sports science

(NEURAL) BIO (MECHANICAL) ENGINEERING: DOES IT WORK?

The proof of a performance concept lies in the data. If neural bio mechanical engineering can improve human performance in a specific application such as skiing, skating or cycling then it should be possible to demonstrate meaningful performance improvement with quantifiable metrics generated from data captured from the actual activity. In the case of cycling, meaningful improvement would be shown by an increase in metrics such as peak force transferred to the pedal spindle that cannot be explained by other factors. In order to attribute any change in performance, whether positive or negative, to neural bio mechanical engineering the effect must be immediate, reversible and reproducible. In the case of the improvement seen with Podborski’s performance using ski boots fit with the dorsal fit system, reverting to identical boot shells fit with a conventional liner reversed the improvement in performance.

Where possible, standard protocols should be used and testing performed by experts in the field. In the case of the cycling shoe Tekscan F Scan data comparison, my only involvement was to analyze the human lower limb requirements for cycling and generate the design and specification for the device that produced the neural bio mechanical engineering effect. I played no role in designing the test protocol or conducting the tests. I was not even an observer.

So how did the neural bio mechanical engineering system work in the application to cycling?

Performance Metrics

There are numerous metrics that can be used to assess and compare performance. The subject test was limited to pressure analysis using the Tekscan F Scan system.

In the graphic below the upper image outlined in red is the F Scan pressure image of an elite cyclist captured at 3 o’clock in the crank cycle at moderate to high load using their own conventional cycling shoe. The F Scan pressure image outlined in green below the first image is of the same cyclist using the device that bio engineered the foot and lower limb.

Results

There are a number of significant differences between the forces applied with the same cyclist with the conventional cycling shoe and the bio-engineering. In the 2 F Scan images, the contact area of the application of force across the heads of the metatarsals over the pedal spindle with bio-engineering is much greater and the force much higher than the force applied to the heads of the metatarsals in the conventional shoe.

The two significant, quantifiable (measurable) metrics that relate directly to cycling performance are: Peak Force and Anterior-Posterior (forward-backward) Excursion of the Center of Force.

Peak Force

The peak (maximum) force with the device that bio-engineered the foot and lower limb was 140% of the peak force applied with the conventional cycling shoe.

Anterior-Posterior (fore-aft) Force Excursion

This is the range of forward-backward movement of center of force through the crank cycle.

The graphic below shows the tracking of center of force forward and backward in the pedal stroke. Notice how straight the force tracks in the lower image with bio engineering compared to the upper image captured from the conventional cycling shoe.

The ability to move the center of force forward and backward, not just down and, more important, substantially aligned with the crank rotation is both more consistent and efficient than the excursion tracking with the conventional shoe. The bio engineering device improved excursion by 175% in rearward tracking force (long bars) and 200% in forward tracking force (over the top) as shown by the short bars below the images.

In my next post I will discuss how I designed a ski boot from the snow up using principles of neural bio-mechanical engineering.

INTRODUCTION TO (NEURAL) BIO (MECHANICAL) ENGINEERING

Neural biomechanical engineering is an external, non-invasive, reversible process that alters the neuralbiomechanics of the human feet and lower limbs in a manner that makes their function specific to an activity such as skiing, skating or cycling. In some cases, the process can potentiate muscle power and/or the processes of balance. Neural biomechanical engineering is human function centric.

The graphic below is the pressure image of the right foot of the same elite cyclist in the last post except that the foot has undergone neural biomechanical engineering.Red is highest force. Dark blue is the lowest force. Forces were recorded with a Tekscan F Scan system fit to the shoe.

The highest primary forces are now across the heads of all five metatarsals with secondary forces under the big toe and, to a lesser extent, the second and third toes. The primary force is now applied to the pedal spindle. The applied force is also more focussed under the heel.

There are many other more subtle but important changes. But the central issue is whether metrics show a significant quantifiable improvement in performance.

What, if any, improvement in performance resulted from the application of neural biomechanical engineering? Any guesses?

 

 

WHAT SHOULD A SKI BOOT DO?

After Steve Podborski won the 1981-82 World Cup Downhill title using a revolutionary dorsal fit technology I developed for his ski boots in June of 1980, he proposed that we become partners in a venture to develop a new ski boot that would do for every skier what the dorsal fit system had done for him. In exchange for my creative efforts, Podborski would fund the venture up to a point after which we would try to raise funds from investors for the project.

