hyperpronated foot type group. Individuals with hyperpronated feet are expected to demonstrate plastic deformation of the passive stabilizers of the subtalar joint due to the long-term effects of foot misalignment, with subsequent effects on joint proprioception [65,66,67]. This may potentially affect the mediolateral stability of the foot, particularly under more demanding conditions such as uphill and downhill walking.

4.3. Vertical Ground Reaction Forces

Our findings revealed that both groups exhibited similar magnitudes and patterns of vGRFs across all foot regions and walking conditions, with some notable exceptions. Subjects with hyperpronated feet demonstrated greater vGRFs in the midfoot region compared to those with neutral feet. Additionally, significantly lower vGRFs were exerted on the lateral forefoot and, occasionally, on the medial forefoot by subjects with hyperpronated feet compared to their neutral foot counterparts in nearly all tested gait conditions
Similarly to our findings, some researchers have reported increased forces on the entire midfoot region [68] or the medial midfoot region [24] in hyperpronated feet, as well as weak to fair relationships between peak pressure exerted on the medial midfoot and various indices used in the classification of hyperpronation [69]. Other investigators have also reported lower forces and/or pressures under the fourth and fifth metatarsophalangeal joints, anatomical structures located in the lateral forefoot region, thereby supporting our results [24,26,27,48,51]. Our findings did not confirm previous observations of increased peak pressure under the middle region of the forefoot, which includes the second and third metatarsophalangeal joints [48,70], and decreased forces on either the entire or the lateral region of the rearfoot [26,27]. Some researchers have shown greater forces and pressures under the hallux [26,28,48,69] and the second toe [48], but these findings could not be supported by our data due to the inability to distinguish between the various regions of the toes.
The increased forces in the midfoot are likely due to the misalignment of the subtalar joint and the associated collapse or flattening of the medial longitudinal arch. Kinematic studies have demonstrated significantly higher peak rearfoot eversion [17,51,52] and an increased medial deviation in the trajectory of the center of pressure [29,48]. Furthermore, the ligament laxity resulting from repetitive stress on plantar ligaments, such as the spring ligament [67], may allow the medial longitudinal arch to collapse more easily during gait, as evidenced by the increased relative vertical displacement of the navicular bone [71]. These changes may explain the redistribution of plantar loads, placing greater stress on the midfoot region as the foot compensates for the altered joint alignment and reduced stability. Additionally, as the medial longitudinal arch collapses and the foot excessively pronates, the structures in the inner region of the foot, such as the second and third metatarsophalangeal joints, may become overburdened. This diminishes the forces exerted on structures located in the medial region (first metatarsophalangeal joint) and, more notably, the lateral regions (fourth and fifth metatarsophalangeal joints) of the forefoot [24,26,27] and, consequently, reducing their contribution in supporting body weight during gait.
Comparisons between slopes revealed that midfoot forces were lower during uphill and level walking compared to downhill walking. Excessive pronation facilitates forefoot contact with the ground and, by increasing the relative distance between the calcaneus and metatarsals, imposes greater strain on the plantar fascia while impairing the efficient function of the windlass mechanism [72]. However, increased ankle dorsiflexion during uphill walking facilitates the windlass mechanism by enhancing plantar fascia tension through the stretch of the Achilles tendon, whose collagen fibers envelop calcaneus and integrate into its superficial layers [62,72,73]. These responses may be even more pronounced in individuals with hyperpronated feet, as plantar fascia tension is likely to increase more due to passive stretching of a tighter Achilles tendon, as indicated by the reduced range of motion of ankle dorsiflexion exhibited by these individuals compared to those with neutral foot posture in this study. Ultimately, these responses may reduce medial longitudinal arch depression and subsequently lower the vGRFs at the midfoot. In contrast, during downhill walking, the anticipated reduction in ankle dorsiflexion range [62] may decrease the tensile loading of the Achilles tendon on the plantar fascia [74]. This increased compliance may lead to greater medial longitudinal arch depression, ultimately contributing to higher vGRFs. Clinically, this finding suggests that downhill walking may intensify repetitive loading, potentially leading to plantar fascia pathology, a common injury in individuals with hyperpronated feet [72,74,75].
The significantly lower vGRFs exerted on the lateral and occasionally on the medial, regions of the forefoot, remained lower in individuals with hyperpronation compared to those with a neutral foot during all walking conditions. These regions, along with the inner forefoot, generally exhibited greater vGRFs during level and uphill walking compared to downhill walking. Conversely, the vGRFs exerted on the rearfoot were greater during downhill compared to uphill walking. These findings highlight the crucial role of the forefoot in facilitating propulsion during uphill walking and the heel in absorbing the impact of deceleration during downhill walking, despite hyperpronation-related alterations in vGRFs distribution across foot regions [64].

4.4. Limitations

The results of this study should be evaluated considering certain limitations related to the sample characteristics and the methodology of the study, which may affect the generalizability of the findings. The participants in our study were young, asymptomatic, and physically active individuals, factors that could potentially limit the applicability of the results to older individuals, those with symptoms, and less active populations. Previous studies have indicated that beyond the adaptations expected from repetitive loading due to foot misalignment, older individuals are likely to exhibit muscle atrophy in the arch-supporting muscles such as the abductor hallucis and flexor hallucis brevis muscles [76]. These muscles may also be less developed in inactive individuals compared to the more developed muscles typically found in healthy, athletically active individuals [17,77,78], such as the participants in our study, affecting foot stability and, consequently, the ability to maintain an undisturbed gait. Additionally, the presence of symptoms can affect gait kinematics and the related parameters, even if the symptoms are manifested more centrally (e.g., lower back pain) [49]. Furthermore, participants were assessed barefoot, which may alter the results, as footwear is a significant variable that influences gait mechanics in individuals with hyperpronation [25]. The classification of hyperpronation is another limitation, as inconsistencies exist among tests regarding the identification of affected individuals [79]. Finally, our findings should be interpreted within the context of the specific technique used for gait analysis, as different methods may produce varying results [80]. To enhance the generalizability of findings, future research should include diverse populations, such as older adults, symptomatic individuals, and those with varying activity levels with various degrees of hyperpronation, employ multiple assessment methods to accurately identify hyperpronation of the feet, and implement standardized methodologies alongside advanced technologies, such as wearable sensors and machine learning algorithms, under various footwear conditions.

4.5. Clinical Significance

Integrating treadmill-based gait analysis across various disciplines such as physical therapy, sports science, orthotics, and footwear design, provides a comprehensive approach to understanding and managing hyperpronation, leading to improved mobility, performance, and quality of life for affected individuals. Within physical therapy contexts, instrumented treadmill-based gait analysis may enable physical therapists to identify individuals with hyperpronated feet and monitor their progress through personalized rehabilitation programs allowing for adjustments in therapy to ensure optimal outcomes. These interventions often include strengthening and flexibility exercise programs targeting the foot and leg muscles to support the arches and prevent tightness in the Achilles tendon [81], as well as gait retraining programs that provide real-time feedback during walking assessments, enabling precise monitoring and adjustment of gait patterns [82]. The use of instrumented treadmills in rehabilitation settings may also facilitate comprehensive gait analysis and monitoring in individuals with hyperpronated foot types during prolonged walking sessions. Unlike short-duration assessments, extended walking induces ground reaction forces that generate external moments on lower limb joints, necessitating internal moments from muscle activation to maintain joint stability [83,84]. Prolonged walking may alter these dynamics, affecting muscle activation patterns and the alignment of lower extremity joints, pelvis, and spine, potentially influencing gait parameters, and contributing to joint pathology [11].
Sports scientists and trainers can benefit from the controlled environment provided by treadmill-based gait analysis to personalize training programs aimed at enhancing athletic performance and preventing injuries associated with hyperpronation, such as shin splints and knee pain. This approach involves selecting appropriate footwear and designing exercises to correct biomechanical imbalances, thereby maximizing training outcomes [85].
Gait analysis techniques, such as plantar pressure mapping, enable also specialists to assess the effectiveness of custom or prefabricated orthotics designed to provide necessary arch support, correct foot positioning, and alleviate discomfort associated with hyperpronation. This personalized assessment facilitates the adjustment of orthotic devices to meet each patient’s unique needs, enhancing mobility and reducing pain while ensuring optimal support and comfort. Furthermore, analyzing the interaction between hyperpronated feet and various shoe designs under dynamic conditions enables footwear designers to optimize features that provide enhanced support and stability, such as appropriate arch support, effectively managing hyperpronation [86,87].

