Evaluation of The Sole Morphology of Professional Football Players Revised Final Columns

Evaluation of football players sole morphology International SportMed Journal, Vol.13 No.
1, March 2012,
pp. 8-17. Available at URL: http://www.ismj.com

8 Official Journal of FIMS (International Federation of Sports Medicine)

ISMJ
International SportMed Journal

Original research arti cle
Evaluation of the sole morphology of professional football players

Dr Cenk Murat Ozer, MD, *Associate Professor Cagatay Barut, MD, PhD
Department of Anatomy, School of Medicine, Zonguldak Karaelmas University, Zonguldak, Turkey
*Corresponding author. Address at the end of text.

Abstract
Background: Footprint analysis is one of the methods that can be used to diagnose foot pathologies.
Football is usually seen as a team sport whereby players attempt to move the ball, primarily with the
action of the foot to an opponents goal area to score. Players have a high risk of injury in this sport.
Research question: The aim of this study is to evaluate the sole morphology of professional football
players. Type of study: Cross-sectional study. Methods: One hundred and ten professional Turkish
football players and healthy volunteers participated in the study. Footprint images of both feet were
obtained by means of a specially designed scanner system. By means of this system images of the
right and left static weight-bearing footprints were acquired, firstly with 50% of the body weight on each
foot and then with 90% of the body weight (standing straight, single-limb, weight-bearing stance) were
obtained. Measurements were performed using the AutoCAD 2004 software. Results: Arch angle,
Chippaux-Smirak, Staheli, arch length, arch, footprint, truncated arch were calculated for both left and
right feet. In the 50% weight-bearing stance of the right foot, the arch angle and ChippauxSmirak,
Staheli, footprint, and truncated arch indices were significantly higher in the professional football
players than in the controls. For the left foot, only the arch angle and Staheli index were significantly
higher in the professional football players compared with the controls. In the 90% weight-bearing
stance of the right foot, the arch angle and truncated arch index were significantly higher in the
professional football players than in the controls. For the left foot, the arch angle, and the arch length,
footprint, and truncated arch indices were significantly higher in the football players compared with the
non-athlete controls. Concl usion: Foot morphology of football players may assist in the design of the
best football boots for the sport. Keywords: foot, footprint, footprint index, football

Dr Cenk Murat Ozer, MD
Dr Ozer is a medical doctor in the Department of Anatomy, School of Medicine, Zonguldak Karaelmas
University, Zonguldak, Turkey. He has specialised in anatomy. His main research interests are clinical
anatomy, anthropometry and sports.
Email: ozercenkmurat@hotmail.com

*Associate Professor Cagatay Barut, MD, PhD
Dr Barut is an Associate Professor in the Department of Anatomy, School of Medicine, Zonguldak
Karaelmas University, Zonguldak, Turkey. His main research interests are clinical anatomy, radiologic
anatomy, anthropometry, and lateralization.

Introduction
When humans adopted a bipedal posture and
gave up the use of the upper extremities for
movement, body weight was transmitted from
the vertebral column through the pelvis and
lower extremities, especially the feet
1
. The foot
became the contact point with the ground and
evolved so that it could easily adapt to
changes in both weight and the ground surface
to absorb forces while walking or standing and
to facilitate rotational movements
2-5
. For this
purpose, its structure forms an arch on a bony
skeleton strengthened by ligaments and
muscles, unlike the feet of other primates
6,7
.

Evaluation of football players sole morphology International SportMed Journal, Vol.13 No.1, March 2012,


Pathology involving the sole of the foot affects
bipedal locomotion, as the foot plays a very
important role in locomotion
1,8
. Pes planus and
pes cavus are pathologies of the medial
longitudinal arch (MLA) and are usually
overuse injuries resulting from standing or
walking for long periods of time
8,9
. Pes planus
can also cause low back pain
10
. In addition,
Mei-Dan et al. found a relationship between
low arches and ankle sprains
11
, and J ones
suggested that individuals with pes cavus were
unsuitable for the military and should never be
enlisted
12
.

Direct or indirect methods are used to
diagnose MLA pathologies
13
. The direct
methods include anthropometric and
radiographic techniques; whereas footprint
analysis is an indirect method
13
. Many footprint
indices have been described for evaluating
MLA problems
14
. Cavanagh and Rodgers
described the use of the arch index and stated
that it was a valuable tool for assessing arch
height
9
. Staheli et al. described another type of
arch index called the Staheli index
15
. Some
authors found that direct anthropometric and
radiographic measurements were more
effective for assessing the MLA
16,17
. Kanatli et
al. and McCrory et al. found a significant
relationship between footprint indices and
radiographic measurements
13,18
. Despite a lack
of consensus about the use of footprint indices
for MLA assessment, these indices are still
used.

