Technology and Health Care 13 (2005) 185192 IOS Press

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Three dimensional stress analysis of diabetic insole: A nite element approach

Zohreh Barania, , Mohammad Haghpanahib and Hamid Katoozianc
for Science and Technology in Medicine, Tehran Medical Science University, Emam Khomeini Hospital, Keshavarz Bulvard, Tehran, Iran E-mail: zbarani 2000@yahoo.com b Department of Mechanics, Iran University of Science and Technology, Tehran, Iran E-mail: mhaghpanahi@yahoo.com c Biomedical Engineering Department, AmirKabir University of Technology, Tehran, Iran E-mail: katoozian@engineer.com
Received 9 February 2004 Accepted 2 February 2005 Abstract. Current research in foot biomechanics includes studies on prevention of recurrence of neuropathic foot ulcers. This paper attempts to prescribe accommodative insoles, which reduce plantar pressure levels particularly under the hallux. There is little quantitative information available regarding the effects of insole materials on reduction of plantar pressure. The insole models available in the literature are mostly two-dimensional (2-D). Hence, there is a need to develop a 3-D model with actual geometry which includes sufcient details. In this study a three-dimensional (3-D) model of the insole was constructed. A linear and non-linear static analysis using nite element method (FEM) was performed. Results were compared for different materials such as Silicon Gel, Plastozot, Polyfoam, and Ethinil Vinyl Acetate (EVA). Our 3-D nite element model was constructed using 16170 ten-node tetrahedral, mixed U-P (displacement-pressure), hyperelastic, solid elements. Four different hyperelastic and foam materials were used and compared and the loading condition was based on the mid-stance phase of the gait. This research has shown that most of these materials are very effective in terms of reduction of plantar stress concentrations. The technique used in this research provides a promising approach to understanding of behavior of insole materials and suggests a design guideline for therapeutic footwear and orthoses. Keywords: Diabetic insoles, silicon gel, plastozot, polyfoam, ethinil vinyl acetate (EVA), hyperelasticity, three dimensional FEM
a Research Center

1. Introduction Patients with diabetes mellitus and Hansens disease are at high risk for developing neuropathic ulcers on the plantar surface of their feet [1]. If infected, these ulcerations can lead to amputation [2]. Statistics shows that high percentages of the world population are subjected to diabetes [3]. To understand the biomechanics of diabetic feet, Jacob and Patil used a 3-D model of foot and studied the stresses in normal and early stages of Hansens disease with muscle paralysis [4]. Footwear can be particularly important to the feet of diabetic patients when their sensation is lost [5]. Narrow footwear and unsuitable insole

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materials causes foot abnormal pressure distribution, which leads to a major dysfunction of foot; this in turn may produce more problems. Unsuitable insole increases stresses in lower part of foot such as hallux, metatarsal head, and heel. At the present, one of the best prophylaxes for foot ulcers is to accommodate polymeric and hyperelastic insole materials made of closed cell foam. Therapeutic footwear and insoles are one of the best options to prevent the neuropathic plantar ulceration in patients with diabetes mellitus and Hansens disease. Finite element method is an appropriate tool for studying the effects of sole geometry and its materials on the shoes responses to external forces [6]. Lemmon et al. showed the effect of insole thickness on plantar pressure [7]. They have indicated the stress distribution in their quasi-static plane strain nite element models of the foot-shoe interface. In their model the materials used were PPT (Poly Propylene Thermoplastic) and Cloud Crepe. DAgati and Ladin utilized a nite element model of Ethinil Vinyl Acetate with linear, elastic, isotropic material properties and applied plantar pressure distributions to study the effect of midsole material on pronation [8]. Ziad et al. used Force Sensing Resistors with a microprocessor-based data acquisition system to acquire multistep pressure data [9]. Ralphs et al. measured plantar pressure by using Fuji prescale lm [10]. Sacco and Amadio studied the temporal parameters and peak pressure pain tolerance threshold in analysis of diabetic neuropathic patients gait [11]. The insole models of Lemmon et al were 2-D which represented only part of the insole and did not consider actual 3-D geometry. To achieve a more realistic behavior, in this study a 3-D model of the insole was developed.