5. Conclusions

Our findings revealed that spatiotemporal gait parameters during both level and sloped walking remained unchanged in individuals with hyperpronated feet, indicating the presence of potential compensatory mechanisms that facilitate the maintenance of a relatively stable and controlled gait cycle despite structural deviations. However, the observed increase in vGRFs exerted on the midfoot is clinically significant, as it suggests altered load distribution and impact forces, which could lead to long-term musculoskeletal injuries in the foot and other centrally located weight-bearing joints of the lower limb. Understanding these factors aids clinicians in developing more targeted interventions, such as orthotic support or specific strengthening exercises, to mitigate potential adverse effects while preserving functional gait.

Author Contributions

Conceptualization, N.K. and D.M.; methodology, N.K. and D.M.; formal analysis, N.K. and I.K.; investigation, N.K.; resources, D.M.; data curation, I.K.; writing—original draft preparation, D.M.; writing—review and editing, D.M.; visualization, D.M.; supervision, D.M.; project administration, N.K. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Bioethics Committee of the School of Physical Education and Sport Science of the National and Kapodistrian University of Athens (Reg. No 1486/15-02-2023).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

The data presented in this study are available upon request from the corresponding author.

Conflicts of Interest

The authors declare no conflicts of interest.

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Figure 1. Regions of the plantar surface of the foot analyzed for vGRFs. MRF = medial rearfoot; LRF = lateral rearfoot; MF = midfoot; MFF = medial forefoot; IFF = inner forefoot; LFF = lateral forefoot.
Figure 1. Regions of the plantar surface of the foot analyzed for vGRFs. MRF = medial rearfoot; LRF = lateral rearfoot; MF = midfoot; MFF = medial forefoot; IFF = inner forefoot; LFF = lateral forefoot.
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Figure 2. Means and standard deviations (error bars) for normalized (a) stride length, and (b) step width in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking. Significantly different compared to a A (p < 0.001); b A and B (p < 0.001); c A, B, and C (p < 0.001); d B, C, and D (p < 0.001); e C and D (p < 0.01); f A (p < 0.001) and B (p < 0.01) walking conditions. %LL = percentage of leg length.
Figure 2. Means and standard deviations (error bars) for normalized (a) stride length, and (b) step width in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking. Significantly different compared to a A (p < 0.001); b A and B (p < 0.001); c A, B, and C (p < 0.001); d B, C, and D (p < 0.001); e C and D (p < 0.01); f A (p < 0.001) and B (p < 0.01) walking conditions. %LL = percentage of leg length.
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Figure 3. Means and standard deviations (error bars) for foot rotation in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking. Significantly different compared to a B (p < 0.01); b B (p < 0.001); c A, B, and C (p < 0.001); d A (p < 0.05) and B (p < 0.001); e A, B, C, and D (p < 0.001); f A and B (p < 0.001), C (p < 0.01) and D (p < 0.05) walking conditions.
Figure 3. Means and standard deviations (error bars) for foot rotation in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking. Significantly different compared to a B (p < 0.01); b B (p < 0.001); c A, B, and C (p < 0.001); d A (p < 0.05) and B (p < 0.001); e A, B, C, and D (p < 0.001); f A and B (p < 0.001), C (p < 0.01) and D (p < 0.05) walking conditions.
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Figure 4. Means and standard deviations (error bars) for normalized (a) stride time and (b) cadence in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C), and uphill (D and E) walking. Significantly different compared to a A (p < 0.001); b B (p < 0.001); c A, B, and C (p < 0.001); d A, B, C, and D (p < 0.001) walking conditions.
Figure 4. Means and standard deviations (error bars) for normalized (a) stride time and (b) cadence in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C), and uphill (D and E) walking. Significantly different compared to a A (p < 0.001); b B (p < 0.001); c A, B, and C (p < 0.001); d A, B, C, and D (p < 0.001) walking conditions.
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Figure 5. Means and standard deviations (error bars) of the (a) anteroposterior and (b) mediolateral center of pressure (COP) location in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking. Negative numbers on the vertical axis of the graphs indicate the posterior and left locations of the COP in the anteroposterior and mediolateral axes, respectively. Significantly different compared to a A (p < 0.05); b B and C (p < 0.001); c A, B, C and D (p < 0.001); d A and B (p < 0.001); e A (p < 0.05) and B (p < 0.001) walking conditions. * p < 0.05; ** p < 0.01.
Figure 5. Means and standard deviations (error bars) of the (a) anteroposterior and (b) mediolateral center of pressure (COP) location in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking. Negative numbers on the vertical axis of the graphs indicate the posterior and left locations of the COP in the anteroposterior and mediolateral axes, respectively. Significantly different compared to a A (p < 0.05); b B and C (p < 0.001); c A, B, C and D (p < 0.001); d A and B (p < 0.001); e A (p < 0.05) and B (p < 0.001) walking conditions. * p < 0.05; ** p < 0.01.
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Figure 6. Means and standard deviations (error bars) and pairwise comparisons for maximum vertical ground reaction forces (vGRFs) normalized to body mass (BM) across plantar foot regions during walking under the following conditions: (a) −20% slope, 3.5 km·h−1 (A); (b) −10% slope, 5.0 km·h−1 (B); (c) 0% (level), 5.0 km·h−1 (C); (d) +10% slope, 3.5 km·h−1 (D); and (e) +20% slope, 2.5 km·h−1 (E) for individuals with hyperpronated and neutral foot types. LRF = lateral rearfoot; MRF = medial rearfoot; MIF = midfoot; LFF = lateral forefoot; IFF = inner forefoot; MFF = medial forefoot. * p < 0.05; ** p < 0.01; *** p < 0.001.
Figure 6. Means and standard deviations (error bars) and pairwise comparisons for maximum vertical ground reaction forces (vGRFs) normalized to body mass (BM) across plantar foot regions during walking under the following conditions: (a) −20% slope, 3.5 km·h−1 (A); (b) −10% slope, 5.0 km·h−1 (B); (c) 0% (level), 5.0 km·h−1 (C); (d) +10% slope, 3.5 km·h−1 (D); and (e) +20% slope, 2.5 km·h−1 (E) for individuals with hyperpronated and neutral foot types. LRF = lateral rearfoot; MRF = medial rearfoot; MIF = midfoot; LFF = lateral forefoot; IFF = inner forefoot; MFF = medial forefoot. * p < 0.05; ** p < 0.01; *** p < 0.001.
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Table 1. Means ± standard deviations of anthropometric measurements of the study sample in individuals with hyperpronated and neutral foot type.
