malalignment syndrome was defined by wolf schamberger as a set of clinical orthopaedic 
 symptoms , as follows : malalignment associated biomechanical changes , especially a shift in 
 weight bearing and asymmetries of muscle tension and strength , and joint ranges of motion 
 affecting soft tissues , joints , and organ systems throughout the body . in particular , the 
 pelvis transfers loads generated by body weight and gravity during standing , walking and 
 sitting1 , 2 , and acts as a basis for the axial system .
thus , pelvic alignment 
 influences spinal posture and stability , and pelvic malalignment is a common cause of lower 
 back , hip , and leg pain in both the general public and in athletes .
the symptoms and signs 
 of malalignment syndrome include persistent foot , leg , or low back pain that is activity 
 dependent , curvature of the spine , asymmetrical muscle bulk , or strength or inability to 
 turn the body as much in a particular direction . according to schamberger , there are three 
 common presentations of pelvic malalignment , rotational malalignment , upslip of the 
 sacroiliac joint , and inflare / outflare , and all three cause some form of asymmetry .
malalignment syndrome is commonly treated using some form of orthotic device , and 
 biomechanical foot orthosis ( bfo ) treatment is the only form of therapy that addresses the 
 correction of biomechanical malalignments in the lower extremity kinetic chain .
the goal of 
 treatment is the restoration of normal structure and function of the spine and pelvis ; 
 therefore , the devices used are designed to realign the body .
these orthotics increase foot 
 stability by providing contact for weight bearing across a larger part of the sole and 
 decrease the tendency of the feet to roll inwards or outwards after alignment has been 
 achieved , and may decrease torque forces on legs .
orthotics increase sensory input from the 
 sole surface , and the stimulation of proprioceptive receptors has been shown to help control 
 pain
. a reduced perception of pain may also elicit reflex relaxation of muscles , which may 
 help to reduce muscle tension asymmetry ( a chronic tension myalgia caused by a constant 
 state of compensatory muscle contraction ) .
orthotic intervention is believed to influence 
 the pattern of lower extremity movement through a combination of mechanical control and 
 biofeedback .
foot orthoses have been widely used to successfully treat a range of pathologies related to 
 biomechanical dysfunction of the lower limb by altering impact forces and kinematic 
 variables3,4,5,6,7 .
orthosis inserts are widely 
 prescribed in the belief that they can alter lower extremity joint alignment and 
 movement8,9,10,11 , but the biomechanical effects of the orthoses used for the 
 clinical treatment of malalignment syndrome are not completely understood .
previous studies 
 have focused primarily on the effects of orthotic devices on foot structure rather than on 
 the pelvis or lower limbs , and the wider biomedical implications of orthoses remain unclear . 

furthermore , recent reports have seriously questioned the reliabilities of clinical 
 measurements , and the validities of static measurements with respect to predicting dynamic 
 foot functional behavior12,13,14 .
this study 
 investigated the effects of bfo on malalignment syndrome using three - dimensional gait 
 analysis , focusing on the correction of asymmetry .
ten patients ( two males and eight females ; meansd , age 42.213.04  years , range 20 to 
 57  years , height 163.15.76  cm , weight 55.58.03  kg ) were recruited .
no patient had a 
 previous history of a neurologic or psychiatric problem , joint abnormalities of the lower 
 limbs or operative intervention , pregnancy , vascular insufficiency , or a systemic problem 
 ( e.g. , a cancerous , cardiovascular , or endocrinologic disease ) that affected ability to 
 walk .
patients were selected using the following criteria : pelvic rotational malalignment 
 with or without low back pain , that showed more posterior rotation on one side during 
 walking on the spot as measured by a pelvic angulometer ( biomechanics co. , bundang , korea ) ; 
 an age of 2060 years ; and varus or valgus abnormalities of the rearfoot .
all participants 
 provided their written consent prior to participating in the study , which was approved by 
 the institutional review board of yeungnam university hospital .
three types of walking conditions were used in this study : walking barefoot ( barefoot ) , 
 walking with a flat insole in shoes ( shoes ) , or walking with a bfo in shoes ( bfo ) . a flat , 
 full - length insole was added to control the height of the bfo , and was made without 
 inclination because heel lift has been demonstrated to alter pelvic position and tilt during 
 the stance period of the gait cycle15 , 16 .
all the shoes and insoles were made by 
 biomechanics co. ( bundang , korea ) and go meditech ( daegu , korea ) .
bfos were custom - made and 
 the sizes and heights of the insoles were adjusted to fit each subject .
the bottoms of the shoes and insoles were composed of ethylene 
 vinyl acetate , whereas the bfos were of the standard full - length type comprising a 
 polypropylene shell , metatarsal base assistance dome , heel lift , and full length lift , with 
 an accessory posting made of ethylene vinyl acetate covered with cork ( fig .