2. Methods In this study four hyperelastic foam materials were used. These materials were Silicon Gel (617H43), Plastozot (617S7), Polyfoam (617S3), (Otto Bock, Duderstadt, Germany) and Ethinil Vinyl Acetate or EVA (Wien Shoe, Tehran, Iran). Insole geometry was obtained from computed tomography scanning (CTS) as shown in Fig. 1 and it was brought into the computer modeling software in IGES format, then a 3-D solid model was developed. The insole model was discretized into ten-node, tetrahedral, mixed U-P (displacement-pressure), hyperelastic, solid elements. These elements are applicable to nearly incompressible rubber like, hyperelastic and foam materials [13]. Figure 2 shows the insole model which consisted of 14736 nodes and 16170 elements. 2.1. Experimental setup Tests were performed using a Dartec Material Testing System equipped with hydraulic grips [16]. Load, deection, stress and strain were monitored for quasi-static experiments. Quasi-static tests were performed under a ramp function loading from 0.64 KN to fracture of specimen. All tests were performed in normal room temperature. 2.2. Test specimens The specications (dimensions, standards) of the tests specimen in quasi-static loading conditions of hyperelastic materials are presented in Table 1. The specimen were cylindrical disk shape cut from a standard sheet, drilled and lubricated using available techniques; then, they were placed and xed in the compression device. Extreme attention was given in placing the specimens exactly in the center between

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Fig. 1. Insole geometry was obtained by (CTS) imaging.

Fig. 2. The insole model is discretized into3-D, ten-node, tetrahedral elements.

the plates in order to avoid tilting. Specimens from each material sample were tested using the standard protocol [15]. Figure 3 shows the non-linear stress-strain curves for the four materials tested. Hyperelastic behavior refers to materials which can experience nite elastic deformation that is completely recoverable. Rubber and many polymers fall into this category [14]. The stresses for these materials are usually derived from strain energy density (or stored-energy) functions. The basic assump-

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Table 1 The specications (dimensions, ASTM standards) of the tests specimens in quasi-static loading conditions, for full characterization of hyperelastic materials Type of test Quasi-static compression Test specimens Cylindrical disk Thickness(mm) 12.5 0.5 Diameter(mm) 29.0 0.5 Standard D 395 89 Note With hydraulic grips

EVA

Plastozot

Polyfoam
Fig. 3. Stress (MPa) and strain curves for four materials.

SilconGel

tions for modeling solid rubber or rubber-like materials are: The material behavior is hyperelastic. The material is isotropic. The material is considered incompressible. These assumptions yield strain energy density function, U, of the Mooney-Rivilins characterization of rubber-like materials:
U = C10 (I1 3) + C01 (I2 3)
2 2 I1 = 2 1 + 2 + 3

(1) (2)

Z. Barani et al. / Three dimensional stress analysis of diabetic insole Table 2 Plantar pressure distribution (MPa) for six discrete locations Locations Mean peak pressure Hx 594.5 1M 527.1 2M 469.3 3&4 M 392.2 5M 271.6 H 567.6

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Fig. 4. The six discrete locations: hallux (Hx), head of the rst metatarsal (1 M), head of the second metatarsal (2 M), third and fourth metatarsal heads (3&4 M), head of the fth metatarsal (5 M), heel (H).
2 2 I2 = 1/2 1 + 1/2 + 1/3

(3)

where C10 and C01 are constants, I 1 and I2 are strain invariants, and the i s (i = 1, 2, 3) are principle extension ratios [12]. This function is used for Silicon Gel behavior. The multi elastic function is considered for Plastozot, Polyfoam and EVA. To apply boundary conditions it is assumed that the insole structure is t into the footwear and the bottom layer of insole is constrained in all directions. The top layer is assumed to be subjected to loading (the magnitude of in-shoe plantar pressure), based on Ziad et al. [9]. They employed a portable Holter type microprocessor-based sensor which was used to measure the in-shoe plantar pressure data as shown in Fig. 4. Pressures were recorded from six discrete plantar locations at the hindfoot, midfoot, and forefoot regions of the insole. These locations consisted of hallux (Hx), head of the rst metatarsal (1 M), head of the second metatarsal (2 M), third and fourth metatarsal heads (3&4 M), head of the fth metatarsal (5 M), and heel (H) as indicated in Table 2. According to the studies of Ziad et al. and the data given in Table 2, it is apparent that the most critical region is the hallux. Assuming 50% of body weight acts on each foot in static condition, this percentage is subdivided into 10% on H, 9.5% on 1 M, 8% on 2 M, 7% on 3&4 M, 5% on 5 M, and 10.5% on Hx. This pressure distribution was applied on insole model, in the direction of the thickness of insole. Shear loads were not used for simplicity and also because there is no adequate methodology to measure them accurately [7]. Loads were applied in one step for linear analysis and in three steps for non-linear analysis.

