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. Author manuscript; available in PMC: 2023 Jun 1.
Published in final edited form as: Clin Biomech (Bristol). 2022 May 7;96:105662. doi: 10.1016/j.clinbiomech.2022.105662

Midfoot and ankle movement coordination during heel rise is disrupted in people with diabetes and peripheral neuropathy

Hyo-Jung Jeong a,b, Baekdong Cha c, Jennifer A Zellers d, Ling Chen e, Mary K Hastings d
PMCID: PMC9616002  NIHMSID: NIHMS1840808  PMID: 35569256

Abstract

Background

A heel rise task can be used to evaluate midfoot and ankle movement dysfunction in people with diabetes mellitus and peripheral neuropathy. Quantifying movement coordination during heel rise is important to better understand potentially detrimental movement strategies in people with foot pathologies; however, coordination and the impact of limited excursion on coordination is not well-understood in people with diabetes.

Methods

Sixty patients with diabetes mellitus and peripheral neuropathy, and 22 older and 25 younger controls performed unilateral heel rise task. Midfoot (forefoot relative to hindfoot) sagittal and ankle (hindfoot relative to shank) sagittal and frontal kinematics were measured and normalized to time (0 to 100%). Cross-correlation coefficients were calculated across individuals in each group. A graphical illustration was used to interpret the relationship of midfoot and ankle excursion and cross-correlation coefficient during heel rise.

Findings

People with diabetes mellitus and peripheral neuropathy showed significantly lower midfoot and ankle cross-correlation coefficients during heel rise compared to older controls (p=0.003 – 0.007). There was no difference in the midfoot and ankle cross-correlation coefficients during heel rise for the older and younger controls (p=0.059 – 0.425). The graphic data illustrated a trend of greater excursion of two joints and a higher cross-correlation coefficient. Some individuals with lower excursion showed a high cross-correlation coefficient.

Interpretation

Foot pathologies, but not aging, impairs midfoot and ankle movement coordination during heel rise task. Investigating both movement coordination as well as joint excursion would better inform and characterize the dynamic movements of midfoot and ankle during heel rise task.

Keywords: Coupling, heel rise, peripheral neuropathy, aging, foot

1. Introduction

A heel rise task is a simple, clinical, diagnostic tool that has been commonly used to identify midfoot and ankle movement dysfunction (Chimenti et al., 2014; Hastings et al., 2014; Houck et al., 2009). The magnitude and direction of foot and ankle motions during heel rise performance (expected motion: midfoot and ankle plantarflexion and subtalar joint inversion) have been the primary methods for measuring and reporting movement deficits in a variety of foot-associated problems (e.g., diabetes associated foot deterioration, posterior tibialis tendon dysfunction) (Chimenti et al., 2014; Hastings et al., 2016; Hastings et al., 2014; Houck et al., 2009; Jeong et al., 2021b). While magnitude and direction of motion during heel rise is important, synchronous and coordinated movement of the midfoot and ankle is critical for optimal heel rise performance (DiLiberto and Nawoczenski, 2020; Jeong et al., 2021b). Further, understanding heel rise coordination has important clinical implications since heel rise is a reasonable and efficient surrogate for observing foot function during walking (Jeong et al., 2021a). Due to potential progression of deformity (Hastings et al., 2016) and tissue breakdown in people with diabetes mellitus and peripheral neuropathy (DMPN) (Birke et al., 2000), investigating movement coordination during heel rise could be clinically useful to properly diagnose and treat foot and ankle associated complications. However, the biomechanical coordination during heel rise performance remains poorly understood in people with DMPN.