If I accepted Podborski’s proposal (which I eventually did), I knew the we faced significant hurdles. After giving the proposal a lot of thought, I accepted Steve’s offer. Steve and I became partners in a company called MACPOD Enterprises Ltd. While I had identified some of the pieces of the puzzle, I didn’t yet know the answer to the question what a ski boot should do. But I knew that when the time came to raise money I would need to provide investors with convincing evidence that I knew the answer to this question.

Podborski’s success lent credibility to the project. But his credibility was based on his subjective assessment supported by his race results. To be credible, a ski boot design based on principles of science would need to be supported with data from actual skiing maneuvers that could generate meaningful, quantifiable metrics for such things as balance and ski control. When the metrics were compared to the same metrics from data captured from the same skiers using conventional ski boots, they would need to unequivocally demonstrate superior performance of the MACPOD ski boot. I had to come up with a format that would satisfy potential investors that the new ski boot MACPOD would develop would be at least as good, if not better, than the system Podborski used to win the 1981-81 World Cup Downhill title. Whatever format I came up with had to be capable of allowing investors who skied to ski in it.

In 1992, MACPOD raised money from investors to fund the first phase of the venture. The pressure was on.

The single variable assessment protocol

The factor that convinced Podborski of the merits of my dorsal fit system was the comparison test he did against identical Lange boot shells fit with conventional Lange liners.

After rupturing his ACL testing skis at the end of July in 1980 Steve went to France 2 weeks before the opening downhill race of the 1980-81 World Cup season at Val d’isere to be with the team to support them. He had not planned on skiing, let alone racing, because he had been told by his doctors he was out of commission for the 1980-81 World Cup Downhill season. But Podborski had brought 2 pair of identical Lange boot shells to France with him just in case. One pair had the untested dorsal fit system with only the upper cuff of a Lange liner mounted on the boot shaft. The other pair had conventional Lange liners.  The only difference between the boots was the fit system; the classic single variable assessment protocol.

The graphic below from my US Patent shows a conventional tongue format (20) in FIG 3 (prior art) compared to my dorsal fit system (30) in FIG 5. The shin component (31) is like a conventional tongue.

On a whim, Podborski decided to see if he could ski in the boots with the dorsal fit system. He was amazed to find that he could ski well with little pain in his partially healed, reconstructed ACL. But when he tried to ski in the boots with the conventional liner he could barely ski.  I found this interesting because the impetus for the new fit system was my hypothesis that dorsal loading of the bones of the midfoot might reduce strain on the knee by dampening decompression of the arches resulting from perturbations in ground reaction force due to asperities and undulating terrain. A conventional liner could not be used because it would have interfered with the interface of the lower shell overlap closure on the upper surface of the dorsal fit system required to apply force to it. Fig 9 below from the patent shows how the overlap of the shell applies force to the upper surface of the dorsal fit system. The buckle closures allow the force, which should be minimal, to be regulated.

The ability to compare the dorsal fit system against a conventional liner system on the same day and in same conditions made the superiority of the dorsal fit system apparent. The unprecedented improvement in performance with no run-in period or special training program strongly suggested that the improvement resulted from reducing factors in conventional ski boots that limit or degrade human performance. This experience caused me to undertake a critical analysis of the functional requirements of the human system for skiing. This exercise opened the door to the possibility of technologies that would integrate external appendages such as skis and skate blades with the human system, what I later came to term Bio-Integration.

Bio-Engineering

If structures of ski boots, ice skates and cycling shoes can limit or degrade the human performance of the user it also became apparent to me that it might be possible to modify the function of the feet and lower limbs that would make it specific to activities such as skiing, skating or cycling and even potentiate neuromuscular function. I termed this concept Bio-Engineering. I didn’t realize until 1991 that the dorsal fit system used principles of Bio-Engineering.

The graphic below is the pressure image of the right foot of an elite cyclist showing the forces applied by the foot to the sole of the shoe on the pedal spindle at 3 o’clock in the stroke sequence at a low cadence with a moderate to high load on the crank. The cyclist is wearing a conventional rigid sole cycling shoe with no arch supports, wedges or other accessories.

Red is highest force. Dark blue is the lowest force. Forces were recorded with a Tekscan F Scan system fit to the shoe.