1.the biomechanical foot orthosis ( bfo ) and shoes(a ) front side of custom - made bfo and ( b ) back side(c ) shoes showing exposure for foot markers ; bfos or flat insoles were inserted in 
 the shoes ) .
the biomechanical foot orthosis ( bfo ) and shoes ( a ) front side of custom - made bfo and ( b ) back side ( c ) shoes showing exposure for foot markers ; bfos or flat insoles were inserted in 
 the shoes three - dimensional gait analysis was conducted using the 12-camera vicon motion analysis 
 system ( oxford metrics , oxford , uk ) with two force plates ( amti or6 series ) to capture 
 ground reaction forces and identify gait cycle events .
sixteen 14-mm - diameter reflective 
 markers were placed over the following anatomic locations of the pelvis and lower 
 extremities : anterior superior iliac spines ( asis ) , posterior superior iliac spine ( psis ) , 
 lateral epicondyle of the knee joints , lateral malleoli , heels , second metatarsals , and 
 lateral aspects of the thigh and calf segments .
the reliability and validity of gait 
 analysis using the vicon motion analysis system are well - established17,18,19 . before beginning the gait analysis experiments ,
subjects were instructed to walk a number 
 of times along an 8  m walkway at a normal comfortable walking speed , and a static trial was 
 conducted to establish relationships between the markers in a static position for each 
 subject in the initial anatomical position .
data were then collected under the three 
 specific test conditions : walking barefoot ( barefoot ) , with flat insoles in shoes ( shoes ) , 
 or with bfo in shoes ( bfo ) .
each subject walked barefoot , with a flat insole in the shoes , 
 and with a bfo in the shoes , in that order . for each condition ,
five trials of gait data 
 were acquired for each subject walking at a self - selected speed .
gait patterns were 
 obtained by averaging the data of five different cycles of gait for each participant .
all statistical analysis was performed using spss for windows ( spss version 12.0  k , spss 
 korea ) .
the 
 difference between equivalent measurements was interpreted to be significant when the 
 corresponding p values were less than 0.05 .
the spatiotemporal data of each test condition are shown in table 1table 1.spatiotemporal gait parametersbarefootwith shoeswith bfomeansdmeansdmeansdcadence ( steps / min)105.576.92104.635.83106.525.50step length ( m)0.550.050.59 * 0.040.60 * 0.04step time ( s)0.570.030.570.030.570.03step width ( m)0.140.050.150.040.240.31stride length ( m)1.100.101.18 * 0.071.20*0.08stride time ( s)1.140.071.140.071.130.06speed ( m / s)0.970.141.03 * 0.111.07*0.11*p<0.05 , vs. barefoot ; p<0.05 , vs. shoes ; sd : standard deviation ; bfo : 
 biomechanical foot orthosis . step and stride lengths in shoes and
bfo were significantly longer than when 
 barefoot ( step length : shoes vs. barefoot , p<0.001 ; bfo vs. barefoot , p<0.001 , stride 
 length : shoes vs. barefoot , p=0.001 ; bfo vs barefoot , p<0.001 ; bfo vs shoes , p=0.018 ) . 

also , walking speed of bfo was significantly faster than walking barefoot or in shoes ( shoes 
 vs. barefoot , p=0.034 ; bfo vs. barefoot , p=0.01 ; bfo vs. shoes , p=0.028 ) .
p<0.05 , vs. barefoot ; p<0.05 , vs. shoes ; sd : standard deviation ; bfo : 
 biomechanical foot orthosis peak pelvic tilt and obliquity angle were significantly higher for bfo than for barefoot 
 ( pelvic tilt p=0.037 ; pelvic obliquity p=0.02 ) . furthermore ,
peak hip flexion / extension 
 angle ( shoes vs. barefoot , p=0.002 ; bfo vs. barefoot , p<0.001 ) , peak knee 
 flexion / extension ( shoes vs. barefoot , p<0.001 ; bfo vs. barefoot , p<0.001 ) , and 
 rotation angle ( shoes vs. barefoot , p=0.013 ; bfo vs. barefoot , p=0.003 ) were significantly 
 higher for the bfo and shoes conditions than for the barefoot condition .
