1. Introduction
The phenomenon of obesity among children is serious in recent years; obesity is one of the main diseases threatening children’s health in today’s society and has become a global concern [
1]. Obesity is detrimental to the development of children’s physical and mental health. It will not only cause a decline in athletic ability and cardiopulmonary dysfunction [
2], affecting daily life, but also lead to abnormal skeletal muscle stress patterns [
3], resulting in reduced stability in children’s posture, increasing the risk of injury and falls. The foot, as the foundation of the human body, bears the majority of the body’s weight [
4]. Obese children bear more weight than healthy children in the process of walking and running. Moreover, due to the long-term overload in obese children, the physiological structure is prone to the collapse of the foot arch, leading to flat feet, foot inversion, knee valgus, etc. [
5]. Increased mechanical loading can cause damage to the hip, knee ankle, and other joint parts, ultimately leading to issues such as injury, lesions, and lower-limb osteoarthritis. There is a significant difference in the distribution of plantar pressure and bone stress between obese children and healthy children during walking [
6]. Obesity has a great influence on the arch structure, heel inversion, body stability, and impulse in children [
7]. Footwear, as the intermediate medium between the foot and the ground, plays an important role in daily living and provides protection for the foot to avoid the impact of the ground, by reducing torque to achieve the effect of shock absorption [
8]. At present, the common insole structure of children’s footwear is the solid structure of EVA elastic foam material [
9,
10]. This structure will not only aggravate the concentration of plantar stress in obese children but also lead to plantar fasciitis and foot ulcers caused by long-term uneven stress in obese children [
11,
12]. Compared with solid footwear, a hollow structure can evenly distribute the plantar pressure, also providing support for the foot arch and absorbing the ground reaction force. This structure could play the role of a shock buffer, reducing the internal and external rotation of the plantar fascia of in obese children [
13,
14].
The implications of obesity on the foot have been studied through gait analysis [
13,
15,
16]. Previous studies of gait in obese subjects have shown that the greater the degree of obesity, the lower the postural stability and the more obvious the compensation by adjusting step width, temporal phase, and full-foot support time [
17,
18]. However, the results of all the previous studies on the soft tissues and structures of the foot in obese children (e.g., plantar pressure) were based on gait experiments that provide externally measurable parameters [
13,
15,
16,
17,
18]. In contrast to these parameters, which can be measured by pressure transducers, internal stress cannot be obtained by experimental measurements since most foot pathologies caused by obesity (e.g., flat foot) are derived from within the foot bone to the soft tissue surface. They are difficult to identify and detect at an early stage, which can be addressed by finite element modeling (FEM). Few studies have been conducted to obtain information on internal stresses and strains in the foot skeleton through model simulations as a complement and validation of experimental results. FEM simulation techniques have been used as an effective analytical method to support biomechanical analysis of the human body and have great potential for application in the medical field over the years [
19,
20]. Furthermore, FEM allows biomechanical modeling and simulation of the soft tissue, bone, and midsole structures of the foot to analyze the deformation, force, displacement, and stress–strain of each tissue structure under different loading conditions, material properties, and boundary conditions [
21,
22,
23,
24].
Most of the previous studies on footwear midsole design via FE simulation were based on adult foot diseases, and few were designed for obese children to distribute the bone stress distribution and reduce plantar pressure. Ma et al. [
25] used FE analysis to study the porous structure units of a diabetic insole designed with an adjustable gradient modulus, but they only focused on the porous structural units, and the foot model was not added. Xie et al. [
26] used the FE method to design and optimize the shape of the sole for the elderly, which can realize the rapid customization of bionic sneakers for the elderly. However, their study did not consider the design of the shoe soles and only focused on the improvement of the shape of the insole. Jhou et al. [
27] studied the deformation of the lattice structure when a 3D-printed polymer sandwich with a lattice core was placed in the midsole of the footwear but did not delve into the stress distribution in the foot bone and soft tissue. Li et al. [
28] investigated the differences in peak plantar pressure during landing in the weight-bearing period between an FE model of a bare foot and a coupled FE model of the foot and barefoot running footwear, but only the condition of landing in the weight-bearing period was simulated using static analysis without considering the dynamic response while wearing the barefoot running footwear. Guo ying et al. [
29] used FE static models to study the stress distribution in different shoe sole designs, such as Diamond, Grid, X shape, and Vintiles. However, they mainly focused on the design of the sole structure and lacked the analysis of the foot bones. Tang et al. [
30] proposed a new design method that can generate a fully customized porous shoe sole and found that, compared with a flat shoe sole, the top surface of a customized sole could fully conform to the bottom surface of patient’s feet, which can significantly reduce peak plantar pressure. However, only the static loading condition was considered, and the functional volume was not manually divided into several sub-regions.
Therefore, this study aims to investigate the effect of different midsole structures on the foot biomechanics based on a static FE model. The effects of different footwear midsole constructions on plantar pressure and bone stress in healthy and obese children were also simulated and compared through FE analysis. The preliminary study on the analysis of plantar pressure and bone stress in obese children by FEM described in this paper can provide new ideas for manufacturers to research and develop footwear for obese children and give support to the clinical study of childhood flat foot caused by obesity with models.
4. Discussion
4.1. Comparison of Distribution of Plantar Pressure
Figure 11 presents the distribution of plantar pressure in 50 kg obese children and 25 kg healthy children with different midsole structures. It can be seen that the plantar pressure was mainly concentrated in the metatarsal region and the heel region, with almost no pressure on the arch part. In contrast, the hollow structures (chiral and lattice) transferred some of the pressure from the heel to the arch when compared with the solid EVA and the comparison group (ground), resulting in a release in the pressure at heel region and providing support at the arch. A larger area of contact surface was observed for the chiral structure in the arch and heel than for the lattice, resulting in an even distribution of body weight and providing more support to the arch.
In simulations of the three structures with the comparison group, the pressure in the lateral heel region (HL) was significantly greater than that in the medial heel region (HM), and the pressure in the lateral phalange region (T2~5) was significantly greater than that in the medial phalange region (T1) in both obese and healthy children.
There are three important pressure points in the plantar fascia that distribute the pressure on the foot [
37], i.e., first metatarsal, fourth metatarsal, and heel bone, corresponding to the plantar regions M1, M4, and HM and HL. The heel bone bears the majority of the gravitational force and the impulse due to the change in the COG (center of gravity), which acts on the heel bone and soft tissue surrounding the heel bone [
38]. In a 25 kg healthy child, the
Pr in the M1, M4, HM, and HL regions was 33.99%, 28.25%, 56.08%, and 56.96% for the chiral structure; 29.42%, −15.97%, 37.12%, and 35.14% for the lattice structure; and 19.97%, −27.88%, 21.66%, and −2.63% for solid EVA, respectively. In a 50 kg obese child, the
Pr in the M1, M4, HM, and HL regions was 38.69%, 34.25%, 64.24% and 54.03% for the chiral structure; 26.50%, −7.16%, 24.04%, and 36.88% for the lattice structure; and −2.73%, −37.41%, 4.07%, and −4.17% for solid EVA, respectively. It was found that, in both healthy and obese children, the
Pr of plantar pressure in the M1, M4, HM and HL regions for the chiral structure was greater than that for the lattice and solid EVA structures, which could largely relieve the pain in the heel and forefoot parts caused by gravity concentrated at three pressure points during walking. Moreover, the
Pr of plantar pressure in HM and HL was greater than that in M1 and M4 for the three midsole structures.
4.2. Comparison of Stress Distribution of Foot Bone
Of the 17 foot bones in a healthy child, solid EVA had more bones with a higher Pr of MVSS (15 bones in total, all bones except the talus and intermediate cuneiform) than the lattice (2 bones in total, fourth and fifth metatarsal) and chiral (6 bones in total, lateral cuneiform, medial cuneiform, first metatarsal, and third to fifth metatarsal) structures, but the value of Pr for the chiral structure was greater than that for the lattice and solid EVA structures. Of the 17 foot bones in an obese child, the lattice structure had more bones with a higher Pr of MVSS (12 bones in total, all bones except the calcaneus, talus, intermediate cuneiform, cuboid, and fifth phalange) than the chiral (9 bones in total, medial cuneiform, lateral cuneiform, intermediate cuneiform, first metatarsal, third to fifth metatarsal, and first and second phalange) and solid EVA (11 bones in total, all bones except the calcaneus, talus, intermediate cuneiform, cuboid, and fourth and fifth phalange) structures, but the value of Pr for the chiral structure was greater than that for the lattice and solid EVA structures.
In both healthy and obese children, the MVSS of the calcaneus was the greatest, followed by that of the talus, for all three structures. The reason for this may be due to the way the boundary conditions are imposed, resulting in increased bone stress around the tibia and fibula due to fixation of the distal tibia and fibula.
4.3. Comparison of Obese and Healthy Child
It could be seen that a greater Pr occurred for the chiral structure in the area in which the three pressure points are located than for the other two structures in both obese and healthy children. Moreover, the greater the weight, the more pronounced the effect of the reduction and the more even the distribution of the plantar pressure, which could reduce the impact force from the ground.
For the lattice structure, the Pr of MPP increased in T1, T2~5, M2, M5, and HL in an obese child compared with a healthy child, with a Pr value of 59.10%, 55.55%, 12.10%, 62.27%, and 36.88% in obese children and 56.89%, 50.06%, 7.10%, 57.06%, and 35.14% in healthy children. For the chiral structure, the Pr of MPP increased in M1, M4, and HM in an obese child compared with a healthy child, with a Pr value of 38.69%, 34.25%, and 64.24% in obese children and 33.99%, 28.25%, and 56.08% in healthy children. For the solid EVA structure, the Pr of MPP increased in M2, M5, and MF in an obese child compared with a healthy child, with a Pr value of 29.14%, 42.62%, and 46.81% in obese children and 25.15%, −7.61%, and 8.04% in healthy children. It was found that the chiral structure was not highly sensitive to the external application of body weight, which means that the region and value of the Pr will not change much with an increase in body weight. This indicates that the chiral structure was more stable than the other two structures and was minimally affected by changes in external conditions. It was found that the support effect and stress dispersion effect of the chiral structure in obese children were more obvious than those in healthy children. In addition, the results commonly show that, among the three structures, the chiral structure had the best performance in plantar pressure distribution and bone stress distribution.
However, this study has some limitations. The geometric model of the foot was overly simplified, neglecting ligaments, muscles, and nerves. In addition, this study also lacked model validation corresponding to the FE model. Future work should, therefore, consider more-precise model construction and validation. Furthermore, it was found that the chiral structure was minimally affected by changes in external conditions, but the changes in external conditions in this paper were limited to two different values of body weight (50 kg and 25 kg), and future research can introduce more values of body weight.
5. Conclusions
This study compared three numerical models of different footwear midsole structures with a static analysis on plantar pressure distribution and bone stress in obese and healthy children. The simulation results of the three different footwear midsole structures were also compared in terms of the plantar pressure distribution and bone stress distribution.
It was found that the plantar pressure was mainly concentrated in the forefoot and heel due to the distribution of gravity (three pressure points) on the foot in normal standing. For the chiral structure, the plantar pressure was transferred from the heel to the arch when compared with the solid EVA and the comparison group (ground), resulting in a release in the pressure at the heel region and providing support at the arch. A larger area of contact surface was observed for the chiral structure in the arch and heel than for the other three midsole structures, resulting in an even distribution of body weight and providing more support to the arch.
In addition, the chiral structure was not highly sensitive to the external application of body weight, that is, the region and value of Pr did not change much with an increase in body weight. This indicates that the chiral structure was more stable than the other two structures and was minimally affected by changes in external conditions.
The validated FEM model discussed in this study could be used to predict foot deformation and contact pressure in obese children and provide new research ideas for shoe midsole manufacturers. Moreover, it could also provide FE support for clinical prevention and intervention in foot disorders in obese children, such as flat foot, horseshoe foot, and other pathologic foot conditions.