The highest force is applied under the ball of the great toe and the great toe and to a lesser extent, the second, third and fourth toes. The dashed line shows the approximate location of the pedal spindle which is the source of resistance/reaction  force. This pressure pattern is typical of elite cyclists. Ideally, the highest force should be applied across the width of the pedal spindle by the heads of all five metatarsals. Note that aside from the high pressure patterns on the ball of the foot and toes 1 through 4 the pattern is diffuse across the heads of metatarsals 2 through 5 and under the heel.


In my next post, I will show a pressure pattern of the same foot in the same position with a technology that Bio Engineers the foot and lower limbs and discuss the significant differences.

WHY STANCE TRAINING IS ESSENTIAL

When readers click on my blog address at skimoves.me, analytics give me a hierarchy of the countries with the most views and the most popular posts in ascending order. This helps me identify which content resonates most strongly with viewers and which content draws a blank.

As I write this post, the top five countries are the US followed by Croatia, the United Kingdom, Slovakia and France.

The most viewed post today is THE SHOCKING TRUTH ABOUT POWER STRAPS; far and away the most popular post I have published to date. But the most important posts by far that I have ever written, A DEVICE TO DETERMINE OPTIMAL PERSONAL RAMP ANGLE and STANCE MUSCLE TENSIONING SEQUENCE EXERCISE barely sputtered in comparison. This strongly suggests that far from just some small gaps in the knowledge base skiing is founded on, massive craters exist.

Arguably the most important aspect of skiing is a strong stance. Any variance in the fore-aft angle of  the plane of support under the feet and the plane of the base of the ski has significant impact on stance. Yet these subjects are barely blips on the Doppler Radar of the ski industry.

Since I started the dynamic ramp angle assessment project a few weeks ago I have found that when asked to do so, it is rare for a skier of any ability to be able to assume a strong ski stance in an off the ski hill environment. Even when a skier  skis with a relatively strong stance, they seem to lack a sense of what a strong stance feels like. Because of this, they lack the ability to consciously replicate a strong stance. If asked to do so, they would be unable to coach a skier in the sequence of events that I described in my last post

In the dynamic ramp angle assessment project, I  have also observed that skiers with with a boot/binding ramp angle greater than 2.8 degrees appear to have become accustomed to the associated unstable, dysfunctional feeling and identify with it as ‘normal’. Before I can test them, I have to spend time coaching them into the correct stance because it feels unnatural to them.

When I go back and forth between a strong functional stance on a flat, hard level surface to a stance on the dynamic ramp angle device set to an angle of 4 degrees, I can get close to the same angles of ankle, knee and hip. But when I do, I feel strong tension, stiffness and even pain in my mid to lower back which is  common in some skiers and even racers.

Based on results to date with the dynamic ramp angle device, it appears as if strong skiers ski best with ramp angles close to zero. But depending on their sense of balance and athletic ability, they may have a wide range in which they sense little difference on the effect of ramp angle until they approach the upper limit of stability. While they may be able to ski well with a ramp angle close to the maximum limit of stability, ramp angles much above 1.2 to 1.5 degrees may not offer any benefits. This can only be tested on skis where balance is tested by dynamic forces which cannot be replicated in a static setting.

Issues affecting skier stance were discussed in detail in my post, THE SHOCKING TRUTH ABOUT POWER STRAPS. Here are the excerpts I posted from the chapter on The Ski Boot in the book, The Shoe in Sport (1989), published in German in 1987 as Der Schuh Im Sport– ISNB 0-8151-7814-X

“If flexion resistance stays the same over the entire range of flexion of the ski boot, the resulting flexion on the tibia will be decreased. With respect to the safety of the knee, however, this is a very poor solution. The increasing stiffness of the flexion joint of the boot decreases the ability of the ankle to compensate for the load and places the entire load on the knee”. – Biomechanical Considerations of the Ski Boot (Alpine) – Dr. E. Stussi,  Member of GOTS – Chief of Biomechanical Laboratory ETH, Zurich, Switzerland

“The shaft of the boot should provide the leg with good support, but not with great resistance for about two thirds of the possible arc, i.e., (14 degrees) 20 to 22 degrees. Up to that point, the normal, physiologic function of the ankle should not be impeded”.

“Previous misconceptions concerning its role in absorbing energy must be replaced by the realization that shaft pressure generates impulses affecting the motion patterns of the upper body, which in turn profoundly affect acceleration and balance.