Football (known in some countries as soccer)
is the most popular sport in the world, with 265
million football players worldwide
19
. As it is a
contact sport, there is a high risk of injury to
the lower extremities
20-23
. The reported rates of
injuries to the foot and ankle vary
20,24,25
. The
mechanisms of injury in football include (1)
contact injuries caused by another player,
including tackling and collisions, and (2) non-
contact injuries, including those incurred while
running, kicking the ball, turning, and jumping,
and (3) those resulting from overuse
21,23-25
.
The different types of soccer boot affect the
non-contact injuries to the foot and ankle and
can even influence the risk of serious knee
injury, especially to the anterior cruciate
ligament
26
. In order to reduce the risk of these
injuries and increase the performance of
football players, suitable ergonomic soccer
boots with foot orthoses can be designed.

This study evaluated the sole morphology of
professional Turkish football players and
compared it with healthy volunteers who have
never played sports professionally.

Methods
One hundred and ten professional Turkish
football players took part in this study (mean
age was 25.11 4.2 years; mean height
179.43 5.56cm; mean weight 75.21 6.37kg)
belonging to clubs in the Turkish Football
Federation Super League and League A. The
control group consisted of 104 non-athletic
healthy volunteers who had no major foot
deformities or history of injury or surgery to
their feet (mean age 24.07 3.67 years; mean
height 174.25 7.19cm; mean weight 75.01
12.54kg). Informed consent was obtained in
accordance with Ethics Committee guidelines.
The Ethics Committee of Karaelmas University
in Turkey also approved the study.

Footprint images of both feet were obtained
using a specially designed scanner system
which consisted of three platforms, with a
scanner connected to a computer. A wooden
platform measuring 55 35 25cm with a 1cm
thick safety glass top with a scale marked on
the glass contained the scanner (HP Scanjet
4570c). The second wooden platform without
the glass top, scale, and computer connection
had the same dimensions. The third wooden
platform measured 35 31 25cm. The
subject stood with one foot on the first platform
covered with safety glass and the other foot on
the second wooden platform. In this way,
images of right and left static, weight-bearing
footprints were acquired with 50% of the body
weight on each foot. To obtain right and left
static weight-bearing footprint images with 90%
of the body weight (standing straight, single-
limb, weight-bearing stance), the third wooden
platform was placed on top of the second
platform, and the subject stood with one foot
on the first platform with safety glass and the
other foot on the two-platform stack (Figure
1a). All images were obtained after the
subjects stabilized their positions. The digital
images were then input to a computer (Figure
1b). The footprints in the digital images were
measured using AutoCAD 2004 software by
the same researcher.



Figure 1a: The specially designed scanner system, which consisted of three platforms with a scanner
connected to a computer to obtained footprint images and position of the 90% weight-bearing stance
of the right foot
Figure 1b: An example of footprint images which were obtained from the system

Measuring the footprint indices
Seven footprint indices were calculated: the
arch (Clarke) angle, ChippauxSmirak index,
Staheli index, arch length index, arch index,
footprint index, and truncated arch index.
These are described below (Figure 2a-f):



Figure 2a-f: Graphical illustrations of the various footprint parameters

Arch (Clarke) angle (Figure 2a): This is the
angle between the line connecting the medial
side-most points of the heel and metatarsal
regions and the line connecting the lateral-
most point on the medial foot border to the
medial-most point of the metatarsal
region
14,16,27,28
.
Chippaux-Smi rak index (Figure 2b): This is
the ratio of the minimum width of the midfoot
arch region to the maximum width of the
forefoot region
9,14,27,28
.
Staheli index (Figure 2b): This is the ratio of
the minimum width of the midfoot arch region
to the maximum width of the rearfoot
region
14,15,28-31
.
Arch l ength index (Figure 2c): This is the
ratio of the length of the line between the
medial area -most points of the metatarsal and
heel regions to the border length of the arch
outline between these points
14,16
.
Arch index (Figure 2d): This is the ratio of the
area of the middle third of the toeless footprint
to the overall toeless footprint area. A line is
drawn between the centre point of the second
toe and the posterior-most point on the heel.
Two parallel lines perpendicular to this line are
drawn to divide the toeless footprint area into
equal thirds
9,14,16,32-36
.
Footprint index (Figure 2e): This is the ratio
of the non-contact area to the contact areas of
the toeless footprint. The non-contact area is
the area between the medial borderline axis
formed by the medial-most points of the
metatarsal and heel regions of the footprint
and the medial border of the footprint outline.
The contact area is the area of the toeless
footprint
14,16,36
.
Truncated arch index (Figure 2f): This is the
ratio of the non-contact area (the arch area) to
the truncated footprint area. The non-contact
area is the area between the medial border line
and the medial footprint outline. The truncated
footprint area is bounded by the area between
the lines perpendicular to the medial borderline


axis of the footprint through the medial-most
points of the metatarsal and heel regions of the
footprint
14,16
.