peak pelvic rotation angle was 
 non - significantly lower for bfo than for shoes or barefoot ( table 2table 2.kinematic and kinetic databarefootwith shoeswith bfomeansdmeansdmeansdpeak pelvic tilt angle ( )9.024.0410.365.5810.48 * 5.58peak pelvic obliquity angle ( )4.431.234.681.254.92 * 1.37peak pelvic rotation angle ( )4.431.633.991.433.981.19peak hip f / e angle ( )35.547.8837.11 * 8.4037.55 * 8.10peak hip ab / ad angle ( )7.092.707.252.747.422.91peak hip rotation angle ( )7.3220.529.37 * 19.869.0419.68peak knee f / e angle ( )61.855.1270.38 * 4.6169.15*4.82peak knee ab / ad angle ( )12.3816.7913.40 * 17.1213.0316.68peak knee rotation angle ( )21.428.2924.16 * 7.2724.47 * 7.63peak ankle df / pf angle ( )18.824.2418.105.9017.635.41*p<0.05 , vs. barefoot ; p<0.05 , vs. shoes ; sd : standard deviation ; bfo : 
 biomechanical foot orthosis ; ab : abduction ; ad : adduction ; f : flexion ; e : extension ; 
 df : dorsiflexion ; pf : plantarflexion ) . however , bfo reduced the difference of the pelvic rotation between the left 
 and right sides significantly more than the other conditions ( bfo vs. barefoot , p=0.003 ; bfo 
 vs. shoes , p=0.001 ) ( table 
 3table 3.kinematic data of left - to - right differencesdifferencebarefootwith shoeswith bfomeansdmeansdmeansdpelvis tilt ( )1.030.480.970.320.920.42pelvis obliquity ( )3.723.743.873.674.043.87pelvis rotation ( )4.463.083.89 * 2.782.79*2.20hip f / e ( )2.721.241.860.491.830.43hip ab / ad ( )3.692.593.762.602.782.36hip rotation ( )6.553.206.563.636.373.83knee f / e ( )3.501.512.560.862.23 * 0.84knee ab / ad ( )3.202.313.382.273.062.25knee rotation ( )5.984.836.325.026.284.80ankle df / pf ( )3.331.032.37 * 1.032.52 * 1.31*p<0.05 , vs. barefoot ; p<0.05 , vs. shoes ; sd : standard deviation ; bfo : 
 biomechanical foot orthosis ; ab : abduction ; ad : adduction ; f : flexion ; e : extension ; 
 df : dorsiflexion ; pf : plantarflexion , fig .
2.plot of pelvic angleangles of left ( black line ) and right ( dotted line ) sides .
right- and left - sided 
 pelvic rotation was significantly different among the barefoot , shoes , and bfo 
 conditions ( bfo vs. barefoot , p=0.003 ; bfo vs. shoes , p=0.001 ) . ) .
* p<0.05 , vs. barefoot ; p<0.05 , vs. shoes ; sd : standard deviation ; bfo : 
 biomechanical foot orthosis ; ab : abduction ; ad : adduction ; f : flexion ; e : extension ; 
 df : dorsiflexion ; pf : plantarflexion * p<0.05 , vs. barefoot ; p<0.05 , vs. shoes ; sd : standard deviation ; bfo : 
 biomechanical foot orthosis ; ab : abduction ; ad : adduction ; f : flexion ; e : extension ; 
 df : dorsiflexion ; pf : plantarflexion angles of left ( black line ) and right ( dotted line ) sides . right- and left - sided 
 pelvic rotation
was significantly different among the barefoot , shoes , and bfo 
 conditions ( bfo vs. barefoot , p=0.003 ; bfo vs. shoes , p=0.001 ) .
many studies have reported the effects of foot orthoses or insoles on the biomechanics of 
 the lower extremity joints , but the majority focused on the biomechanics of the knee or 
 ankle joints .
