gender differences in plantar loading during three soccer-specific tasks

Gender differences in plantar loading during threesoccer-specific tasks

E L Sims,1,2 W M Hardaker,1,3 R M Queen1,2

1 Michael W. Krzyzewski HumanPerformance Lab, SportsMedicine Program, DukeUniversity, Durham, NC, USA;2 Department of Surgery, DukeUniversity, Durham, NC, USA;3 School of Medicine, DukeUniversity, Durham, NC, USA

Correspondence to:Robin M Queen, 102 FinchYeager Building – DUMC 3435,Durham, NC 27710, USA; [email protected]

Accepted 8 October 2007

ABSTRACTObjective: Examine the effect of gender on plantarloading during three football-specific tasks.Design: Thirty-four athletes (17 men, 17 women) ran anagility course five times while wearing the Nike Vitoriahard ground cleat. Plantar loading data were recordedduring a side cut, a cross-over cut and a forwardacceleration task using Pedar-X insoles.Setting: Controlled laboratory study.Participants: No history of lower extremity injury in thepast 6 months, no previous foot or ankle surgery, notcurrently wearing foot orthotics and play a cleated sportat least two times per week.Main outcome measurements: Contact area, max-imum force and the force-time integral (FTI) in the medialand lateral midfoot, medial, middle and lateral forefoot aswell as the hallux. A univariate ANCOVA (a= 0.05) wasperformed on each dependent variable (covariate wascourse speed).Results: Significant gender differences existed in theforce and force-time integral beneath the lateral midfootand forefoot during the cross-over cut task as well as inthe middle forefoot during the side cut task with the mendemonstrating an increased force. No significant differ-ences existed in the loading on the medial side of the footduring any tasks.Conclusions: The results of this study indicate that theincrease in plantar loading on the lateral portion of themidfoot and forefoot in men could be one possibleexplanation for the increased incidence of fifth metatarsalstress fractures in men. Gender differences in loadingpatterns need to be considered when comparing differentmovements as well as different footwear conditions.

With approximately 200 000 professional and 240million recreational players worldwide, football isone of the most popular sports in the world. Withthe increasing popularity of football, the injuryincidence is high with previous literature reportinga performance-limiting injury every 0.8 to 2matches in competitive football.1 Previous litera-ture has also reported that athletes who participatein sports involving running, jumping and cuttingare at risk for ankle2 and forefoot injuries.3 Footballhas been gaining popularity over the past few yearsespecially among women in the United States,where 43% of the players are female, which isnearly double the percentage worldwide.

Stress fractures are a common sports injury;accounting for approximately 10% of allinjuries.4 5Previous literature has indicated thatstress fractures remain a common problem infootball with 9 of the 24 members of the 1994US National World Cup Football team beingdiagnosed with a stress fracture.6 In a previously

published case study of 23 fifth metatarsalfractures, 35% of the fractures were sustainedwhile playing a cleated sport, however, only six ofthe stress fractures were reported in women.7

Gender differences in the incidence of stressfractures has been examined in a military popula-tion when the men and women were undergoingthe same training. This work by Protzman andGriffis8 indicated that women can develop up to 10times as many stress fractures when compared tomen; however, the location of the stress fractureswas not reported. Sallis et al9 reported that womensustained significantly more foot injuries thenmen, however, when specifically examining foot-ball injuries men tended to have an increasednumber of foot injuries.

In-shoe plantar pressure measurements havepreviously been used in both patient and normalpopulations to determine the effect of changingshoe parameters on pressure and thus the forcebeneath the foot during different tasks. Twoprevious studies have examined plantar pressureand plantar loading during football-specific tasks aswell as on football-specific playing surfaces, butneither of these studies examined gender differ-ences in loading patterns during these activities.10 11

Gender differences in plantar loading have beenpreviously examined in various populations inorder to determine the apparent increased injuryrisk when comparing genders.12215 These previousstudies have identified that gender differences existin loading beneath the hallux 12 15;however, the restof the foot did not appear to demonstratesignificantly different plantar pressure distributionpatterns when comparing genders.13 14