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Z. Barani et al. / Three dimensional stress analysis of diabetic insole Table 3 Difference between one and three stage loading for maximum stress concentration (MPa) at the hallux in Y direction (thickness) for four materials Materials Loading One stage Three stage Max. stress concentration (MPa) EVA 0.115377 0.115399 Silicon gel 0.031447 0.010609 Plastozot 0.062594 0.062446 Polyfoam 0.062447 0.00928 Difference 0.000022 0.020838 0.000148 0.053166

Table 4 Difference between one and three stage loading for maximum stress (mm) at the hallux in Y direction (thickness) for four materials Materials One stage Max. strain EVA Silicon gel Plastozot Polyfoam 0.001427 0.075499 0.002677 0.002668 Loading Three stage 0.001427 0.025323 0.002668 0.002936 Difference 0.000000 0.050176 0.000009 0.000268

3. Results From the stress analysis it is found that the highest stress concentration occurred at the hallux in EVA and the minimum stress were in Silicon Gel as shown in Table 3. When one step loading was performed, using Silicon Gel, stress concentration was reduced by 73% compared with EVA and by 27% when compared with Plastozot and Polyfoam. In terms of stress reduction, Silicon Gel and Polyfoam were more effective. It appears that when three-stage loading was applied stress reduction in Silicon Gel was about 91% less than EVA and 45% less than Plastozot. There was no major difference between Plastozot and Polyfoam when a single stage loading was used. In three-stage loading the difference in stress between Silicon Gel and Polyfoam was small enough to be neglected. The results of strain analysis show that the maximum strain during one- and three-stage loadings occur at the hallux in Silicon Gel as shown in Table 4. There was an increase of strain in Silicon Gel by 98% more than EVA and 96% more than Plastozot and Polyfoam in one-stage loading. This means that Silicon Gel was more effective in terms of stress and strain reduction. More uniformity in Von Mises stress distribution was observed in Silicon Gel when compared with EVA, Plastozot and Polyfoam as shown in Table 5. The very same situation occurred when three-stage loading was performed. There was not a major difference in stress distribution between Plastozot and Polyfoam in one-stage loading. The uniformity of Von Mises stresses distribution in Plastozot is more than it is in Polyfoam. Tables 3, 4, 5 show differences between one and three stage loading for the stress concentration, strain and Von Mises stress distribution at the hallux along the thickness for four different materials. Apparently, from the results obtained in this present study there is not much difference between EVA and Plastozot in one- and three-stage loading. However, since the stress-strain curves for Silicon Gel and Polyfoam are non-linear there is a major difference between their behavior in one- and three-stage loadings.

Z. Barani et al. / Three dimensional stress analysis of diabetic insole Table 5 Difference between one and three stage loading for maximum Von Mises stress (MPa) at the hallux in Y direction (thickness) for four materials Materials EVA Silicon gel Plastozot Polyfoam Max. Von Mises stress (MPa) Loading One stage Three stage Difference 0.001622 0.016243 0.000023 0.09306 0.030227 0.062833 0.013346 0.013354 0.000008 0.013354 0.004124 0.009233

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4. Discussion and conclusion Results in terms of stress and strain distribution in the direction of thickness are evaluated in linear and non-linear cases for four materials particularly in high pressure regions, such as hallux. From the results of the present study, it is concluded that Silicon Gel indicates the optimum outcome in terms of reduction in stress concentration and uniformity of stress distributions. However, Polyfoam and Plastozot with behaviors similar to Silicon Gel can be considered as good alternatives. Silicon Gel can also be used as a good shock absorber with a relatively good elastic property compared to other materials. To assess the validity of the approach utilized in the current study and the acceptability of the results, a literature survey was conducted. The comparison of results indicates a general agreement with the ndings of other investigators [79]. The approach presented in this study would allow us to evaluate the effectiveness of the different materials to be considered for the footwear structures. This modeling approach of individual insoles for the purpose of improving footwear structures is not yet considered as a feasible means in a clinical context. However, it is believed that the present approach, with further renements, has the potential to be used as a general guideline for therapeutic footwear and insoles design. Given the present empirical status of prescribed footwear and insole for design and manufacturing, such an approach has the potential to advance this eld without the laborious experimental studies that would otherwise be necessary.

Acknowledgments Authors are pleased to acknowledge the help they have received from Mrs. Zargar and Mr. Saiedi that without their participation we would not be able to nish this project. We need also to thank the Iran Medical Science University for the computational facilities that they provided for us. Their help is much appreciated.

References
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