Statistical anal ysi s
The statistical analysis was done using SPSS
11.0. Mean and standard deviations were
obtained for all dependent variables. The two
groups of subjects were compared using the
paired samples test.

Results
Table 1 summarises the footprint indices of
both feet in the 50% and 90% weight-bearing
stances of the professional football players and
non-athlete controls.

Table 1: Comparison of the footprint indices of professional football players and non-athlete controls

Footprint Indices
Professional
Football Players
Non-Athletes

t

p
N Mean SD N Mean SD
5
0
%

w
e
i
g
h
t

b
e
a
r
i
n
g

s
t
a
n
c
e

o
f

r
i
g
h
t

f
o
o
t

Arch (Clarke) angle

109 53.13 8.34 103 48.51 6.58 4.456 0.000
Chippaux-Smi rak index 109 0.23 0.12 103 0.19 0.13 2.211 0.028
Staheli index 109 0.41 0.23 103 0.33 0.23 2.461 0.015
Arch l ength index 91 0.76 0.04 77 0.75 0.04 0.800 0.425
Footprint index 109 0.33 0.17 103 0.28 0.18 2.145 0.033
Truncated arch index 109 0.48 0.25 103 0.40 0.25 2.255 0.025
Arch index 109 0.20 0.07 103 0.19 0.07 0.481 0.631
9
0
%

w
e
i
g
h
t

b
e
a
r
i
n
g

s
t
a
n
c
e

o
f

r
i
g
h
t

f
o
o
t

Arch (Clarke) angle

107 51.86 8.34 103 44.36 6.96 7.064 0.000
Staheli index 107 0.50 0.19 103 0.49 0.19 0.530 0.597
Arch l ength index 100 0.76 0.08 97 0.77 0.04 -1.590 0.113
Footprint index 107 0.35 0.12 103 0.32 0.11 1.964 0.051
Arch index 107 0.22 0.06 103 0.22 0.04 -0.419 0.676
5
0
%

w
e
i
g
h
t

b
e
a
r
i
n
g

s
t
a
n
c
e

o
f

l
e
f
t

f
o
o
t

Arch (Clarke) angle

106 52.49 6.66 103 48.16 6.84 4.641 0.000
Staheli index 109 0.41 0.23 103 0.33 0.23 2.461 0.015
Arch l ength index 79 0.77 0.10 75 0.76 0.04 0.773 0.441
Footprint index 106 0.31 0.20 103 0.28 0.18 1.166 0.245
Arch index 106 0.19 0.07 103 0.18 0.07 0.350 0.727
9
0
%

w
e
i
g
h
t

b
e
a
r
i
n
g

s
t
a
n
c
e

o
f

l
e
f
t

f
o
o
t

Arch (Clarke) angle (degrees) 105 51.10 7.27 102 45.09 6.75
6.164
0.000
Chippaux-Smi rak index 105 0.27 0.11 102

0.26 0.11
0.400
0.690
Staheli index 105 0.46 0.19 102 0.46 0.20
0.249
0.804
Arch l ength index 98 0.77 0.04 91 0.78 0.04
-2.637
0.009
Footprint index 105 0.37 0.13 102 0.30 0.12
3.642
0.000
Truncated arch index index 105 0.51 0.19 102 0.41 0.17
4.077
0.000
Arch index 105 00.22 0.05 102 0.22 0.05
0.179
0.858

In the 50% weight-bearing stance of the right
foot, the arch angle and ChippauxSmirak,
Staheli, footprint, and truncated arch indices
were significantly higher in the professional
football players than in the non-athlete controls
(p <0.05). For the left foot, only the arch angle
and Staheli index were significantly higher in
the professional football players compared with
the non-athlete controls (p<0.05).


In the 90% weight-bearing stance of right foot,
the arch angle and truncated arch index were
significantly higher in the professional football
players than in the non-athletic controls (p <
0.05). For the left foot, the arch angle, and the
arch length, footprint, and truncated arch
indices were significantly higher in the football
players compared with the non-athlete controls
(p <0.05).