Table 1. Means ± standard deviations of anthropometric measurements of the study sample in individuals with hyperpronated and neutral foot type.
SideGroups
HFT (n = 21)NFT (n = 21)Total (n = 42)
Sex (M/F) 11/1011/1022/20
Age (yrs) 24.4 ± 2.723.8 ± 3.124.1 ± 2.9
Body Mass (kg) 71.0 ± 14.368.5 ± 9.769.8 ± 12.1
Height (m) 1.7 ± 0.11.7 ± 0.11.7 ± 0.1
Body Mass Index (kg·m−1) 20.5 ± 3.319.9 ± 2.320.2 ± 2.9
FPI-6 scoreR10.6 ± 1.12.4 ± 1.5 **6.5 ± 4.3
L10.5 ± 0.92.6 ± 1.3 **6.5 ± 4.2
Leg length R88.7± 6.187.0 ± 4.087.8 ± 5.1
L88.7± 6.187.0 ± 4.187.8 ± 5.2
Ankle dorsi flexion (°)R53.8 ± 5.150.0 ± 6.0 *51.9 ± 5.8
L53.6 ± 5.550.0 ± 5.8 *51.8 ± 5.9
Note: HFT = hyperpronated foot type; NFT = neutral foot type; * p < 0.05; ** p < 0.001.
Table 2. Means ± standard deviations of the duration of stance phase, swing phase, and double-standing phase in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking.
Table 2. Means ± standard deviations of the duration of stance phase, swing phase, and double-standing phase in individuals with hyperpronated and neutral foot type during downhill (A and B), level (C) and uphill (D and E) walking.
Gait PhasesGroupWalking Conditions (Slope/Speed)
ABCDE
−20%−10%0%+10%+20%
3.5 km·h−15.0 km·h−15.0 km·h−13.5 km·h−12.5 km·h−1
Stance phase (%LL)HFT62.4 ± 0.960.8 ± 0.6 a61.8 ± 0.9 b64.6 ± 0.9 d66.6 ± 1.0 e
NFT62.9 ± 1.160.9 ± 1.1 a61.7 ± 1.1 c64.7 ± 1.3 d67.5 ± 1.6 e
Load response (%LL)HFT12.4 ± 0.910.8 ± 0.6 a11.8 ± 0.9 b14.6 ± 0.9 d 16.6 ± 1.0 e
NFT12.9 ± 1.110.9 ± 1.1 a11.7 ± 1.1 c14.7 ± 1.3 d17.5 ± 1.6 e
Mid-stance (%LL)HFT37.6 ± 0.939.2 ± 0.6 a38.2 ± 0.9 b35.4 ± 0.9 d33.4 ± 1.0 e
NFT37.1 ± 1.139.1 ± 1.1 a38.3 ± 1.1 c35.3 ± 1.3 d32.5 ± 1.6 e
Pre-swing (%LL)HFT12.4 ± 0.910.8 ± 0.6 a11.8 ± 0.9 b14.6 ± 0.9 d16.6 ± 1.0 e
NFT12.9 ± 1.110.9 ± 1.1 a11.7 ± 1.1 c14.7 ± 1.3 d17.5 ± 1.6 e
Swing phase (%LL)HFT37.6 ± 0.939.2 ± 0.6 a38.2 ± 0.9 b35.4 ± 0.9 d33.4 ± 1.0 e
NFT37.1 ± 1.139.1 ± 1.1 a38.3 ± 1.1 c35.3 ± 1.3 d32.5 ± 1.6 e
Note: HFT = Hyperpronated foot type; NFT = Neutral foot type; LL = Leg length. Significantly different compared to a A (p < 0.001), b A (p < 0.05) and B (p < 0.001), c A and B (p < 0.001), d A, B, and C (p < 0.001); e A, B, C, and D (p < 0.001) walking conditions.
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Kamitsou, N.; Kafetzakis, I.; Mandalidis, D. Static Foot Hyperpronation Monitoring in Asymptomatic Young Individuals During Level and Sloped Gait Using an Instrumented Treadmill. Appl. Sci. 2025, 15, 3209. https://doi.org/10.3390/app15063209

AMA Style

Kamitsou N, Kafetzakis I, Mandalidis D. Static Foot Hyperpronation Monitoring in Asymptomatic Young Individuals During Level and Sloped Gait Using an Instrumented Treadmill. Applied Sciences. 2025; 15(6):3209. https://doi.org/10.3390/app15063209

Chicago/Turabian Style

Kamitsou, Natalia, Ioannis Kafetzakis, and Dimitris Mandalidis. 2025. "Static Foot Hyperpronation Monitoring in Asymptomatic Young Individuals During Level and Sloped Gait Using an Instrumented Treadmill" Applied Sciences 15, no. 6: 3209. https://doi.org/10.3390/app15063209

APA Style

Kamitsou, N., Kafetzakis, I., & Mandalidis, D. (2025). Static Foot Hyperpronation Monitoring in Asymptomatic Young Individuals During Level and Sloped Gait Using an Instrumented Treadmill. Applied Sciences, 15(6), 3209. https://doi.org/10.3390/app15063209

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