Clinical Biomechanics 29 (2014) 11581163

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Clinical Biomechanics
journal homepage: www.elsevier.com/locate/clinbiomech

The effect of good and poor walking shoe characteristics on plantar

pressure and gait in people with gout
Sarah Stewart a,, Nicola Dalbeth d,e, Peter McNair a, Priya Parmar b,c, Peter Gow d, Keith Rome a
a
Health and Rehabilitation Research Institute, Auckland University of Technology, AUT North Shore Campus, Private Bag 92006, Auckland 1142, New Zealand
b
The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand
c
Auckland District Health Board, Private Bag 92024, Auckland Mail Centre, Auckland 1142, New Zealand
d
Counties Manukau District Health Board, Private Bag 94052, South Auckland Mail Centre, Manukau, Auckland 2240, New Zealand
e
Faculty of Health and Environmental Sciences, Auckland University of Technology, AUT North Shore Campus, Private Bag 92006, Auckland 1142, New Zealand

a r t i c l e i n f o a b s t r a c t

Article history: Background: Previous research has shown that good footwear characteristics may reduce foot pain and foot-
Received 21 July 2014 related disability in people with gout. The aim of this study was to determine the effect of good and poor footwear
Accepted 23 September 2014 characteristics on plantar pressure and spatiotemporal parameters of gait in people with gout.
Methods: Thirty-six people with gout participated in a cross-sectional repeated measures study. Plantar pressure
Keywords: and spatiotemporal parameters were recorded in two shoe conditions: (1) the participants own footwear, and
Gout
(2) either a new pair of walking shoes with good footwear characteristics (n = 21) or poor characteristics
Footwear
Plantar pressure
(n = 15). Differences between good and poor shoe groups compared to participants own shoes were also
Spatiotemporal determined.
Gait Findings: Compared to participants own shoes, footwear with good characteristics signicantly reduced peak
pressure at metatarsal 3 and 5, reduced pressure time integrals beneath the heel and metatarsals 3 and 5 and
increased pressure time integrals beneath the midfoot. The footwear with poor characteristics signicantly
increased peak pressure beneath the heel and lesser toes, reduced peak pressure at metatarsal 3 and reduced
pressure time integrals in the midfoot compared to participants own shoes. Both good and poor footwear
signicantly increased walking velocity, step length, and stride length compared to participants own shoes.
Interpretation: Walking shoes with good footwear characteristics can inuence plantar pressure values and
encourage a more efcient heel to toe gait pattern in people with gout. These changes may contribute to the
reduction in foot pain and foot-related problems in this population.
2014 Elsevier Ltd. All rights reserved.

1. Introduction
Gout is a form of inammatory arthritis caused by the deposition
of monosodium urate (MSU) crystals in joints and soft tissue. The
disease is characterized by painful acute ares and may progress to
a tophaceous disease and erosive arthritis. Gout has a predilection
to affect the feet, with the knee and smaller joints of the feet the
most commonly affected (Dalbeth et al., 2013). Involvement of the
rst metatarsophalangeal joint (1MTP) is regarded as a discriminatory
diagnostic feature of the disease (Prowse et al., 2013). In a recent
study using dual-energy computed tomography to examine bones and
tendons in patients with gout, Dalbeth et al. (2013) found the rst
metatarsal head was the most commonly affected by MSU deposition
(38%), followed by the lateral malleolus (25%) and proximal calcaneus
(25%). MSU deposition was also observed frequently at the Achilles
tendon (39%) and the peroneal tendons (20%). The clinical relevance
Corresponding author.
E-mail address: sarah.stewart@aut.ac.nz (S. Stewart).
of this is currently unknown despite the important role that tendons
play in musculoskeletal function and gait.
People with gout report signicant foot pain, impairment and dis-
ability during acute ares which cause severe restrictions in activities
related to daily living and recreation (Rome et al., 2012a,b). Importantly,
more than half of patients still report moderate foot-related problems
during intercritical periods (Rome et al., 2012a). Furthermore, everyday
tasks such as walking are rated very highly by people with gout as a dis-
criminatory feature of the disease (Prowse et al., 2013). Our previous
work has shown that people with gout have a signicantly reduced
walking speed compared to healthy controls, which emphasizes the
extent of walking disability in this population (Rome et al., 2012b).
Emerging evidence suggests that footwear to be an effective non-
surgical and non-pharmacological intervention in inammatory disease
(Dufour et al., 2009). However, poorly tting shoes have also been
linked to foot pain in rheumatoid arthritis (Silvester et al., 2010) and
poor footwear characteristics that include inadequate stability, and
poor cushioning have been reported to exacerbate foot pain, disability
and impairment in people with gout (Rome et al., 2011a). Furthermore,