Discussion
The human foot has a very complex structure
involving 26 major bones and more than 30
synovial joints
37
. The sole of the foot has three
arches, and exhibits a wider range of structural
variation than any other part of the body. The
height of the MLA shows the most important
and greatest variation
9,14,37-40
. Foot types are
classified according to the height of the MLA
and differ among populations
9,39
. Many
investigators have evaluated the height of the
MLA using different methods
9,14,41
. Footprint
analysis is a fast, simple, non-invasive, cost-
effective indirect method
14,38
. Unfortunately the
different methods used to acquire footprints,
such as those using ink, Vaseline, or carbon
powder, can be messy
42,43
or cause allergic
reactions
42
. Although Rutherford described a
method that involved pressing the soft tissue
against a flat, rigid glass surface, photographs
deformed the image and obliterated the details
of the skin
42
. These authors believe that they
minimised these problems by using digital
images and digital imaging technology. With
their method, they were able to distinguish
most of the details of the sole. They decided to
perform this study, as there are few studies on
the effects of football, the most popular sport
worldwide, on the arches of the foot
27,31,44
.

Staheli et al. studied an arch index called the
Staheli index in 441 subjects with a large range
in age
15
. Cavanagh and Rodgers described the
arch index and studied 107 subjects using an
ink footprint method and measurements made
with a planimeter
9
. Billis et al. studied the arch
index using a similar method with weight-
bearing footprints, except that they acquired
the footprint with powder and then input the
data to a computer using the AutoCAD
software, as these authors did
32
. The results of
all of these studies gave higher values than the
results described in this research study.

In 2001 and 2005 respectively, Urry and
Wearing studied the arch index and identified
statistically significant differences between
some contact areas of the sole using ink
footprints and electronic images obtained with
pressure platforms (which might skew the
results for small contact areas and cause
inaccuracies)
34,45
.

Their values for the arch
index obtained in their 2001 study, using both
ink footprints and the pressure platform, were
similar to the results obtained in this research,
and the ink footprint results from 2005 were
also similar to the results obtained in this
study
34,45
.

Chu et al. and Wearing et al.
studied the arch index with a foot pressure
platform in small study groups and obtained
results similar to these authors results
35,41.
Mathieson et al. studied the ChippauxSmirak
and Staheli indices using static footprints of the
right feet of 20 volunteers
28
. This present
studys results for the ChippauxSmirak index
for the right feet of both professional football
players and the controls were similar to their
results. Although this studys Staheli index
results for the right feet of the control group
were similar, the professional football players
had a higher Staheli index
28
. Xiong et al.
studied the arch and footprint indices in 48
subjects using ink paper and a pressure
platform
36
. These authors results for the arch
index in both groups were similar to their
results obtained using the pressure platform,
and their results using the inked footprint index
were similar to this studys results for the
control group
36
. Shiang et al. studied all of the
footprint parameters, as was done in this
present study
14
. Their average results for the
ChippauxSmirak, arch length, and Staheli
indices for both feet were higher than those for
both feet in both of this research studys
groups. Although their average results for the
arch angle of both feet were similar to this
researchs results for the control group, these
results for professional football players were
higher. For the footprint index, this research
studys results for both feet in the control group
were close to their results, whereas the values
for professional football players were higher.
For the truncated arch index, although this
studys results for both feet of the professional
football players were similar to that in their
study, the results for both feet of the control
group were smaller. The arch indices of both
feet in this studys groups were similar.
14
In general, many of these authors results
conflicted with those of other studies, although
some were similar. The reasons for these
differences could be as a result of ethnic and
gender differences in the study populations,
small study groups, and the methods used. For
example, some studies used the ink footprint
method, and others transferred the footprints to
computers and measured them using different
programs. In this way, mistakes in the


measurements could occur
9,14,16,17,32,34,36,45
.
The different types of pressure platforms used
have various sensitivities, and a low sensitivity
might cause erroneous measurements. In this
research study digital images were used to
determine the contact area, which is a more
sensitive method, and AutoCAD software was
used to obtain exact measurements.

Overall, none of the footprint indices appear to
be better than the others. Some are easier to
determine, and some are more widely used.
Most studies determined the arch index, which
seems to be the most effective and specific,
although these authors concur with Mathieson
et al. in believing that the arch index is a more
time-consuming method, despite the use of
computer programs for measurement
46
. For
this reason, other indices are still useful,
although they depend on different foot regions:
the ChippauxSmirak index and arch angle are
for the forefoot, and the Staheli index is for the
hindfoot. As all of these measures are based
on measuring lengths and angles, they are
easily affected by a variety of factors.