furthermore , it has been suggested by several electromyographic ( emg ) studies 
 of standardized and medial wedge foot orthoses , that orthoses significantly alter the onset 
 and amplitude of low back and pelvic muscle activities20,21,22,23,24,25 .
rothbart et al.26 demonstrated that foot orthoses with a 
 large medial forefoot wedge can change the body posture during walking of patients with 
 chronic low back pain .
therefore , it is accepted that foot orthoses affect the biomechanics 
 of the proximal lower extremities , including the pelvis and low back . however
, little is 
 known about the clinical usefulness of bfo for the pelvic alignment of patients with 
 malalignment syndrome .
the present study described the immediate influence of bfo on malalignment syndrome , 
 especially with respect to changes in pelvic asymmetry . according to the pelvic kinematic 
 data of right - to - left differences , both shoes and bfo
were found to reduce pelvic - tilt 
 sidedness , and pelvic rotation angle asymmetry was significantly decreased in the bfo 
 condition , compared to the barefoot and shoes conditions , which implies that bfo contributes 
 to the correction of pelvic rotational asymmetry .
an alternative explanation is that bfo 
 reduces body alignment asymmetry thereby reducing muscle activities1 , 2 , 27 . during walking , motion in the plane of progression
is 
 stimulated by a change in momentum induced by foot - floor contact and the height of the 
 body s center of gravity .
reported a change in load distribution was detected 
 under the feet when pelvic floor muscles were unilaterally activated , and suggested tension 
 asymmetry of the pelvic floor affected the relative positioning of the pelvis leading to 
 pelvic malalignment27 .
this result 
 suggests that an equal redistribution of load on the rearfoot improves pelvic asymmetry .
the 
 pelvis is a mobile link between the two lower limbs , and serves as the bottom segment of the 
 unit from the head to trunk that rides on the hip joint . for these reasons ,
the pelvis is an 
 important part of the body alignment and energy conservation system .
it has been established that the axial alignment at the knee is related to maximal knee 
 adduction moment and motion in the coronal plane , and that it facilitates vertical balance 
 over the limb .
nester and chen28 , 29 reported that medially wedged foot 
 orthoses increase knee adduction moment but have no remarkable effect on knee adduction 
 kinematics in normal feet . in the present study , increases in knee adduction moment and 
 angle were observed under the bfo and shoes conditions , but no significant differences , 
 other than that of knee adduction angle , were observed between the shoes and barefoot 
 conditions . in a previous study , it was suggested that the effect of orthoses on knee 
 adduction moment might produce a change in knee adduction motion in the long - term .
this is the first 
 study to report a relation between asymmetry during walking and the efficacy of bfo in 
 malalignment syndrome .
however , this study was limited by its small sample size and the lack 
 of a follow - up study .
in addition , the study participants had moderate to severe pelvic 
 asymmetry , and it remains undetermined whether bfo is effective for patients with mild 
 pelvic asymmetry .
further complementary large - scale studies with long - term follow - up are 
 warranted , and combined studies of emg of lumbosacral muscles are needed in order to confirm 
 the effect of bfo on the correction of pelvic alignment .
 [ purpose ] the biomechanical effects of foot orthoses on malalignment syndrome have not 
 been fully clarified . 
 this experimental investigation was conducted to evaluate the 
 effects of orthoses on the gait patterns of patients with malalignment syndrome . 
 [ subjects 
 and methods ] ten patients with malalignment syndrome were recruited . for each participant , 
 
 kinematic and kinetic data were collected under three test conditions : walking barefoot , 
 walking with flat insoles in shoes , and walking with a biomechanical foot orthosis ( bfo ) 
 in shoes . 
 gait patterns were analyzed using a motion analysis system . 
 [ results ] 
 spatiotemporal data showed the step and stride lengths when wearing shoes with flat 
 insoles or bfo were significantly greater than when barefoot , and that the walking speed 
 when wearing shoes with bfo was significantly faster than when walking barefoot or with 
 shoes with flat insoles . 
 kinetic data , showed peak pelvic tilt and obliquity angle were 
 significantly greater when wearing bfo in shoes than when barefoot , and that peak hip 
 flexion / extension angle and peak knee flexion / extension and rotation angles were 
 significantly greater when wearing bfo and flat insoles in shoes than when barefoot . 
 [ conclusion ] bfos can correct pelvic asymmetry while walking . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION