A pressure map can look convincing. For the person whose insole we are trying to improve, the more useful question is whether it shows where the foot is actually loaded during walking.
A new study in Clinical Biomechanics from Dylan Heino, Scott Telfer, Bill Ledoux and Brittney Muir brings that question into focus. Their findings caution against using a standing pressure measurement as a substitute for dynamic in-shoe assessment when targeting offloading.
What the investigators tested
The team compared standing measurements, both in shoes and barefoot, with walking measurements inside shoes. The study included 31 feet from 18 participants selected for elevated dynamic in-shoe forefoot pressures. Sensors recording more than 200 kPa during walking defined the high-pressure regions.
The practical question was spatial: could a simpler standing test identify the same places that experienced high pressure during shod walking?
The numbers tell two different stories
Static in-shoe measurements performed better than static barefoot measurements on several comparisons. The areas under the receiver operating characteristic curve were 0.85 and 0.72, respectively. But the agreement between the actual maps was limited.
| Reported measure | Static in-shoe | Static barefoot |
|---|---|---|
| Derived static threshold | 40.4 kPa | 55.8 kPa |
| Spatial overlap (Dice coefficient) | 0.31 | 0.27 |
| Sensitivity | 0.80 | 0.66 |
| Positive predictive value | 0.22 | 0.19 |
Dice measures how much two mapped regions overlap; 1 represents complete overlap. Here, the low values are the important warning. A test can rank pressure readings reasonably well while still drawing a poor map of the locations we want an insole to unload.
The low positive predictive values also mean that many locations flagged by the standing thresholds did not meet the walking high-pressure definition. These figures should not be read as an individual patient’s probability of developing an ulcer.
Why this matters for precision offloading
For the limb-preservation team, a pressure-informed insole is a location-specific intervention. Where we remove, soften or redistribute material matters. A broad area marked on a standing scan may not give us the same target as a measurement taken during the activity we want to make safer.
The clinical implication is to retain dynamic in-shoe assessment for targeted offloading rather than assume that a quicker static measurement answers the same question. Standing measurements may still contribute useful information. Their convenience needs to be weighed against what they can establish about loading during walking.
A useful question for any pressure-mapping workflow is: Are we measuring the task, footwear and loading condition that our intervention is intended to address? That question belongs alongside the attractive color map.
Keep the findings in proportion
This was a small, selected sample with elevated forefoot pressures, not a general population screening study. Thirty-one feet should not be mistaken for 31 independent participants. The derived thresholds should not be treated as universal clinical cutoffs.
The reported outcomes concern pressure measurements and spatial agreement. They do not establish that one assessment strategy reduces ulcers or amputations, or that an insole designed from static data inevitably fails. Clinical outcome studies would be needed to answer those questions.
Simplifying care is a worthwhile goal. This study reminds us to verify what is preserved when we simplify a measurement. For people living with a foot at risk, precision should follow them into motion.
Read the study
Heino D, Telfer S, Ledoux WR, Muir BC. Static plantar pressure measurements do not predict high-pressure regions during shod walking in diabetic subjects. Clinical Biomechanics. 2026;141:107014. Published online November 6, 2026. doi:10.1016/j.clinbiomech.2026.107014.
Evidence note: This commentary is based on the published PubMed abstract. The full article was not available for review; detailed methods, uncertainty estimates and additional limitations could not be assessed.
#ActAgainstAmputation #DiabeticFoot #Offloading #LimbPreservation
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