Aydog et al. determined the Staheli index in
Turkish junior-level basketball players using a
podoscope and a video camera, but did not
find any differences between groups
29
.
This
research studys results were smaller for both
feet. Aydog et al. studied the same foot
parameter using the same method in elite
gymnasts and showed that the sole arch
indices of the gymnasts were significantly
lower than those of their controls
30
. By
contrast, the present study found that these
measurements were higher in both feet in
football players. Aydog et al. studied the same
foot parameter in football players, wrestlers,
weightlifters, handball players, and gymnasts
31
.
This present studys results for football players
for both feet were higher than their results for
gymnasts, similar to those of the handball
players, and smaller than those for the other
groups. The differences between these results
and those of Aydog could depend on the
number of subjects in their study groups, as all
of their groups were smaller. The
biomechanics of the various sports and training
programmes could be another reason for such
differences. Age might be a third reason for the
differences, especially for their first study. In
their third study, they also studied football
players, but their study group was small, and it
was not clear whether their subjects were
professionals
2-4
.

Lpez et al. studied the ChippauxSmirak
index and arch angle using ink footprints
27
.
This studys results for the ChippauxSmirak
index of the right foot of professional football
players and the controls were smaller than
those reported by Lpez. Although these
authors results for the arch angles of both feet
of professional football players were higher
than those in all of their groups, these results
for the control group were similar. Soper et al.
also studied the ChippauxSmirak index, using
digital photographs of junior male football
players
44
. This research studys results for both
groups were smaller than their results for junior
male football players. The differences may be
due to ethnic and age differences. In addition,
training time would affect the results, as their
subjects were all amateurs.

The primarily extrinsic muscles, such as the
posterior tibial, flexor hallucis longus, flexor
digitorum longus, and abductor hallucis longus,
and the intrinsic muscles of the foot are
dynamic supporters of MLA and do not
become active until walking
6,33,37,47
. Many
studies have examined the posterior tibial
muscle and its effects on the MLA
6,33,47-49
. Most
movements in football depend on the lower
extremity muscles and, of course, on the foot.
While kicking, the foot must be plantar flexed,
and the extrinsic plantar flexor muscles of the
foot are activated
50
. Consequently, prolonged
activation of these muscles might cause lasting
changes in the sole of the foot, which would be
detected in the static footprint parameters.
Although some of the parameters in the
present study differed between the football
players and the controls, these parameters do
not reflect the same processes, as the arch
angle, footprint index, and truncated arch index
are directly proportional to the arch height,
whereas the ChippauxSmirak and Staheli
indices are inversely proportional to the arch
height. During specific movements in football,
pressure on the different areas of the sole and
resistance to this pressure could have different
effects. Wong et al. found high pressures on
the medial side of the planter surface with
different movements of football
22
. Eils et al.
found that during kicking, high pressure was
exerted on the lateral part of the foot compared
to running
51
. In addition, the number, shape,
and specific placement of the studs on the
bottom of the cleat could have an influence.
Walter and Ng noticed that duration of
midstance, which starts with heel strike and
ends with heel lift, was longer found in athletes
wearing cleats than in those wearing running
shoes
52
. In the light of these findings, the


present authors cannot say whether playing
football directly depresses or raises the sole
simply by discussing seven footprint
parameters. Aydog et al. investigated only the
Staheli index and found that it was smaller in
gymnasts
30
. Of course, the results in this
research study should be substantiated by
means of electromyography (EMG) studies
and dynamic footprint measurements.

Cleats are one of the causes of football
injuries
26
. Walter and Ng stated that the current
designs of cleats do not absorb pressure or
control motion
52
. Although cleats are becoming
more expensive and more attractive, to reduce
the injury rate, foot orthoses and more
ergonomic and comfortable cleats must be
designed. Although Percy and Menz found no
difference in the efficacy of hard orthoses
compared with soft orthoses in maintaining
postural stability in professional football
players
53
, Wong et al. stated that hard foot
inserts should be used for the non-preferred
foot and soft inserts for the preferred foot
22
.
Based on the differences between the
measurements of the parameters in this
research study and the results of other studies,
these authors believe that foot orthoses should
be used in every cleated shoe, as they support
the sole in both dynamic and static situations.

Conclusion
This study is the first to investigate several
static footprint measurements in professional
football players using AutoCAD software.
Further investigations with EMG and dynamic
footprint measurements of professional football
players from different ethnic groups may give
different results, but the requirement for foot
orthoses in cleats is unlikely to change.

Address for correspondence:
Associate Professor Cagatay Barut,
Department of Anatomy, School of Medicine,
Zonguldak Karaelmas University, 67600 Kozlu,
Zonguldak, Turkey
Fax: +90 372 2610264
Email: cagbarut@yahoo.com

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