“When the lateral stability of the shaft (the leg) is properly maintained, the forces acting in the sagittal direction should not be merely passive but should be the result of active muscle participation and tonic muscular tension. If muscular function is inhibited in the ankle area, greater loads will be placed on the knee”. – Kinematics of the Foot in the Ski Boot – Professor  Dr. M. Pfeiffer – Institute for the Athletic Science, University of Salzburg, Salzburg, Austria

It has been over 40 years since international authorities on sports science and safety raised red flags concerning the adverse effects of ski boots design and construction on skier stance, balance and the potential to cause or contribute to injury. It is time that their concerns were taken seriously and acted on. Research on stance and the effect of such things as zeppa and delta ramp angles is urgently needed.

 

SKI BOOT ASSESSMENT PROTOCOL

Step 1 of the synergy 5 Step performance Program described in my last post is a Footbed Check using the Novel Pedar insole pressure analysis system.

Step 3 of the program is the Ski Boot Assessment detailed below. As with the 5 Step performance Program, the Ski Boot Assessment protocol and report were intended to serve as a template to base future programs on. The assessment report was intended to provide clients with information on the effects of their ski boots on their performance and/or as a work order for them to take to a boot-fitter to have any necessary issues identified in the report addressed.  Synergy Sports Performance Consultants Ltd. did not sell products or perform boot modifications.

 



My next post will be called FOOTBEDS: THE GOOD, BAD AND THE UGLY.

 

 

 

 

A FIVE STEP SKIER PERFORMANCE PROGRAM

Almost 40 years ago to the day, the head of the Whistler Pro Patrol, whose boots I had worked on, introduced me to Nancy Greene in the Roundhouse restaurant on top of Whistler Mountain. The rest is, as they say, history. Nancy asked me if I would work on her ski boots. She was so impressed by the results of my work that she approached the National Ski Team to make arrangements for me to work with some of Canada’s best racers.

Recently, while going through some archived files, I found copies of Nancy’s communication with the Program Director of the National Ski Team, Andrzej Kozbial. When Nancy approached me about working with our National Team, I stressed to her that I did not see any potential arrangement with the team as a job opportunity but instead as a vehicle where I could gain further experience and knowledge while providing a crucial service to the team and furthering the sport of skiing.

The graphic below is an excerpt copied from Nancy’s first letter of April 26, 1978 to the National Ski Team Program Director.

At the time that I wrote my US Patent 5,265,350 in early 1992, the intent and purpose of the detailed and lengthy specification was to provide a repository of the knowledge I had acquired to date to serve as a legacy for skiers and skiing to help advance the sport. While this information was in support of the inventions disclosed in the patent, the majority of the information was not subject to protection under the terms of the patent. The information was open access to the world. This was my intent.

In spring of 2000, I formed a company with 2 partners for the 2000-2001 ski season called Synergy Sports Performance Consultants Ltd. The objective of the venture was to gain further experience and knowledge and create a model that could be used as a template for future skier performance programs.

The following series of graphics are from Power Point presentations synergy made to ski schools.

The following graphic is the poster that described the synergy 5 Step Performance Program.

5 Step Performance Program description

The synergy Analysis Program looks at how your body interfaces with your ski equipment; primarily your footbeds and boots because this is the connection to your equipment and through it to the snow.

Synergy offers the program as a package made up of 5 components. They can either be taken as the complete package [recommended], several components or steps at once, or one component at time. Synergy recommends that you begin at step 1 and follow the sequence in numerical order. But the order can be arranged however you wish to suit your needs. The choice is yours.

1.Biomechanical Assessment

Good foot function is the key to control. That’s why the first thing we thing we assess is your biomechanical function. What that means is that we look at how well your foot and lower limb works. The examination is done by a podiatrist who looks at how your foot functions and how the lower limbs all connect.  Then we see how effectively your feet interface with the ground by putting you on insoles that read the pressures under your feet. We coach you through some balance movements while we watch how your foot functions while our computer records the results

2. Footbed Assessment

Footbeds can have a positive, neutral or negative effect on the function of your feet.

That’s why the next thing we check is how your foot interfaces with your footbed or orthotic.  We make sure that it allows your foot to function as well as it should without one.  And if your foot needs some assistance for optimal function we make sure the footbed is helping your foot do what it needs to do.