Cross-correlation coefficient (CC), operationally defined as the spatial and temporal relationships between two time-varying motions (Nelson-Wong et al., 2009), quantifies similarity of the direction and timing of the two joint movements throughout task performance (Takabayashi et al., 2017). Low CC indicates deficits in movement control and coordination of two joints, often associated with presence of pathologies or risk of musculoskeletal injuries (DeLeo et al., 2004; Pohl and Buckley, 2008). Previous studies hypothesized the lack of coordination between segments could be associated with neural and mechanical deficits and contribute to foot complications or poor response to intervention (Deschamps et al., 2013; Van de Velde et al., 2017). Cross-correlation analysis, however, is limited when studying movement dysfunctions that include a component of reduction in magnitude of joint excursion. Two joints that move very little during a task, producing two flattened kinematic waves, would result in a high CC and would be interpreted as “synchronized movements” due to their lack of motion. Investigating the relationship of the CC value and joint excursions would help identify the possible misinterpretation of coordination in individuals with limited joint excursions.

A recent study found ankle and midfoot positions at peak heel rise in people with DMPN could be in either a dorsiflexed or plantarflexed position (Jeong et al., 2021b). With closer examination of the midfoot and ankle movement trajectory during heel rise, the midfoot and ankle motions were illustratively differentiated into two movement patterns: midfoot dorsiflexion with ankle plantarflexion or midfoot plantarflexion with ankle plantarflexion (Jeong et al., 2021b). Although the previous study suggested different movement coordination strategies, they did not adequately characterize and quantify the movement coordination of midfoot and ankle nor was the impact of limited joint excursion on coordination examined in individuals with and without DMPN. To fully comprehend movement patterns and its association with foot and ankle complications, it is necessary to evaluate coordination as well as joint excursions during heel rise.

The purpose of this study was to quantify kinematic coordination between motions of midfoot (forefoot relative to hindfoot) sagittal and ankle (hindfoot relative to shank) sagittal and frontal planes in three cohorts: 1) DMPN group (foot pathology group), 2) older control group (OC; control of DMPN), and 3) younger control group (YC; ideal performance group). We hypothesized that DMPN group would have lower CC compared to OC, and OC would have lower CC compared to YC group. Our secondary purpose of this study was to graphically evaluate the distribution of CC value across joint excursions in the three cohorts.

2. Methods

2.1. Participants

People with type 2 DM and PN comprised the DMPN group (n=60); older participants without DM or PN comprised the OC group (n = 22); and younger participants without DM or PN comprised the YC group (n = 25). Participants qualified for the DMPN group if they had type 2 DM diagnosed by the participant’s primary physician and presence of PN. PN was assessed based on the following criteria: unable to perceive a vibration threshold less than 25 V on the bottom of the great toe utilizing a Biothesiometer (Biomedical Instrument Co, Newbury, OH) (Armstrong et al., 1998), fail to detect a 5.07 monofilament on at least one of the six plantar regions (Armstrong et al., 1998), or Michigan Neuropathy Screening Instrument score ≥ 2 (Moghtaderi et al., 2006). Participants for both OC and YC groups qualified if they did not have DM or PN. The inclusion criteria for DMPN and OC groups were age between 45 and 75, YC was age between 18 and 30. The exclusion criteria for all three groups were: pregnancy, on renal dialysis, severe arterial disease (ankle-brachial index greater than 1.3 or less than 0.9), rigid metatarsophalangeal deformity, foot ulceration, lower extremity amputation, weight greater than 180 kg, metal implants and/or pacemaker (exclusion criteria for the larger cohort study using magnetic resonance imaging), and inability to complete the testing for the study. The additional exclusion criteria for OC and YC groups were a history of foot and ankle surgery or fracture that affected current foot and ankle function (e.g., walking, sit to stand, heel rise), current foot or ankle pain, injuries or pain that changed physical behavior, wore special shoes to accommodate a foot problem, or needed assistance during walking. All study subjects read and signed the provided informed consent form prior to participation. This study was approved by the Washington University Institutional Review Board (IRB# 201511090). The summary of participant characteristics is in Table 1. There were no group differences in the sex ratio and body mass index. There was a significant difference in age between the DMPN and OC (p<0.01), therefore, age was adjusted in our group comparisons for the DMPN and OC.

Table 1.

Participant characteristics.

DMPN
(N=60)		 OC
(N=22)		 YC
(N=25)		 DMPN-OC
p-value		 OC-YC
p-value
Sex (female %) 57 64 56 0.62 0.77
Age (years) 67 (6) 62 (8) 26 (3) <0.01* <0.001*
Body mass index (kg/m2) 35 (7) 32 (6) 34 (8) 0.09 0.28
Diabetes duration (years) 14 (10) - - - -
Hemoglobin A1c (%) 7.1 (1.3) - - - -
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Abbreviation: DMPN, diabetes mellitus and peripheral neuropathy; OC, older controls; YC, younger controls. Values are mean (standard deviation)

*

Significant comparison (p<.05).

2.2. Kinematic data acquisition

A 10-camera Vicon (Vicon MX, Los Angeles, CA, USA) motion analysis system was used to acquire kinematic data of midfoot and ankle joint excursion during a heel rise task. Seventeen reflective markers (10mm) were placed on participants’ bony landmarks as previously described (Jeong et al., 2021b). A modified Oxford multi-segmented foot model was used to generate forefoot, hindfoot, and shank segments in Visual3D software (C-Motion Inc. Germantown, MD, USA). The model used a sequence of Cardan x (sagittal) – y (frontal) – z (transverse) rotations. The kinematic data were processed with a Butterworth filter. The zero position for the midfoot joint was defined as the position of the forefoot relative to the hindfoot during the static standing calibration trial. The zero position of the ankle joint was defined as the position of the shank relative to the hindfoot within the lab coordinate system. The joint excursion was calculated as an angle difference between start (i.e., initiating movement of inferior calcaneal marker in a vertical direction) and peak (i.e., the highest point of inferior calcaneal marker in a vertical direction) of the heel rise. An ideal heel rise would show the midfoot and ankle moving into plantarflexion (−) and the ankle moving into inversion (+).

2.3. Heel rise task

Participants performed five consecutive repetitions of single-limb heel rise by placing their testing limb on the force plate and the knee on the non-testing limb was bent so the foot did not touch the force plate. Participants placed their hands in front on examiner’s outstretched arm for balance. Three trials with the highest ankle plantarflexor power were selected for data analysis (Hastings et al., 2014).

2.4. Cross-correlation coefficient (CC)

The joint angles of the midfoot in the sagittal plane and ankle in the sagittal and frontal planes during three repetitions of the single-limb heel rise task were normalized from 0% to 100% data points (0% as start and 100% as return to the start position of the heel rise, N = 101). CCs were calculated with a zero-time lag for the following segments and planes (1) midfoot sagittal and ankle sagittal, (2) midfoot sagittal and ankle frontal, and (3) ankle sagittal and ankle frontal data points using Python version 3.6.9. (Python Software Foundation, Wilmington, DE, USA). CCs for the three single-limb heel rise repetitions were averaged for the statistical comparisons. For the midfoot sagittal – ankle sagittal, a CC close to 1 indicates high similarity in direction and timing of two joint motions [midfoot and ankle both moving into plantarflexion (−); Figure 1A], whereas close to 0 indicates low similarity in direction and timing of the two joints motions (Figure 1B). A negative CC indicates segments simultaneously moving in opposing directions [midfoot moving towards dorsiflexion (+) while ankle moves towards plantarflexion (−); Figure 1C]. For the midfoot sagittal – ankle frontal and ankle sagittal – ankle frontal, CC close to −1 indicates high similarity in direction and timing of two joint motions [midfoot or ankle plantarflexion (−) and ankle inversion (+)], whereas 0 indicates low similarity in timing of the two joints motions and positive CC indicates one joint moving in the opposite of the expected direction [midfoot dorsiflexion (+) with ankle inversion (+)] (appendix). Strengths of CC values were divided into four categories: poor (< ∣0.3∣), fair (∣0.3 – 0.5∣), moderately high (∣0.6 – 0.8∣), and very high (> ∣0.8∣) (Chan, 2003).

Figure 1.

Figure 1.

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Examples of normalized data for heel rise sagittal plane kinematics of the midfoot (blue) and ankle (orange): (A) very high CC in the expected direction, (B) poor CC in the expected direction, and (C) very high CC in an unexpected direction.

