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The Foot 18 (2008) 142–149

What is the best method for child longitudinal plantar arch

assessment and when does arch maturation occur?
Andrea Naomi Onodera a,∗ , Isabel Camargo Neves Sacco a , Eliana Harumi Morioka a ,
Priscila Saraiva Souza a , Márcia Regina de Sá b , Alberto Carlos Amadio b
a Laboratory of Biomechanics of Human Movement and Posture, Physical Therapy, Speech and Occupational Therapy Department,
School of Medicine, University of São Paulo, Rua Cipotânia 51, Cidade Universitária, CEP 05360-160, São Paulo, SP, Brazil
b School of Physical Education and Sport, University of São Paulo, Brazil

Received 26 June 2007; received in revised form 15 October 2007; accepted 2 March 2008

Abstract
Background: The medial longitudinal arch modifies significantly during growth. Nevertheless, authors differ on the age at which the foot
acquires the adult-like shape. The best method to assess this arch in children is also controversial.
Objectives: Characterize the longitudinal arch of children between 3 and 10 years and compare the applicability of five evaluation methods.
Methods: Plantar prints were acquired from 391 healthy preschools children from the University of Sao Paulo, Brazil. We calculated the
arch indexes of: Cavanagh and Rodgers, Chipaux-Smirak, Staheli and the Alfa Angle, and compared them with the feet posture assessment.
Non-parametric tests were used to compare among methods and ages. Spearman correlation was used to establish relationships among indexes.
Results: 3 and 4 years old showed a high prevalence of low arches (36–86%). Between 4 and 5 years old, significant difference was observed
for all indexes. The indexes presented good correlation among them, although the proportions of the different arch types were different for
each age group (p < 0.001).
Conclusions: The longitudinal arch acquires an adult-like shape progressively, being statistically notorious the moment of medial longitudinal
arch’s formation between 4 and 5 years old. The Chipaux-Smirak Index is the best index to assess children’s feet; it provides a better classification
for lower arches and is easily calculated.
© 2008 Elsevier Ltd. All rights reserved.

Keywords: Anthropometry; Foot; Children; Flat foot; Plantar prints

1. Introduction
The medial longitudinal plantar arch (MLA) has essential
functions in foot biomechanics, such as support and absorp-
tion of foot impact during walking [1,2]. The increase or
reduction of MLA (pes cavus or flatfoot, respectively) can
impair these functions [3] leading to muscular imbalance,
articular misalignment, compensatory pronation of foot and
gait abnormalities [4].
The MLA modifies significantly during growth and
flexible flatfoot and hypermobility can be considered devel-
∗ Corresponding author. Tel.: +55 11 30918426; fax: +55 11 30917462.
E-mail addresses: a naomi@terra.com.br, a.naomi@usp.br (A.N.
Onodera).
opmental profiles [17]. This way, the MLA tends to be lower
in children (idiopathic flatfoot, or postural flatfoot) but mostly
it is asymptomatic [5]. The MLA accentuates naturally when
approaching adolescence [1,6–8] with normally no need for
orthopedic treatment [9–12]. In children’s feet, the struc-
tural constituents of the MLA are not completely developed
and are unprepared to adequately support weight [6,13–16].
One abnormality of the dynamic function of lower limbs
would also interfere significantly with pediatric foot align-
ment [6]. The MLA of children is also fairly visible because
it is masked by thick adipose padding at the plantar surface
[18].
It is known that up to 12 years of age the foot is in a
significant linear growth phase [19–21] which is very intense
during the first years of life. Still, different authors differ on