Gender-related differences that may be respon-sible for the gender disparity in various lowerextremity injuries have been previously investi-gated. These investigations have examined kneejoint kinematics and kinetics during running,cutting and jumping as well as differences inmuscle activation patterns with no consistentresults being reported.16218 Previous literature hasindicated that during cutting women demon-strated a significant increase in knee abductionangle at initial contact, as well as a significantincrease in maximum ankle eversion angle and adecrease in knee flexion angle at heel strike whencompared with men.17 19221 In addition to genderdifferences during cutting, previous literature hasindicated that during running women tended todemonstrate an increase in knee abduction angleduring the stance phase when compared to men.18

With these known gender differences in lowerextremity kinematics and the differences in stressfracture incidence between genders, the goal of this

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272 Br J Sports Med 2008;42:272–277. doi:10.1136/bjsm.2007.042432

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study was to assess the plantar pressure differences betweengenders during different football-specific tasks. Understandingthe gender differences in plantar pressure patterns in cleatedsport athletes may give some insight into the etiology ofdifferent injury patterns. Based on the gender differences inkinematics that have been previously reported during cutting,this study examined three football-specific tasks: a cross-overcut, side cut and forward acceleration during the completion ofa slalom-style agility course. We hypothesised that significantdifferences would exist between genders in the midfoot (medialand lateral), in the three forefoot regions (medial, middle andlateral) as well as beneath the hallux. Based on the kinematicdifferences between genders during the side cut task andrunning, we hypothesised that women would demonstrate anincrease in loading beneath the medial midfoot and forefootwhen compared to men. In addition, during the forwardacceleration we hypothesised that we would also see an increasein loading beneath the hallux in the female athletes based on theprevious gender differences that have been reported duringwalking. However, during the cross-over cut task, we hypothe-sised that the men would demonstrate an increase in loading inthe lateral midfoot and forefoot, which could potentiallyexplain the increase in fifth metatarsal stress fractures seen inmale athletes.

METHODSA total of 34 subjects (17 men, 17 women) were tested (table 1).Subjects were excluded if they had a history of lower extremityinjuries within the past 6 months, an anterior cruciate ligament(ACL) reconstructive surgery within the past 3 years or did notplay football at least two times per week. The subjectsparticipating in this study were a mixture of recreational andcollegiate football players. In addition, subjects were required tobe physically active, which was operationally defined asparticipating in physical activity at least three times per weekfor approximately 1 h each time. Each subject was asked to readand sign an informed consent form, which was approved by theuniversity institutional review board.

A Pedar-X in-shoe pressure measurement system (Novel, St.Paul, MN, USA) was used to collect plantar pressure data. Theinsoles, which covered the entire plantar surface of the foot,were placed bilaterally inside the subject’s shoes. The plantarpressure data were sampled at 100 Hz via Bluetooth technology.All insoles were calibrated prior to data collection (Novel, St.Paul, MN, USA). Subjects were fitted with the appropriate sizeshoe and insole. All testing was completed in the Nike Vitoriahard ground (HG) boot, with 25 moulded cleats (fig 1). Theagility course used for testing was approximately 11.5 m longand 1.8 m wide (fig 2). Running of the agility course wasdemonstrated for each subject prior to data collection.Participants were allowed three practice trials prior to datacollection. The first task, straight acceleration, was collectedduring the initial three steps (combined left and right feet) fromthe start of the agility course. The second task was a side cuttask, which consisted of a right foot plant around the second

flag moving towards the left (fig 3A). The final task was a cross-over cut, which was performed as the subjects rounded the finalflag in the agility course (fig 3B). The cross-over cut was definedas a left foot plant with the right foot crossing over the left,while the subject moved towards the left. Subjects were askedto complete the agility course five times at a sub-maximumspeed in order to reduce the risk of injury, while plantar pressuredata were collected; subjects were given a 1 min rest betweentrials.

In order to analyse the in-shoe pressure data, the foot wasdivided into eight anatomical regions (heel (rearfoot), medialmidfoot, lateral midfoot, medial forefoot, middle forefoot,lateral forefoot, hallux and the lesser toes) using a percentagemask (fig 4) in the Novel Multiproject-ip software(Novel).10 11 22224 The plantar pressure variables that wereobtained for each subject and each task were the force-timeintegral, maximum force, contact time and contact area. Thefive trials for each subject were averaged and used for statisticalanalysis. The maximum force was normalised to each subject’sbody weight (BW), in order to facilitate statistical comparisonsbetween genders. In addition, the contact area of the entire footand each foot region was normalised to the entire insole contactarea and are reported in units of normalised insole contact area(NICA).10 Previous literature has indicated that movementspeed can influence plantar loading,25 26 therefore all of thestatistical comparisons were co-varied for course speed in orderto account for the fact that the men (14.45 (SD 1.20) s)completed the agility course significantly faster than thewomen (15.77 (1.00) s) (p,0.05). Therefore, all of the plantarpressure data were analysed using a one-way ANCOVA todetermine if significant gender differences existed (a= 0.05).While the foot was divided into eight anatomical regions, theonly regions of interest for this study were the medial andlateral midfoot, the medial, middle and lateral forefoot, and thehallux. The three athletic tasks were not statistically compared

Table 1 Subject information split by gender

Female (n = 17) Male (n = 17)

Age (years) 21.06 (3.8) 20.63 (2.2)

Height (m) 1.65 (0.06) 1.77 (0.05)

Weight (kg) 64.37 (5.21) 77.16 (10.18)

BMI (kg/m2) 23.76 (2.08) 24.58 (10.18)

Values given are mean (SD).

Figure 1 Hard ground cleat used for plantar pressure and performancetesting.

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Br J Sports Med 2008;42:272–277. doi:10.1136/bjsm.2007.042432 273




to each other as previous literature has indicated that theplantar pressure distribution patterns during these three tasksare significantly different from each other; instead statisticalcomparisons focused on gender differences.10

RESULTS

Side cut taskStatistical analyses revealed loading, contact area and force-timeintegral differences between genders during the side cut task(fig 3A) in several of the examined foot regions. The contactarea in the lateral midfoot (p = 0.031) and the lateral forefoot(p = 0.035) were significantly different between genders(table 2). In addition, the force-time integral (p = 0.017) andthe maximum force (p = 0.021) were significantly differentbetween genders in the middle forefoot (table 2). For each ofthese differences the men demonstrated a significant increasewhen compared to the women (fig 5).

Cross-over cut taskDuring the cross-over cut task (fig 3B), significant differencesexisted between genders in the force-time integral and the

maximum force (fig 6). The force-time integral was significantlydifferent between genders in the lateral midfoot (p = 0.017) andin the lateral forefoot (p = 0.001), while the maximum forcewas significantly different between genders in the lateralforefoot (p = 0.023) (table 3). For each variable and each footregion the values in men were considerably greater than those inthe women.

Forward acceleration taskDuring the acceleration task significant differences existedbetween genders in the total foot maximum force (p = 0.008)and the total foot contact area (p = 0.004). Both the normalisedmaximum force and the normalised contact area weresignificantly increased in male subjects when compared withfemale subjects (table 4). In addition, significant differences incontact area, force-time integral and the maximum force existedbetween genders in the various foot regions (fig 7). Significantdifferences in contact area existed in the middle forefoot(p,0.0001) and the lateral forefoot (p = 0.001). The contactarea was significantly decreased for the men in both foot regions(table 4). The force-time integral was significantly differentbetween genders in the middle forefoot (p = 0.016) and thelateral forefoot (p = 0.001). For both of these foot regions themen demonstrated a significant increase in the force-timeintegral when compared to the women (table 4). Finally, themaximum force was significantly different between genders inthe middle forefoot (p = 0.002) and the lateral forefoot(p,0.0001). Similar to the results of the force-time integral,both of these foot regions demonstrated an increase in normal-ised maximum force for the men when compared to the women(table 4).

DISCUSSIONIn this study, a pressure analysis of the plantar aspect of thefoot was obtained while cleated sport athletes performed a sidecut, cross-over cut and forward acceleration manoeuvre on anagility course. The results of this study demonstrated significantgender differences in plantar loading during each of the threemanoeuvres. Previous literature on plantar pressure distribu-tions during football-specific activities is limited.10 11 27 28

Recently, two studies by Queen et al10 27examined differencesin foot loading during different football-specific tasks. Both ofthese studies focused on the differences in loading patterns

Figure 2 Agility course used for plantar pressure testing.

Figure 3 (A) Representation of the side cut task. (B) Representation ofthe cross-over cut task. Informed consent was obtained for publication ofthis figure.

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between three football-specific tasks and examined the effect ofdifferent cleat plate configuration on plantar loading. However,neither article examined the effect of gender on plantar loading.

The results of this study support the initial hypothesis thatduring the cross-over cut task men would demonstrate anincrease in plantar loading and the force-time integral beneaththe lateral portion of the foot, specifically in the lateral midfootand forefoot regions when compared to women. While thecurrent literature provides no absolute thresholds for thedevelopment of stress fractures and overuse injuries, the resultsof this study indicate that the lateral portion of the foot(midfoot and forefoot) is experiencing increased loading in malefootball players, which could be associated with the increasedincidence of fifth metatarsal injuries in men.7

The second hypothesis was that women would demonstratea significant increase in plantar loading beneath the medialportion of the foot (medial midfoot and forefoot) during boththe acceleration and side cut tasks. This hypothesis was basedon previous literature that has indicated that women tend tohave an increase in rearfoot eversion when compared to menduring both running and cutting tasks.17221 Contrary to theinitial hypothesis, the results of this study indicate that mendemonstrate an increase in lateral midfoot and forefoot contactarea during the side cut task as well as an increase in themaximum force and force-time integral in the middle portion ofthe forefoot (fig 5). One previous study by Pollard et al29

examined randomly cued cutting in a group of collegiatefootball players and noted no significant differences in lowerextremity kinematics between genders except a decrease in peakhip abduction in the female subjects. While the current studywas not examining randomly cued cutting, it is possible that thelower extremity kinematics while completing an agility courseare not different between genders. Therefore, future workshould be done to examine if gender differences in lowerextremity kinematics exist during a side cut task in thispopulation while completing an agility course.

While the expected difference in plantar loading was notobserved during the side cut task, it appears that a loadingdifference existed in the middle forefoot when comparinggenders indicating that the men may have an increased risk of

forefoot stress injuries when compared to the women. Thisobservation is supported by Sallis et al9who reported that menhad an increased risk of foot injuries when playing a cleatedsport. In addition to the cross-over cut and side cut tasks, thisstudy hypothesised that women would demonstrate an increasein the loading beneath the hallux during the acceleration task,based on the work by Bennett and Duplock15 and Holmes et al.12

However, the results indicate no difference in the loading

Figure 4 Representation of how theregions of the foot were divided forpressure analysis. Definitions of theregions as percentage masks: H, hallux;LFF, lateral forefoot; LMF, lateral midfoot;LT, lesser toes; MDFF, middle forefoot;MFF, medial forefoot; MMF, medialmidfoot; RF, rearfoot.

Figure 5 Significant gender (men compared to women) differencesduring a side cut task by foot region (p,0.04).

Table 2 Gender differences during a side cut task by foot region

Male Female

Contact area (NICA)

Medial midfoot 0.132 (0.220) 0.124 (0.0239)

Lateral midfoot 0.113 (0.032) 0.086 (0.045)

Medial forefoot 0.079 (0.008) 0.079 (0.006)

Middle forefoot 0.087 (0.010) 0.087 (0.007)

Lateral forefoot 0.084 (0.012) 0.074 (0.014)

Hallux 0.061 (0.006) 0.063 (0.007)

Force-time integral (Ns)

Medial midfoot 31.87 (14.52) 23.95 (14.91)

Lateral midfoot 12.71 (9.24) 8.00 (5.82)

Medial forefoot 88.79 (29.63) 75.44 (33.26)

Middle forefoot 46.22 (23.00) 31.97 (14.08)


Hallux 61.20 (23.81) 58.48 (26.09)

Maximum force (BW)

Medial midfoot 0.284 (0.139) 0.250 (0.131)

Lateral midfoot 0.125 (0.073) 0.102 (0.067)

Medial forefoot 0.536 (0.125) 0.485 (0.149)

Middle forefoot 0.290 (0.088) 0.212 (0.065)


Hallux 0.377 (0.095) 0.360 (0.106)

Variables in italics had significant gender differences (p,0.05).BW, body weight; NICA, normalised insole contact area; Ns, Newton seconds.Values given are mean (SD).

Original article





beneath the hallux during the acceleration task or during thecross-over cut or side cut tasks. The initial work examininggender differences in plantar loading was done during walkingand indicated a difference in loading beneath the hallux;however, the fact that no gender differences were observed inthis study would indicate again that movement task isimportant when examining plantar loading.

In addition to understanding the axial loads that are placedon the foot, it is important to understand the shear stress thatmight exist between the foot and the shoe and the implicationsof these forces in the development of stress fractures and otherinjuries.30 Therefore, a potential limitation of this study is thelack of shear stress data that can be obtained from the in-shoepressure measurement system. An understanding of the shearstresses that are placed on the foot during these different tasks

Figure 6 Significant gender (men compared to women) differencesduring a cross-over cut task by foot region (p,0.05).

Table 3 Gender differences during a cross-over cut task by foot region

Male Female

Contact area (NICA)

Medial midfoot 0.071 (0.024) 0.063 (0.018)

Lateral midfoot 0.149 (0.014) 0.149 (0.019)

Medial forefoot 0.072 (0.014) 0.076 (0.011)

Middle forefoot 0.088 (0.005) 0.091 (0.007)


Hallux 0.062 (0.007) 0.062 (0.008)


Medial midfoot 11.23 (6.74) 9.38 (4.09)

Lateral midfoot 65.98 (24.70) 48.88 (21.19)

Medial forefoot 32.16 (27.28) 23.69 (9.45)

Middle forefoot 63.31 (32.45) 45.22 (8.31)


Hallux 38.41 (21.30) 29.21 (8.23)

Maximum force (BW)

Medial midfoot 0.081 (0.038) 0.086 (0.033)

Lateral midfoot 0.483 (0.129) 0.415 (0.122)

Medial forefoot 0.203 (0.116) 0.216 (0.092)

Middle forefoot 0.405 (0.164) 0.375 (0.095)


Hallux 0.256 (0.093) 0.250 (0.076)


Figure 7 Significant gender (men compared to women) differencesduring an acceleration task by foot region (p,0.046).

Table 4 Gender differences during forward acceleration by foot region

Male Female

Contact area (NICA)

Medial midfoot 0.084 (0.015) 0.076 (0.010)

Lateral midfoot 0.135 (0.014) 0.127 (0.021)

Medial forefoot 0.078 (0.001) 0.078 (0.003)

Middle forefoot 0.087 (0.001) 0.088 (0.001)


Hallux 0.063 (0.002) 0.063 (0.003)


Medial midfoot 11.10 (4.74) 9.70 (3.51)

Lateral midfoot 18.19 (8.21) 17.07 (5.47)

Medial forefoot 56.87 (19.26) 51.08 (17.62)

Middle forefoot 56.28 (16.64) 48.32 (10.91)


Hallux 40.94 (11.57) 36.25 (11.69)

Maximum force (BW)

Medial midfoot 0.122 (0.045) 0.105 (0.027)

Lateral midfoot 0.226 (0.088) 0.191 (0.060)

Medial forefoot 0.524 (0.164) 0.448 (0.118)

Middle forefoot 0.500 (0.115) 0.404 (0.072)


Hallux 0.405 (0.114) 0.329 (0.084)


Original article





could aid in the understanding of potential injury risk. Previousliterature has indicated that many factors affect the pressuredistribution patterns, including, but not limited to, runningspeed, shoe design and the type of movement.10 27 31 32 Therefore,when examining plantar loading comparisons between gendersit is important to control for shoe wear as well as movementtype and the speed of movement. Another potential limitationof this study was that course speed was not controlled betweensubjects so as to simulate game conditions better. Whilemovement speed can influence plantar pressure measurementsand the speed was not held constant during testing, thedependent variables in this study were examined using speed asa covariate in order to account for the differences in speedbetween genders.

Future studies could focus on determining if changes in thecushioning properties or stud placement on the football cleatscould alter plantar loading and potentially aid in the preventionof gender-specific injuries. In addition to examining these tasksin football cleats, it would be useful to examine the same tasksin basketball and other sports to determine the influence ofdifferent types of shoe construction on plantar loading and thepotential for foot injuries based on shoe design as well as gender.

Competing interests: None.

Patient consent: Informed consent was obtained for publication of fig 3.

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three soccer-specific tasksGender differences in plantar loading during

E L Sims, W M Hardaker and R M Queen

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gender differences in plantar loading during three soccer-specific tasks

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