Abbreviation: CC, cross-correlation coefficient.

To provide insight into how impaired coordination is distributed across different joint excursion, we illustrated individual data points using values of midfoot and ankle excursion during heel rise and CC in three cohorts (Figure 2).

Figure 2.

Figure 2.

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Scatter plot of individual data points that represent values for different joint excursions: (A) midfoot sagittal and ankle sagittal, (B) midfoot sagittal and ankle frontal, and (C) ankle sagittal and ankle frontal. Circles are the DMPN group, triangles are the OC group, and squares are the YC group. Individuals with expected excursion (i.e., midfoot and ankle sagittal in plantarflexion or ankle frontal in inversion) would be displayed in the upper right quadrant. The darker green color indicates higher CC. Individuals with one of the joints moving in opposite from expected direction (i.e., midfoot sagittal in dorsiflexion while ankle sagittal in plantarflexion or ankle frontal in inversion) would be displayed in the upper left quadrant. The darker orange indicates higher CC in opposite direction. Red circled points on the graphs are examples of individuals that have similar CC value with high or low excursions.

Abbreviations: DMPN, diabetes mellitus and peripheral neuropathy; OC, older controls; YC, younger controls; CC, cross-correlation coefficient.

2.5. Statistical analysis

Fisher’s transformation was used to transform the cross-correlation values to Z-scores so that the transformed correlation values become normally distributed. To examine the effect of diabetes on coordination and excursion, demographic variables that were significantly different between DMPN and OC must be controlled. Therefore, analysis of covariance was conducted to compare values of CC and excursion between groups of DMPN and OC with age as covariate. To examine the effect of age on coordination and excursion, an independent t-test was conducted to compare the values of CC and excursion between the groups of OC and YC. All the statistical tests were two-sided at the significance level 0.05. The effect size of group difference on CC and excursion was calculated using partial eta squared (η2) for analysis of covariance and Cohen’s d for independent t-test. The partial eta squared effect size of 0.01, 0.06, and 0.14 are interpreted as small, medium, and large effect, respectively and Cohen’s d effect size of 0.2, 0.5, and 0.8 are interpreted as small, moderate, large effect, respectively (Cohen, 2013). All statistical tests were two-sided at a significance level 0.05 and analyses were performed with SAS 9.4 (SAS Institute Inc., Cary, NC).

3. Results

3.1. Cross-correlation coefficient

The CC values in DMPN group were poor to fair in midfoot/ankle sagittal (CC = 0.31) and midfoot sagittal/ankle frontal plane (CC = −0.24), but very high in ankle sagittal/ frontal plane (CC = −0.85). The OC group showed moderate midfoot sagittal/ankle sagittal (CC = 0.65) and fair midfoot sagittal/ankle frontal plane (CC = −0.58) values, but very high CC value in ankle sagittal/frontal plane (CC = −0.93). The YC group had very high CC values for all comparisons (CC = ∣0.80 – 0.91∣; table 2).

Table 2.

Mean (standard deviation) of cross-correlation coefficient and joint excursion.

DM
PN		 OC YC DMPN-OC OC-YC
Mean
differenc
e 95%
CIa 		p-
valueb 		Partial
eta
Squared
c 		Mean
differenc
e 95%
CIa 		p-
value
d 		Cohen’
s de
Cross-correlation coefficient Midfoot sagittal&Ankle sagittal 0.31 (0.61) 0.65 (0.52) 0.90 (0.16) (−1.40, −0.30) 0.003* 0.10 (−1.02, 0.02) 0.059 0.59
Midfoot sagittal & Ankle frontal −0.24 (0.61) −0.58 (0.53) −0.80 (0.20) (0.21, 1.21) 0.006* 0.09 (−0.21, 0.70) 0.286 0.33
Ankle sagittal & Ankle frontal −0.85 (0.16) −0.93 (0.04) −0.91 (0.09) (0.10, 0.60) 0.007* 0.09 (−0.31, 0.13) 0.425 0.23
Joint excursion Midfoot sagittal 2.2 (5.8) 8.5 (8.6) 11.4 (5.4) (−9.9, −2.8) <0.001* 0.15 (−7.3, 1.5) 0.192 0.40
Ankle sagittal 12.5 (6.0) 21.3 (6.5) 23.2 (5.1) (−12.4, −5.9) <0.001* 0.29 (−5.5, 1.6) 0.275 0.33
Ankle frontal 8.8 (4.0) 10.1 (2.2) 10.3 (3.8) (−3.0, 0.85) 0.274 0.02 (−2.0, 1.6) 0.812 0.07
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a:

Mean difference 95% confidence interval (CI) (lower bound, upper bound). The CI of the cross-correlation coefficient is based on the transformed Z-score.

b:

Analysis of covariance controlling for age. The p-value of the cross-correlation coefficient is based on the transformed Z-score.

c:

Partial eta squared is the effect size of DMPN-OC comparison. The effect size of the cross-correlation coefficient is calculated based on the Z-score.

d:

Two sample t-test. The p-value of the cross-correlation coefficient is based on the transformed Z-score.

e:

Cohen’s d is the effect size of OC-YC comparison. The effect size of the cross-correlation coefficient is calculated based on the Z-score.

*

Significant comparison (p<.05).

Abbreviation: DMPN, diabetes mellitus and peripheral neuropathy; OC, older controls; YC, younger controls; CI, confidence interval.

The DMPN group had significantly lower CCs compared to the OC group (Table 2. Midfoot sagittal & Ankle sagittal: p = 0.003, η2= 0.10; Midfoot sagittal & Ankle frontal: p=0.006, η2= 0.09; Ankle sagittal & Ankle frontal: p=0.007, η2= 0.09; medium to large effect size). However, there was no significant difference in any CCs between the OC and YC groups (Table 2. Midfoot sagittal & Ankle sagittal: p = 0.059, Cohen’s d=0.59, Midfoot sagittal & Ankle frontal: p=0.286, Cohen’s d=0.33, Ankle sagittal & Ankle frontal: p=0.425, Cohen’s d=0.2; small to large effect size).

3.2. Excursion

The DMPN group had lower excursion compared to OC group in midfoot and ankle sagittal (Table 2. Midfoot sagittal: p<0.001, η2= 0.15; Ankle sagittal: p<0.001, η2= 0.29; medium to large effect size), but not in ankle frontal (p=0.274, η2= 0.02; small effect size). OC and YC groups did not have significant difference in excursions (Table 2. Midfoot sagittal: p=0.192, Cohen’s d = 0.40; Ankle sagittal: p=0.275, Cohen’s d = 0.33; Ankle frontal: p=0.812, Cohen’s d = 0.07; small effect size).

3.3. Excursion relationship to cross-correlation coefficient

In Figure 2A and 2B, our data show that 22 individuals in the DMPN group (37%) and two individuals in the OC group (10%) performed midfoot dorsiflexion, which is the opposite direction of the ideal joint movement. All individuals across groups performed ankle in plantarflexion and inversion (Figure 2C). Figure 2 shows that individuals with greater joint excursion have higher CC values in midfoot sagittal and ankle sagittal/frontal, indicating better coordination. However, some individuals with lower joint excursion also had high CC values, which would be interpreted as better coordination despite poor performance.

4. Discussion

This is the first study to quantify coordination using CC during a heel rise task in people with DMPN and in older and younger controls. Moreover, we examined the relationship of excursion and CC that provides individual and group levels of movement strategies during heel rise performance. The DMPN group had less inter-joint coordination and excursion of the midfoot and ankle compared to the OC group, whereas there were no group difference between the OC and YC. Individuals with higher joint excursion, combining all three cohorts, had greater inter-joint coordination. However, some individuals with lower joint excursion also had very high inter-joint coordination.

People with DMPN had poorer coordination between midfoot/ankle and ankle/ankle motions in the sagittal and frontal planes as well as lower excursion in midfoot and ankle sagittal planes. Deschamps et al. (2013) found similarly poor midfoot sagittal/ankle frontal coordination during stance phase of walking as we found during the heel rise task in people with DMPN (Deschamps: CC=−0.4, present study: CC=−0.24) compared to healthy controls (Deschamps: CC=−0.76, present study: CC=−0.58) (Deschamps et al., 2013). The excursions in our DMPN group were reduced 118% in midfoot sagittal (DMPN: 2.2 °, OC: 8.5°) and 52% in ankle sagittal (DMPN: 12.5°, OC: 21.3°), but not significantly different in ankle frontal excursions (14% difference; DMPN: 8.8°, OC: 10.1°), compared to OC group. These results are similar with previous findings (Hastings et al., 2014) that showed difference of 89% in midfoot sagittal (DMPN: 5°, control: 13°) and 50% in ankle sagittal (DMPN: 12°, control: 20°), but no significant difference in ankle frontal excursions (29% difference; DMPN: 6°, OC: 8°), between DMPN and controls.

Complications associated with DMPN, such as distal muscle atrophy and fat infiltration (Andersen et al., 2004a; Andreassen et al., 2009; Cheuy et al., 2013; Hastings et al., 2016), reduced strength (Andersen et al., 2004b), and joint stiffness (Salsich et al., 2000), could be contributing to the delayed timing of the movements, altered position of the joint, and increase the risk of abnormal mechanical loading (Deschamps et al., 2013; Drewes et al., 2009; Rao et al., 2010; Van de Velde et al., 2017). The current findings in heel rise coordination and excursion could be used to identify injury-related performance deficits and risk factors associated with musculoskeletal injuries (Chuter and de Jonge, 2012; DeJong et al., 2021). More study is required to better understand the relationship of the inter-joint coordination and injury mechanism in people with DMPN.

The graphical relationship of excursion and coordination showed that people who have larger joint excursions generally have higher CC values and vice versa. This relationship was expected since ideal heel rise performance requires both the magnitude and synchronous movements of midfoot and ankle (Figure 3A). However, data points in the figure 2 identified individuals with relatively lower midfoot and ankle excursions and a high CC value (Figure 3B) during heel rise. CC values are less sensitive to the amplitude of the motion and researchers using cross-correlation analysis should carefully assess individual data to avoid misinterpretation, especially in populations with known movement dysfunction and/or low joint excursion. Future work should consider the use of continuous relative phase (Lamb and Stöckl, 2014) or vector coding (Needham et al., 2020) to better quantify the movement coordination during heel rise.

Figure 3.

Figure 3.

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Examples of midfoot sagittal (blue) – ankle sagittal (orange). (A) Individual with very high cross-correlation coefficient (CC = 0.97) and larger ankle excursion compared to (B) individual with very high cross-correlation coefficient (CC = 0.96) and lower ankle excursion during unilateral heel rise.

Abbreviation: CC, cross-correlation coefficient.

The primary joint motion contributing to the abnormal CC values in this study was the midfoot movement into dorsiflexion. Midfoot dorsiflexion during heel rise is concerning because of the potential contribution to progressive foot deformity and the similarity of foot biomechanics during heel rise to the push-off phase of walking (Jeong et al., 2021a). Midfoot plantarflexion power accounts for 36% of the variance in unilateral heel rise task performance (DiLiberto, 2020). Because the midfoot is critical in effective and efficient transfer of plantarflexor force from the hindfoot to the forefoot during heel rise, the role of midfoot stability is critical in injury prevention and treatment (Chimenti et al., 2014; Hastings et al., 2014). Improving the movement of the midfoot might be the main driver to improve coordination of the midfoot and ankle during heel rise. The findings of this study could help clinicians guide the treatments of patients with DMPN by better understanding and addressing the main contributor of the foot and ankle movement coordination.