0958-2592/$ – see front matter © 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.foot.2008.03.003
 A.N. Onodera et al. / The Foot 18 (2008) 142–149
the age at which the foot will acquire the adult-like shape, with
the MLA formation. For Magee [18], it occurs at 2 years of
age; for Hennig and Rosenbaum [22] at 6 years; for Donatelli
and Wolf [15], between 6 and 8 years and for Forriol and
Pascual [1] at 9 years.
On the other hand, an MLA increase, or pes cavus, is
infrequent in healthy children and in most cases is associated
with neuromuscular disorder [23].
It is known that anthropometrical foot measures vary
according to the population [16,24,25]. The use of stan-
dards and measures not related to shoe users can result in
discomfort, problems and deformities of the foot [7,26–29].
When the body and feet are still developing, feet and adjacent
segments (knees, hip, pelvis, trunk) can be severely mis-
aligned from the ideal posture causing harm. Nevertheless,
few studies have been done to obtain anthropometrical data
on children’s foot morphology and even less so in Brazilian
children.
The MLA can be assessed in several ways, including
observation, used in posture assessment, and quantitative
methods, that involve direct and indirect anthropometrical
measuring methods. The clinical evaluation of posture is sub-
jective, thus affecting its use in scientific studies. Moreover,
it does not allow the precise follow-up of the changes on
the foot after a postural treatment. Radiographic analysis is
relatively expensive and radiation represents a risk for chil-
dren, making it difficult to apply in large-scale studies. Plantar
prints can be easily obtained with a pedograph. They are
an inexpensive, simple, fast, and non-invasive way to obtain
a permanent register of morphological features of the foot.
The MLA measurement in plantar prints has already been
correlated with radiographic assessment [30,31] and direct
measurement [32,2,33,34] and has been the method of choice
in recent works in different populations [26,35–38].
Some of the methods already proposed for MLA assess-
ment using plantar prints are the Cavanagh and Rodgers Arch
Index (AI) [39], the Chipaux-Smirak Index (CSI) [1], the
plantar print Alpha Angle (AA) [40], and the Staheli Index
(SI) [8] and they presented a good repeatability [33] and reli-
ability inter- and intra-observer [2]. Nevertheless, studies are
few and inconclusive with respect to the correlation between
these methodologies [33,34] and their application in differ-
ent populations. In children, the presence of soft tissues and
fat pad under the plantar skin mask the age of MLA forma-
tion, due to the influence of fat mass on the midfoot area and
arch index [41]. There is an agreement that foot and MLA
develop gradually according with the time, but when exactly?
The objective assessment of these indexes and the character-
ization of MLA in children of different age groups would be
very useful to orthopedic technicians and shoemakers for the
manufacture of ergonomic shoes. Health professionals such
as physical therapists and orthopedists could also benefit by
having parameters to verify if development is as expected
for age, and reliable methods to observe patient evolution
or to objectively compare evaluations performed by different
professionals.
143
In this context, the aim of this work is: to characterize
the MLA in school children, aged from 3 to 10 years old,
using the feet posture assessment (PA) and four classification
methods from plantar print; to compare the applicability of
the diverse methods of MLA assessment and classification in
evaluating children, considering that these methods were not
specifically designed for pediatric use. The following indexes
were calculated: AI; CSI; AA; SI.
2. Methods
The sample came from places that take care of children
in the University of São Paulo, Brazil (Central Day Nursery;
NURI, Childish Recreation Center; PET, Project of Sport
and Talent) in a total of 560 children. To calculate the sample
minor size, it used a 95% confidence interval and a precision
value of 5%. Based on the total of children in the University
of São Paulo, we used the calculation described by Haddad
[42] resulting in a total of 228 children to be evaluated. This
value summed of 10%, to sample losses, result in 251 children
to be assessed. Therefore, we obtained 391 written informed
consent by parents or tutors authorizing their children to par-
ticipate in the study. Concluding, our sample consisted of
782 plantar prints from volunteer healthy school children
from São Paulo, of both sexes and ages ranging from 3 to
10 years, whose parents or tutors have given. This written
informed consent and the procedures followed protocol has
been approved by the local ethics committee. The prints were
subdivided in age subgroups. Due to the small number of indi-