http://dx.doi.org/10.1016/j.clinbiomech.2014.09.009
0268-0033/ 2014 Elsevier Ltd. All rights reserved.
 S. Stewart et al. / Clinical Biomechanics 29 (2014) 11581163 1159

we have recently reported that poor footwear may contribute to the Randomization involved the presentation of one of a series of sealed en-
development and delayed healing of ulceration in people with gout velopes, indicating the order in which the footwear was to be assessed
(Rome et al., 2014). Previous plantar pressure studies in other chronic by the participant. Participants were blinded to footwear brands and
conditions such as diabetes and rheumatoid arthritis have focused on logos during their selection to ensure they based their choice on com-
relieving areas of high pressure through footwear in order to reduce fort, t, style, sole and weight. Brand names and logos were concealed
pain and the risk of tissue damage (Bus et al., 2009; Hennessy et al., using small lengths of black masking tape, which did not cover any of
2007; Kastenbauer et al., 1998; Lavery et al., 1997; Mueller, 1999; the design features of the shoe. At the baseline visit, patients participat-
Perry et al., 1995). Interestingly, people with gout have been shown to ed in this repeated-measures study, in which each individual walked in
exhibit high pressure patterns in the midfoot and heel only, when com- two different conditions: (1) their own footwear, and (2) their chosen
pared to controls, while pressure values beneath the hallux are reduced new study footwear. For the purpose of this analysis, participants
(Rome et al., 2012b). Coupled with the reduced walking speed also were stratied into two groups based on their chosen study footwear:
observed in this population, these pressure patterns may reect inef- (1) the good shoe group (Cardio Zip) (n = 21) and (2) the poor shoe
cient propulsion and forward load progression (Rome et al., 2012b). group (Viper, Apollo, Asteroid) (n = 15) (Fig. 1).
The role of footwear in gout may therefore be to encourage normal
heel to toe loading and gait efciency in order to reduce abnormal strain
2.2. Participants
on areas of the foot prone to crystal deposition including the rst
metatarsophalangeal joint and Achilles tendon.
Participants were recruited from the rheumatology clinics based at
Our group has previously undertaken an 8-week prospective
the Auckland and Counties Manukau District Health Boards, Auckland,
intervention study comparing the effect of four different participant-
New Zealand. As previously reported (Rome et al., 2013), participants
selected walking shoes on patient-reported foot pain and disability in
were included if they were (i) over 18 years of age, (ii) had a history
gout (Rome et al., 2013). The shoe with good characteristics (ASICS
of gout according to the 1977 ACR preliminary classication criteria
Cardio Zip; RRP US$225) was both acceptable to patients in terms of
(Wallace et al., 1997) and (iii) were able to walk a minimum of 10 m
comfort, t and support. This resulted in signicantly greater improve-
without the use of a walking aid. They were excluded if they had
ments in pain, impairment and disability at the 8-week follow-up
(i) received any treatment for foot pain in the previous 4 weeks,
compared to the three low-cost shoes classed with poor footwear char-
(ii) an acute gout are at the time of assessment, (iii) a history of
acteristics (Helix Viper, Dunlop Apollo, and Dunlop Asteroid; RRP US
surgery to the foot or (iv) received treatment with foot orthoses
$30-35). A number of features in the Cardio Zip shoe, which were
or footwear within the previous 3 months. The Northern Regional
lacking in the other three shoe types, may have been responsible for
X Ethics approved this study and local institutional approval was
the reduction in pain and disability (Rome et al., 2013). The medial
also obtained. All participants provided written informed consent. The
size zip closure in the Cardio Zip shoe enhances the ease of putting on
trial was registered with the Australian New Zealand Clinical Trials
and taking off the shoe. The Cardio Zip shoe also uses a dual-density
Registry (ACTRN12612000735853).
midsole system to control motion (Rome et al., 2013). Barton et al.
(2009) reported that the motion control properties of footwear are
considered an important shoe feature in the management of patients
with rheumatoid arthritis and musculoskeletal injuries. Another feature
of the Cardio Zip shoe that may have reduced foot pain was the use
of gel cushioning in the heel and forefoot regions to improve shock
attenuation. This shoe element was not present in the other three
shoe types. Dufour et al. (2009) reported that shoes that have softer out-
soles and midsoles, or insoles that use elements of gel, foamed polyure-
thane or air chambers can smooth (low pass lter) the shock wave
associated with foot-strike. Finally, the Cardio Zip shoe midsole/outsole
has a rocker type system to create a smoother heel to toe transition
during the gait cycle while maintaining both stability and comfort.
Previous studies have reported that the toe rocker-soled shoe is thought
to reduce pain by decreasing forefoot loading and promoting a normal
heel-toe motion during gait (Bagherzadeh et al., 2013; Cho et al.,
2009; Fong et al., 2012); Cho et al. (2009) reported that rocker-soled
shoes with comfortable insoles may be enough to reduce foot pain
and increase foot function for people with rheumatoid arthritis. It is
unknown how good and poor footwear characteristics inuence the
functional and biomechanical characteristics of the foot and whether
this may contribute to the improvement observed in patient outcomes.
The aim of this study was to determine the effect of shoes with good
and poor footwear characteristics on plantar pressure and gait parame-
ters in people with gout.