Although aging has been shown to play a critical role in foot biomechanics (Menz, 2015), inter-joint correlations were not different when comparing our OC and YC groups. Our results are similar to that of Legault-Moore (2012) who reported no age-related differences in midfoot and ankle kinematics during gait (Legault-Moore et al., 2012). Contrary to our findings, a previous heel rise study showed age-related differences in midfoot and ankle sagittal plane excursion during heel rise (Chimenti et al., 2014). Body mass index (BMI) appears to be an important contributor to heel rise performance, accounting for 31% of variance of midfoot motion during heel rise in the previous study of people with DMPN (Jeong et al., 2022). When BMI was similar between young and older controls, there was no difference in foot biomechanics associated with age (Legault-Moore: younger 25 kg/m2 vs. older 26 kg/m2 and current study: younger 34 kg/m2 vs. older: 32 kg/m2). The previous study of Chimenti et al. did not use the BMI as a covariate due to insignificant relationship of BMI and foot-ankle kinematic variables; however, the BMI between the younger and older groups was significantly different (younger: 22 kg/m2, older: 26 kg/m2), which may have contributed to the difference in heel rise performance related to age (Chimenti et al., 2014). Lack of clarity on the role of aging could be due to group characteristics, different protocols, load of task, insufficient sample size, and the interaction of BMI and age that requires a more complex study design and larger sample sizes.

The limitation of this study is that the coordination of midfoot and ankle were only explored in the midfoot and ankle sagittal plane and ankle frontal plane. Although heel rise is primarily performed in the sagittal and frontal planes, the coordination and joint excursion of midfoot and ankle with transverse plane motion could provide a better insight of inter-joint relationships association with injury mechanisms. Although the current study provides helpful information about the quantitative analysis of coordination during heel rise, calculating CC values is not clinically feasible. However, the ease of slow-motion video capture with simple and available devices allows translation of these findings into clinical practice through visual assessment of joint coordination qualitatively. Another limitation of this study is the insufficient sample size of both OC and YC groups. The required sample size was 46 in each OC and YC group to detect a significant Cohen’s d of 0.59 with at least 80% power at significance level of 0.05 based on a two-sided two-sample t-test. Thus, the current study was underpowered to detect small to medium effects of age.

5. Conclusions

The current study is the first to investigate midfoot and ankle coordination and its relationship with joint excursion during heel rise in people with and without DMPN. The significant differences in CC and excursion between DMPN and OC show that foot pathology in DMPN group results in disrupted coordination, but we did not observe age-related change in any kinematic outcomes. Our graphical data showed individuals with relatively high coordination in the presence of excursion deficits. Future study is required to validate the findings in across other foot pathologies with excursion deficits.

Supplementary Material

1

Highlights.

  • People with diabetes showed less movement coordination compared to older controls.

  • The movement coordination was not different between older and younger controls.

  • Greater coordination was observed across low and high joint excursions.

  • Heel rise analysis should consider both coordination and joint excursion.

Acknowledgements

The authors acknowledge Kathryn Bohnert, Darrah Snozek, and Christopher Sorensen for their contributions to the subject recruitment and data collection, Haley Brogan, Jessica Stumpf, Jadean Hoff, Hana Bernhardson, Nick Youmans, Mary Ellis, and Nick Schroeder for their help on data post-processing. We acknowledge support from the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK107809, F32 DK123916), the Research Division of the Program in Physical Therapy, Washington University School of Medicine, St. Louis, Missouri, and the Administration for Community Living, U.S. Department of Health and Human Services (award number 90ARHF0006).

Footnotes

CRediT authorship contribution statement

Hyo-Jung Jeong: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing.

Baekdong Cha: Conceptualization, Formal analysis, Methodology, Software, Validation, Writing – review & editing.

Jennifer A. Zellers: Conceptualization, Methodology, Writing – review & editing.

Ling Chen: Formal analysis, Writing – review & editing.

Mary K. Hastings: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Writing –review & editing.

Conflict of interest statement

We disclose that all authors do not have conflicts of interest that could inappropriately bias the study. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by National Institute of Diabetes and Digestive and Kidney Diseases, Administration for Community Living, U.S. Department of Health and Human Services, or the U.S. Government.

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