viduals of ages 7 and 8 years they were grouped to form an
age subset from 7 to 8 years old.
Footprints acquisition was performed with a pedograph
in the bipedal position with bilateral weight bearing. After
the plantar prints, the MLA classification variables were cal-
culated: CSI, SI, AA and AI. During printing acquisition,
two physiotherapists performed independent PA of the foot
in a child in the bipedal position with bilateral symmetric
weight bearing, while watching the horizon. It was evaluated
the height of the medial border of the feet (medial longitu-
dinal arch) to the ground according with the experience of
each physiotherapist, without discussion among them dur-
ing the evaluation, and the MLA was classified as low when
the medial border reached or was very close to the ground,
high when the medial border was far from the ground and
normal when it was between the other two observations.
The inter-observer (physiotherapist) assessment was concor-
dant in 99% of cases. There were collected two footprints
for each foot, so each variable was calculated twice, and
the indirect measurements were performed by one appraiser,
with the ICC of 97%. The aim of the study did not include
the reliability inter- or intra-observer because these mea-
surements were already validated for adults in the literature
[1,2,8,39,40].
The CSI is the ratio between the smallest length of
mid-foot and the largest length of the metatarsal heads
144 A.N. Onodera et al. / The Foot 18 (2008) 142–149
Fig. 1. Graphical illustration of lines used for the calculation of CSI.
CSI = b/a; in which (CSI) Chippaux-Smirak Index; (a) maximal width of
the metatarsal print; (b) minimal width of the MLA’s area, being (b) parallel
to (a).
regions (Fig. 1). Five categories are described for the MLA
classification according to CSI—0%: foot with elevated
arch; 0.1–29.9%: foot with a morphological normal arch;
30–39.9%: intermediate foot; 40–44.9%: foot with a lowered
arch; 45% or higher: flatfoot [1].
The SI is the ratio between the smallest length of the mid-
foot and the largest length of the heel (Fig. 2). Values between
two standard deviation from mean, i.e. between 0.44 and 0.89
[8], were considered as normal values.
The AA is the angle formed between the line that joins
the most medial point of the metatarsal heads region with the
apex of the concavity of MLA print and the internal tangent of
the plantar print (Fig. 3). The MLA is classified in: 0–29.9◦ ,
low arch; 30–34.9◦ , dropped arch; 35–41.9◦ , intermedi-
ate arch; 42–46.9◦ , normal arch; above 47◦ , elevated arch
[1].
The AI is obtained from the ratio between the mid-
foot area and the total foot area, excluding the toe area
(Fig. 4). The MLA is classified as follows: AI < 0.21: elevated
MLA, 0.22 < AI < 0.26: normal MLA, AI > 0.26: low MLA
[38].
Variables were described in terms of mean, standard
deviation, standard error and percentages distribution. The
differences among ages were analyzed for each method by
the Kruskal–Wallis ANOVA tests after verifying the non-
normality by the Shapiro–Wilks test. Differences between
methods in each age group were analyzed by the Friedman
ANOVA test (the different types of MLA were converted
Fig. 2. Graphical illustration of lines used for the calculation of SI. SI = b/c;
in which (SI) Staheli Index; (b) minimal width of the MLA’s area; (c)
maximal width of the heel print, being (c) parallel to (b).
into an ordinal scale). For the MLA proportions compari-
son between ages, for each index, the χ2 -test for multiple
responses was used. Correlations were classified as two-by-
two by the Spearman correlation test because of the ordinal
nature of the MLA classification. For comparison between
classifications performed by each index, the MLA subclasses
were made uniform in the following ordinal scale—1: low
MLA, 2: normal MLA, and 3: high MLA. The flatfeet, low-
ered and intermediate arch heights were grouped inside the
classification 1. For every analysis the significant level was
lower than 5% (α < 0.05). Because of the statistical simi-
larities between sexes (t test, p = 0.23), boys and girls were
analyzed together among age groups.
3. Results
Table 1 shows the sample distribution in terms of height,
corporal mass and percentage of males as a function of age
in the studied sample (n = 391 children).
When comparing the obtained index values through devel-
opment from 3 to 10 years old a similarity between 3 and 4
years of age; between 5 and 6 years of age; between 6 and
7–8 years of age and between 9 and 10 years of age was
observed in CSI (Fig. 5), SI (Fig. 6), AA (Fig. 7), and AI
(Fig. 8). Thus, between the closest ages, indices classified
the feet in a similar manner. Nevertheless, 4 and 5-year-old
subjects showed differences between them. When CSI and
 A.N. Onodera et al. / The Foot 18 (2008) 142–149 145