3. Ski Boot Assessment

Now that your foot is functioning optimally we make sure your ski boot lets it keep functioning. We conduct a thorough examination of your boot and provide you with a report that tells you how your boot is affecting your performance. Most important, we tell you what has to be done to fix the problem.

4. Kinesthetic Training

Skiing is about making the right moves. Kinesthetic Training is next. It teaches you how to tell when your body is making those moves. What is Kinesthetic Training? In simple terms it means to train your body to associate a feeling or sense with the right movements made at the right time. It is feeling and bringing about an awareness so you know when you are doing it right because we have taken you there and you have felt it. A picture may be worth a thousand words, but in skiing a feeling is worth a thousand pictures. We bring you to understand what you should feel in your foot at the start of the turn and then what it feels like to settle and balance onto the foot that drives the ski. By acquiring this sense you become more aware of how to allow your foot to transfer energy directly to the edge of the ski by using the body the way it was designed to be used. Remember, your body was not made to be a lever.

5. On-Hill Data Collection

This is where everything comes together. We move to the ski hill for this part of the package. We meet up top on Whistler or Blackcomb Mountain. We put our pressure insoles in your ski boots.  A pair of cables from the insoles goes up your ski pants where it connects to the data box [a kind of mini computer] we attached to your waistband.  Then we go out for a run on moderate, groomed terrain.  We record data in three takes in medium radius turns at a speed you are most comfortable with. While this is happening we videotape your skiing. Then we head into the lodge and synchronize the video with your foot pressure data. When this is done we watch your foot function in your boots on the computer screen on one side while we study your ski video on the other side of the screen. This way we confirm that your foot is functioning optimally as confirmed by analyzing your movement patterns and the timing of your skills.

My next post will be on the synergy Boot Assessment program.

 

THE SHOCKING TRUTH ABOUT SKI BOOTS

In this post, I will expand on the content of The Shocking Truth About Power Straps (1.) which was by far the most popular post since I started this blog in 2013.

While the truth about what power straps can potentially do if improperly adjusted is shocking, the lack of support in principles of applied science for the basic premise that I describe as indiscriminate envelopment as the approach to achieving a fit of a ski boot with the foot and leg of the user with the objective of substantially immobilizing it’s joints with unknown consequences, is even more shocking. Little or no consideration appears to be given to the effects of indiscriminate envelopment on the balance and motor control systems of the skier.

What is done to the foot and (lower) leg can affect the entire body. In his post, Foot biomechanics is dead. Discuss (2.), Professor Chris Nester states:

The foot is not a compilation of interconnected mechanical components that respond precisely to the laws of mechanics. It is a complex matrix of at least 11 biological tissues (i.e. skin, fat, muscle, tendon, joint capsule, ligament, bone, cartilage, fascia, nerves, blood vessels….) that responds to external loads through the symbiotic relationship between the motor control system and tissue properties.

Professor Nester goes on to state:

I believe the integration of our current foot biomechanics knowledge with insights from motor control, neurophysiology and related domains (e.g. tissue biology) will drive advances in foot function more than pursuing a pure mechanics paradigm.

Professor Nester proposes that the term biomechanics be replaced with the term Neurobiomechanics. I concur.

How Does the Ski Boot Affect the Human Performance of the Skier?

The short answer is that when the structures of a ski boot indiscriminately envelop the structures of a foot and a portion of the leg (aka the Perfect Fit or the Holy Grail), no one knows. While it is essential that a ski boot create a secure connection of the foot of a skier with the ski, it should not achieve this connection at the expense of natural neuromuscular function, especially balance.

In 1980, when I was about to prepare a new pair of Lange race boots for Steve Podborski, I asked myself whether it was possible to obtain a secure connection of the foot with the ski without compromising natural neuromuscular function or, even better, was it possible to enhance natural neuromuscular function?

I took a significant step towards answering this question in 1980 when I designed and fabricated a device I called a Dorthotic. The Dorthotic supports the upper or dorsal aspect of the foot as opposed to supporting the plantar aspect (i.e. the arch). My theory that loading the top of the foot or dorsum with a force perpendicular to the transverse or medial-lateral plantar plane of the foot has positive benefits for motor control and balance has begun to be recognized. The Dorthotic enabled Steve Podborski to compete and win on the World Cup Downhill circuit mere months after reconstructive ACL surgery and to eventually win the World Cup Downhill title, a feat no non-European has repeated. US and international patents for the dorsal device were awarded to me (David MacPhail) in 1983.