2. Methods

2.1. Study design

This study was conducted at the start of a larger prospective inter-

vention study in which 36 participants with gout selected one of four
pairs of new commercially-available walking shoes which they wore
for an 8-week period (Rome et al., 2013). At the baseline visit, all partic-
ipants tried each of the shoes in a randomly determined order.
Fig. 1. Cross section of study shoes. (A) Shoe with good footwear characteristics (Cardio
Zip). (B) Shoe with poor footwear characteristics (Dunlop Asteroid). (For interpretation
of the references to colour in this gure, the reader is referred to the web version of this
article.)
1160 S. Stewart et al. / Clinical Biomechanics 29 (2014) 11581163

2.3. Study procedure Table 1

Participant demographics.

Clinical data were collected including age, gender, ethnicity, body Good Poor
mass index and gout disease characteristics. Participants own shoes n = 21 n = 15
were assessed and the age of their shoes were recorded as b6 months Age, years, mean (SD) 57 (13) 58 (14)
old, 6 to 12 months old, and N12 months old. Male, n (%) 20 (95%) 13 (87%)
Plantar pressure readings were obtained using the F-Scan Mobile Ethnicity, n (%) 9 (43%) European 6 (40%) European
4 (19%) Mori 3 (20%) Mori
system (Tekscan Inc., South Boston, MA, USA), which incorporates
6 (29%) Pacic 3 (20%) Pacic
insoles with 960 different pressure-sensing locations (sensels) and a 2 (10%) Asian 3 (20%) Asian
spatial resolution of four sensels/cm2. Prior to data acquisition, the pres- BMI (kg/m2), mean (SD) 35 (8) 32 (7)
sure insoles were calibrated to the participants weight and participants Cardiovascular disease, n (%) 7 (33%) 9 (60%)
were instructed to walk freely in the clinical setting to ensure they felt Type 2 diabetes mellitus, n (%) 5 (24%) 2 (13%)
Diuretic use, n (%) 6 (29%) 3 (20%)
comfortable using the equipment. Data were acquired using the ve- Allopurinol use, n (%) 16 (76%) 13 (87%)
stride protocol in which seven strides were obtained for each foot Colchicine use, n (%) 12 (57%) 7 (47%)
with the rst and last strides excluded (Barker et al., 2006). Participants Prednisone use, n (%) 4 (19%) 6 (40%)
were instructed to walk at their own self-selected walking speed during NSAID use, n (%) 13 (62%) 9 (60%)
Serum urate, mmol/l, mean (SD) 0.41 (0.14) 0.36 (0.10)
data acquisition. Three trials of the ve-stride protocol were recorded
Disease duration, years, mean (SD) 13 (8) 18 (13)
for each shoe condition. Data analysis was conducted with the F- Age at rst episode, years, mean (SD) 44 (20) 40(19)
Scan software package (Tekscan Inc., Version 5.24). The plantar foot Self-reported ares in preceding 2 months, 6 (14) 1.5 (1.9)
was manually masked into 10 regions based upon automated masking mean (SD)
software protocols (Research Foot Software, Version 5.24), which is Days off work in last two months, 0.8 (2.6) 0 (0)
mean (SD)
reliable for capturing plantar pressure measurement in people with
In paid employment, n (%) 12 (57%) 5 (33%)
gout (Rome et al., 2011b). Mean peak pressure (KPa) and pressure Aspirate proven, n (%) 8 (38%) 7 (47%)
time integrals (KPa*sec) were calculated for the 10 masked regions. Foot tophus count, mean (SD) 1.4 (1.7) 1.1 (2.0)
The GAITMAT II TM was used to measure the following spatial Total tophus count, mean (SD) 4.0 (3.7) 5.1 (4.7)
Any subcutaneous tophus, n (%) 15 (71%) 11 (73%)
and temporal parameters of gait: step and stride length (m), velocity
(m/s) and cadence (steps/min). This device contains six arrays of sen-
sors encapsulated in a walkway, producing an active area of 1 m wide
and 3.7 m long. Each participant was asked to walk along its length at 3.3. Peak plantar pressure
his or her preferred comfortable walking speed (Barker et al., 2006).
Three repetitions were performed for each shoe condition. Peak pressure values for each of the 10 regions are presented in
Table 2. Compared to participants own footwear, the group who wore
the footwear with good characteristics demonstrated a signicant
2.4. Data analysis
reduction in pressure at metatarsal 5, while the poor shoe group dem-
onstrated signicant increases in peak pressure at the medial and lateral
Independent t-tests and chi-square tests were performed to test for
heel and lesser toes. Both good and poor shoe groups showed signicant
statistical differences in demographic characteristics between the good
and the poor shoe groups. Linear mixed models analyses were conduct- reductions in pressure at metatarsal 3 compared to their own footwear.
When comparing the good and poor shoe groups, signicant differences
ed to determine whether there were signicant differences in peak
pressure, pressure time integrals and spatial and temporal gait parame- were observed for lateral heel and metatarsal 5, with the good shoe
group showing reductions in pressure while the poor shoe group dem-
ters between the two shoe conditions: own shoes and study shoes.
Along with shoe condition as a xed effect, the interaction between onstrated increased pressure.
the two study shoe groups and shoe condition was also entered as
xed effects. The variation between right and left feet for each partici-
3.4. Pressuretime integrals
pant was accounted for through random effects. The signicance levels
for testing were adjusted using a Bonferroni correction. Analyses were
Table 3 presents the analysis of the Pressuretime Integrals (PTI).
performed using SPSS (v20.0, SPSS Inc., Chicago, IL, USA).
Compared to participants own shoes, the group who wore the foot-
wear with good characteristics produced a signicant reduction in
3. Results PTI at the medial and lateral heel and metatarsals 3 and 5. The good
shoe also resulted in a signicant increase in PTI under the midfoot,
3.1. Clinical characteristics while the shoe with poor characteristics demonstrated signicant
reductions in midfoot PTI. The study shoe groups also signicantly
Clinical characteristics at baseline for the participants are differed for medial and lateral heel where the good shoe group pro-
shown in Table 1. Patients were predominantly middle-aged men duced a signicantly greater decrease in PTI at the medial and lateral
with longstanding disease. Obesity and cardiovascular disease were heel compared to the poor shoe group. Comparison of the good and
common comorbidities. There were no signicant differences in the poor shoes for metatarsal 5 also demonstrated a signicant differ-
clinical characteristics between the good and poor shoe groups. ence with the good shoes decreasing pressure and the poor shoes
increasing pressure.
3.2. Characteristics of participants own shoes

Participants own shoes represented a range of styles: athletic shoes
(n = 12, 33%), Oxford shoes (n = 7, 19%), walking shoes (n = 5, 14%),
jandals (n = 4, 11%), boots (n = 3, 8%), moccasins (n = 2, 6%) and ther-
apeutic shoes (n = 1, 3%). Most shoes worn by participants were older
than 12 months (n = 16, 44%), or between 6 and 12 months old (n =
11, 31%), with few that were less than 6 months old (n = 6, 17%).
3.5. Gait parameters
The temporal-spatial gait parameters are presented in Table 4. There
was a signicant increase in walking velocity, step length and stride
length for both study shoes when compared to participants own
shoes. No signicant differences were observed for cadence.
 S. Stewart et al. / Clinical Biomechanics 29 (2014) 11581163 1161

Table 2
Peak pressure (kPa) linear mixed models analysis.

Parameter Mean estimate Difference 95% CI p-valuea Type III p-valuea

Lower Upper Good vs. poor

Medial heel Own (ref) 259.0 0.005

Good 260.5 1.5 11.4 14.3 0.823
Poor 286.8 27.8 14.4 41.3 0.000
Lateral heel Own (ref) 246.4 0.000
Good 231.9 14.5 27.4 1.6 0.028
Poor 284.9 38.5 25.0 52.1 0.000
Midfoot Own (ref) 184.4 0.261
Good 187.6 3.2 8.6 15.0 0.589
Poor 178.0 6.4 18.7 6.0 0.313
Metatarsal 1 Own (ref) 257.1 0.450
Good 272.5 15.4 1.5 32.3 0.073
Poor 263.2 6.1 11.6 23.8 0.498
Metatarsal 2 Own (ref) 304.1 0.659
Good 300.6 3.5 14.4 21.4 0.700
Poor 306.3 2.2 20.8 16.5 0.820
Metatarsal 3 Own (ref) 317.0 0.989
Good 290.5 26.5 43.8 9.2 0.003
Poor 290.3 26.7 44.8 8.6 0.004
Metatarsal 4 Own (ref) 231.9 0.179
Good 210.0 21.9 39.7 4.2 0.016
Poor 226.0 5.9 24.4 12.6 0.527
Metatarsal 5 Own (ref) 208.5 0.000
Good 183.1 25.4 40.1 10.8 0.001
Poor 225.2 16.6 1.4 31.9 0.033
Hallux Own (ref) 200.3 0.052
Good 209.8 9.6 7.7 26.9 0.277
Poor 185.4 14.9 33.1 3.3 0.108
Lesser toes Own (ref) 129.1 0.536
Good 137.7 8.6 0.8 16.4 0.030
Poor 141.2 12.1 4.0 20.2 0.003
a
Bolded values indicate signicance after Bonferroni correction at p b 0.0050.

Table 3
Pressure Time Integral (kPa*s) Linear Mixed Models Analysis.

Parameter Mean estimate Difference 95% CI p-valuea Type III p-valuea

Lower Upper Good vs. poor

Medial heel Own (ref) 64.61 0.003

Good 55.49 9.12 12.05 6.18 0.000
Poor 61.93 2.68 5.74 0.38 0.085
Lateral heel Own (ref) 60.89 0.001
Good 52.72 8.17 11.11 5.22 0.000
Poor 60.02 0.86 3.94 2.21 0.522
Midfoot Own (ref) 43.94 0.000
Good 49.71 5.77 3.44 8.09 0.000
Poor 40.18 3.75 6.19 1.32 0.003
Metatarsal 1 Own (ref) 50.31 0.557
Good 50.20 0.11 2.75 2.54 0.936
Poor 51.33 1.03 1.73 3.79 0.465
Metatarsal 2 Own (ref) 56.89 0.483
Good 53.51 3.38 6.45 0.31 0.031
Poor 55.07 1.83 5.03 1.37 0.261
Metatarsal 3 Own (ref) 58.77 0.020
Good 52.01 6.76 9.51 4.00 0.000
Poor 56.61 2.16 5.03 0.72 0.141
Metatarsal 4 Own (ref) 55.53 0.258
Good 51.39 4.14 7.03 1.25 0.005
Poor 53.71 1.82 4.84 1.20 0.237
Metatarsal 5 Own (ref) 53.95 0.0046
Good 48.24 5.71 9.66 1.76 0.0048
Poor 55.96 2.01 2.08 6.11 0.334
Hallux Own (ref) 30.64 0.566
Good 32.51 1.87 0.58 4.32 0.135
Poor 31.49 0.85 1.71 3.41 0.515
Lesser toes Own (ref) 21.86 0.262
Good 23.44 1.58 0.75 3.90 0.183
Poor 25.20 3.62 0.88 6.36 0.010
a
Bolded values indicate signicance after Bonferroni correction at p b 0.0050.
1162 S. Stewart et al. / Clinical Biomechanics 29 (2014) 11581163

Table 4
Gait parameters linear mixed models analysis.

Parameter Mean estimate Difference 95% CI p-valuea Type III p-valuea

Lower Upper Good vs. poor

Velocity Own (ref) 0.852 0.080

Good 0.883 0.031 0.020 0.042 0.000
Poor 0.898 0.047 0.033 0.060 0.000
Step length (m) Own (ref) 0.566 0.027
Good 0.581 0.015 0.007 0.022 0.000
Poor 0.593 0.027 0.019 0.036 0.000
Stride length (m) Own (ref) 1.142 0.053
Good 1.172 0.030 0.019 0.040 0.000
Poor 1.188 0.046 0.033 0.058 0.000
Cadence (steps/min) Own (ref) 90.517 0.427
Good 91.346 0.798 0.344 1.942 0.168
Poor 91.983 1.465 0.235 2.697 0.020
a
Bolded values indicate signicance after Bonferroni correction at p b 0.0125.

4. Discussion
This study has shown that new commercially-available walking
shoes inuence plantar pressures and spatiotemporal parameters of
gait in people with gout compared to their own shoes. Walking shoes
with good footwear characteristics resulted in signicantly different
plantar pressure values compared to shoes with poor footwear charac-
teristics for certain areas of the foot.
Wearers of the shoes with good characteristics displayed reductions
in heel PTI compared to participants own shoes while the poor charac-
teristic shoe wearers displayed signicant increases in heel peak pres-
sure. This may be attributed to the addition of the gel midsole and
advanced shock absorption properties in the rearfoot of the good shoe
and the hollow sole construction of the poor shoes (Hennessy et al.,
2007; Lane et al., 2014; Wegener et al., 2008). The small walking heel
bevel and inbuilt rocker feature of the good shoe may also have contrib-
uted to ankle plantarexion at heel contact and directed load forward at
heel contact (Kavros et al., 2011). Reduced heel PTI may be considered
benecial considering the high heel pressure values previously reported
in the gout population (Rome et al., 2012b).
The good shoes also demonstrated signicant increases in midfoot
PTI while the poor shoes showed reduced midfoot PTI. Our previous
casecontrol study found that patients with gout exhibited signicantly
greater midfoot PTI compared to controls which we hypothesized was
due to the increased duration of mid stance (Rome et al., 2012b). In
the current study, we believe the increased PTI in the good shoes can
be attributed to with the promotion of normal loading through the
shoes rocker feature which redistributes load away from the rearfoot
and forefoot (Brown et al., 2004; Bus et al., 2009; Schaff & Cavanagh,
1990).
The distribution of pressure in the forefoot also differed between the
shoe conditions. Compared to participants own shoes, the shoes with
good footwear characteristics demonstrated a decrease in pressure
and PTI beneath the third and fth metatarsals. These results are consis-
tent with other studies which have shown that rocker-soled shoes
(Brown et al., 2004; Bus et al., 2009; Kavros et al., 2011; Schaff &
Cavanagh, 1990) and athletic shoes with good footwear characteristics
(Bagherzadeh et al., 2013; Hennessy et al., 2007; Wiegerinck et al.,
2009) effectively decrease pressure across the forefoot. The absence of
any signicant pressure reduction in the medial forefoot may be due
to the good shoes Guidance Line which shifts pressure from the lateral
to medial forefoot for efcient propulsion. Although the poor shoes also
demonstrated a signicant reduction in plantar pressure at metatarsal 3
compared to participants own shoes, they produced a signicantly
greater increase in pressure time integrals at metatarsal 5 compared
to the good shoe wearers and a signicant increase in lesser toe plantar
pressure compared to participants own shoes. This may be attributed to
the minimal technology and cushioning in the poor shoes. Although our
previous work has demonstrated that people with gout exhibit reduced
pressure beneath the hallux compared to controls (Rome et al., 2012b),
and the footwear used in the current study did not inuence this area.
The gait parameters also differed between the participants own
shoes and their chosen study shoes. The shoes with good and poor
footwear characteristics performed similarly with signicant increases
observed for velocity, step and stride length compared to participants
own shoes. These results suggest that new shoes, regardless of their
characteristics, may be capable of altering walking parameters in people
with gout.
This study should be considered in light of limitations. The small
sample size in the current study was not powered as it resulted from
the sample size calculated for the larger prospective intervention
study (Rome et al., 2013). We acknowledge that this may have inated
any type II error. We acknowledge that the participants own footwear
varied and therefore resulted in unstandardized measurements taken
in this shoe condition. However, providing participants with a pair of
standardized footwear would have not reected a genuine clinical
setting. The high percentage of males in the current study reects the
greater prevalence of gout in the male population; it limits the general-
izability of the results to both genders. This study was conducted in
New Zealand where severe gout is frequently observed in Mori and
Pacic people suffer from tophaceous gout, which may also limit the
generalizability to other populations. Furthermore, we did not normal-
ize spatiotemporal parameters according to leg length or height.
Further longitudinal investigations would be benecial in evaluating
the effect of specic footwear characteristics on functional and biome-
chanical parameters of the foot in people with gout over a longer period
of time. We are currently conducting a single-blind randomized clinical
trial over 6-months with 140 people with gout to evaluate the effect of
walking shoes on pressure and gait. Future research looking at the cost-
effectiveness of commercially available footwear would provide further
insight into the potential use of this intervention in people with gout.
Foot problems continue to be common and disabling despite the
progress in pharmacological interventions. Future research examining
the effects of different footwear characteristics on foot function and
patient-reported outcomes, including rocker-sole shoes (Menz et al.,
2014), the location of different shoe exion points (Van der Zwaard
et al., 2014) or in combination with foot orthoses, would provide further
insight into the role of footwear in people with gout.
5. Conclusion
This study has shown that new walking shoes with good footwear
characteristics decrease heel and lateral forefoot pressure values and
increase midfoot pressure values in people with gout compared to
wearing their own footwear. In contrast, walking shoes with poor char-
acteristics increase heel, lateral forefoot and lesser toe pressure values
and decrease midfoot pressure values compared to participants own
footwear. The ndings from this study suggest that improvements in
 S. Stewart et al. / Clinical Biomechanics 29 (2014) 11581163
foot pain by people with gout who wear shoes with good footwear char-
acteristics may occur through alterations in plantar pressure patterns.
Conict of interest
The authors declare that they have no competing interests.
Acknowledgements
We thank Maria Lobo and Hazra Sahid (Rheumatology Nurse
Specialists) for their assistance with recruiting patients into the study.
This work was funded by the Health Research Council of New Zealand
(12/622).
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