Fig. 4. Graphical illustration of footprint length division into three equal

areas for the calculation of AI (L/3). AI, the ratio of the area of the
middle third of the toe less footprint to the total toeless footprint area
(M/(F + M + R)); in which AI, Arch Index; F, forefoot area; M, midfoot
area; R, rear foot area.

of low MLA at 3 years of age was statistically higher with

Fig. 3. Graphical illustration of points and lines used for the calculation of
AA, in which α is the angle between the medial borderline of the footprint
and the line connecting the most medial point of metatarsal region and the
apex of the concavity of the MLA (modified from Forriol and Pascual [1]).
SI were assessed by age, 7–8- and 9-year-old groups were
similar. In relation to CSI, SI, and AA there were similarities
between the 5 and 7–8 age groups. The other comparisons
were statistically different.
When the association between ages was studied on the
basis of the MLA ordinal classification scale, it was observed
that ages 3 and 4 were very similar with a statistically sig-
nificant difference only for the MLA proportion classified as
low for PA (higher at the 3 years old group). The two groups
were very different respect to the others. The relative amount
respect to every other age, and for every index except for the
comparison with the groups of 5 and 6 years of age for SI
and 7–8 years for PA.
Similarly to the 3-year-old group, the 4-year-old group
showed a statistically higher proportion of low MLA when
compared to other groups for most indices. The exception
was for PA in which 4-year-old subjects showed differences
only with respect to 9-year-old children.
We observed that 5-year-old subjects showed very similar
MLAs to those obtained in 6- and 7–8-year olds, except while
comparing the proportion of low MLA with the 7–8 group
for SI (higher proportion of low MLA in 5-year-old group).

Table 1
Height, body mass and percentage of males by age (n = 391)
Age (years) n Body mass (kg) Height (cm) Males (%)
mean ± S.D.a mean ± S.D.a
3 32 15.1 ± 1.8 95.3 ± 3.3 37.5
4 73 18.4 ± 3.5 104.6 ± 5.4 45.2
5 62 20.3 ± 3.8 110.8 ± 6.0 33.9
6 74 21.7 ± 3.2 115.7 ± 5.4 48.6
7 23 22.0 ± 2.1 122.1 ± 5.4 65.2
8 9 31.1 ± 6.9 131.8 ± 6.8 22.2
9 83 33.2 ± 7.3 140.3 ± 35.1 54.2
10 35 38.5 ± 11.4 141.3 ± 8.0 62.9
a S.D., standard deviation. Fig. 5. MLA development by mean of the CSI.
146 A.N. Onodera et al. / The Foot 18 (2008) 142–149

In 6- and 7–8-year-old groups, similar proportions of low

Fig. 6. MLA development by mean of the SI.
MLA for every index were verified, except for CSI and SI in
which a higher proportion occurred in the 6-year-old group.
Six-year old children showed a higher proportion of low MLA
than 9-year-old children for CSI, SI and AA and than the
10-year-old children for CSI, SI, AA, and AI.
The 7–8-year group showed a higher amount of low MLA
than the 9-year-old children for AA and AI and than the 10-
year-old children for CSI, AA and AI. Nine-year-old children
already showed a higher proportion of low MLA for CSI, SI,
and AI than 10-year-old children.
The indices showed clear and significant correlations
between each other (R above 0.75, p < 0.001) except for SI
and AA with AI.
The comparison of different methods of MLA assessment
showed (with the Friedman ANOVA test) that indices usually
determine low, normal or high arch in different proportions
for each age group (p < 0.001) (Table 2).
While comparing the proportions of the three MLAs by
index it was observed that in 3-year-old children there was
no concordance between SI and CSI; SI and AA; SI and
AI; PA and AI. For 4-year-old children all comparisons were
different except between CSI and AA; SI and PA. For 5-
year olds, only CSI and AA; PA and SI; PA and AI showed
similarities in proportions of the three MLAs. In 6-year-old