The success of the Dorthotic gave me a start towards answering the question of whether a secure connection of the foot with a ski was possible without compromising natural neuromuscular function. But I knew that I needed to learn a lot more. I realized that finding the answers I was seeking and especially unraveling the secret that enables the world’s best skiers to stand and balance on their outside ski, would require a multi-disciplinary approach.

The Missing Factor in Skiing: A Multi-Disciplinary Approach

A significant influence that served as the impetus for the design of the Birdcage research vehicle and the on-snow studies, was the work of Dr. Benno Nigg. In 1981, Dr. Nigg accepted an invitation to move from ETH Zurich, where he was the director of the biomechanics laboratory, to the University of Calgary, where he founded and developed the Human Performance Laboratory (HPL), a multi-disciplinary Research Center that concentrated on the study of the human body and its locomotion.

The publication of the Shoe In Sport in English in 1988 served as a seque to introduce me to Nigg’s research at HPL. Studies done at HPL found that any interference with the function of the human foot, even a thin sock, extracts a price in terms of the adaptive process the human body has to undergo to deal with what is really an externally imposed disability.

The Effect of Footwear on the Neuromusculoskeletal System

There is an excellent discussion in a recent post on the Correct Toes blog (3.) on the impact of a narrow toe box, toe spring and elevated heel of traditional footwear on the human body. Elevating the heel in relation to the forefoot will predictably cause a realigment of the ankle-knee-pelvis joint system with a corresponding adjustment in the tension of the associated muscles with a global effect on the Neuromuscularskeletal System. This has been known for decades. Elevating the heel in relation to the forefoot, will cause the ankle joint to plantarflex (reduce dorsiflexion) in relation to the support surface under the foot in order to maintain COM within the limits of the base of support.

Ramp Angle Rules

Due to the unstructured nature of the indiscriminate envelopment characteristic of the fit of the majority of conventional ski boots, it is extremely difficult, if not impossible, to determine the effect of constraint of this nature on the Neuromusculoskeletal System. So I’ll focus on the one aspect of the ski boot that has consistent and profound implications on skier human performance, especially motor control and balance; boot board ramp angle or zeppa. Binding ramp angle or delta compounds any effect of zeppa. For the sake of simplicity we’ll assume zero delta.

Contrary to the widely help perception, raising the heel of a skier in a ski boot does not cause CoM to move forward. In fact, it usually has the exact opposite effect. It puts a skier in the back seat with the weight on their heels. Worse, it can disrupt the competence of the biokinetic chain that dynamically stabilizes and protects the joints of the lower limbs. Excessive heel elevation can render a skier static and cause the balance system to resort to using the back of the shaft as a security blanket.

As of this writing, I am unaware of any standard within the ski industry for zeppa. It appears to be all over the map with some boots having as much as 6.5 or more degrees. The default zeppa for the human foot on a hard, flat level surface, is zero.

Through subjective experiments in 1978, I arbitrarily determined that zeppas in excess 3° had a detrimental affect on skier balance. In 1991, zeppas of 2.3° and 2.5° were chosen for the large (US 8-12) and small (US 4-8) Birdcages based on an analysis of the effect of ramp angle on COM and neuromuscular activity. This range appears to work for a majority of recreational skiers. But recent tests with a dynamic ramp angle assessment device that I designed and fabricated is finding the stance of elite skiers optimizes at much lower zeppa angles, with some skiers below 1.5°. Interestingly, when NABOSO insoles are introduced for the assessment, zeppas decrease even further. With minimal training, most skiers are sensitive to dynamic changes in zeppa of 0.1 degrees.

Implications for the future of skiing

A tectonic shift is underway on a number of fronts (see A Revolution) that is challenging the mechanical and static premises that form the underpinnings of the key positions in ski teaching and the design of equipment such as ski boots and the fit process. In my next post I will post recent material by Dr. Emily Splichal, functional podiatrist and inventor the revolutionary NABOSO small proprioceptive stimulating insole.


  1. https://wp.me/p3vZhu-UB
  2. https://talkingfeet.online/2018/01/18/question-3-foot-biomechanics-is-dead-discuss/
  3. https://www.correcttoes.com/foot-help/footwears-impact-musculoskeletal-system/