Table 2
Distribution of MLA types for each MLA evaluation method by age: low,
normal and high
Age Arch type CSIa (%) SIb (%) PAc (%) AAd (%) AIe (%)
(years)
3 Low 82.8 21.9 75.9 85.9 81.0
Normal 14.1 73.4 10.3 14.1 17.5
Fig. 7. MLA development by mean of the AA. High 3.1 4.7 13.8 0 1.6
4 Low 85.6 30.8 40.5 83.6 71.0
With respect to the 9- and 10-year-old subjects, the 5-year- Normal 11.6 65.1 38.1 16.4 18.6
old group showed a higher proportion of low MLA for every High 2.7 4.1 21.4 0 10.3
index, except for CSI (9-year olds) and for PA (10-year olds), 5 Low 62.4 15.2 39.5 70.4 52.8
where MLAs were similar. Normal 33.6 75.2 36.8 29.6 28.0
High 4.0 9.6 23.7 0 19.2
6 Low 67.6 12.8 34.1 64.9 48.6
Normal 25.7 73.6 47.7 35.1 31.5
High 6.8 13.5 18.2 0 19.9
7/8 Low 62.5 3.1 60.0 62.5 60.9
Normal 34.4 82.8 20.0 37.5 21.9
High 3.1 14.1 20.0 0 17.2
9 Low 56.6 6.0 19.4 36.1 39.2
Normal 34.3 74.7 50.0 63.9 27.7
High 9.0 19.3 30.6 0 33.1
10 Low 42.9 5.7 21.4 32.9 21.4
Normal 52.9 74.3 57.1 67.1 52.9
High 4.3 20.0 21.4 0 25.7
a CSI, Chipaux-Smirak Index.
b SI, Staheli Index.
c PA, Postural assesment.
d AA, Alfa angle.
Fig. 8. MLA development by mean of the AI. e AI, Arch Index.
 A.N. Onodera et al. / The Foot 18 (2008) 142–149
children, the PA and SI; PA and AA; PA and AI were similar.
There was a statistically significant difference between SI
and CSI; SI and AA; SI and AI for 7–8-year-old subjects. At
9 years of age, a similarity was only seen between PA and
SI; PA and AA. At 10-years of age, there was a concordance
between AA and PA; AA and AI; AA and SI; SI and PA.
4. Discussion
In every index a progressive increase of the MLA con-
cavity in parallel to the growth and development of children
between 3 and 10 years of age confirming what El et al.
[17] observed when studying the SI. Meanwhile, between
contiguous ages, such as 3 and 4, 5 and 6, 6 and 7/8, there
were no differences except between 4 and 5 years of age,
and 7–8 and 9 years of age. Probably because between the
age of 4 and 5 important changes are occurring in foot con-
formation with significant increases in MLA. After 6 years,
the arch maturation continues, but in slower velocity until 10
years old. Although the statistical differences seen between
4 and 5 years, in these age groups the mean of indexes clas-
sify the MLA as low. According to the CSI and AA, the
means classify the MLA as normal only after 9 years old.
All means were classified as normal MLA for the SI. The AI
defined two distinct groups of means: the age groups of 3,
4, 5 and 7/8 presented low MLA, and 6, 9 and 10 presented
it as normal. The 7–8-year-old group is potentially the most
heterogeneous enclosing a higher age interval and thus can
deviate from the general tendency of other groups, as seen
in CSI and AI values progression, which deviates from the
general tendency of index decrease with growth. Therefore,
the differences seen between 7–8 and 9 years of age were not
taken in consideration.
For the Contac II index, Volpon [21] observed a simi-
lar behavior recording an important index decline (that is an
increase in MLA) between 2 and 6 years of age, a slower
decline between 6 and 10 years of age and stabilized values
from that age on. This suggests that for the variables assessed
in this work, few index alterations would be observed after
10 years of age. The supposition that at 2 years [18], 6 years
[22] or between 6 and 8 years [8] of age the MLA would
already be formed seems to be wrong.
Analyzing the distribution and classification of the MLA
over the age groups, the low MLA proportion was similar
for every index between 3 and 4 years old, except for PA.
In those groups a fairly high prevalence of flatfeet (between
35.9% and 85.9% depending on the index) was observed,
significantly higher than in other groups. Another study, in
which CSI, AA, and SI were applied in children [26], also
verified that in this age group most subjects had flatfeet. Lin et
al. [6] also observed a high prevalence of low MLA between 3
and 4 years of age (40%). In this age groups great alterations
in the gait pattern [32], which could be reflected in the MLA
conformation [43], would be occurring, similarly to that in
adults [22]. Among the oldest children, the proportion of low
147
MLA decreases up to 10 years of age, but in a less obvious
way than in children between 4 and 5 years of age. These
results confirmed that the prevalence of flatfoot decreases
significantly with age as Pfeiffer et al. [12] also observed and
in this study 54% of the 3-year-old children presented low
MLA, while only 24% of the 6-year-old children showed
this type of MLA.
Altogether with the decline in low MLA prevalence, a pro-
gressive increase in the relative amounts of normal MLA was
observed, showing that its formation occurred in a physiolog-
ical and gradual way. This points out that there is no need to
use therapeutic measures in children with non-symptomatic
flatfeet, in accordance to other studies [10,11]. Even in sub-
jects with low MLA that report foot or tibia pain, the use
of supportive shoes can be enough to lessen symptoms [11],
probably due to a better distribution of plantar pressure [44].
On the other hand, the prevalence of high MLA was relatively
small in all age groups, as expected [23].
Among the studied indexes the PA was the least sensitive
to identify changes in ALM, discriminating only the 3-year-
old group from to the others, and was the only one unable
to detect changes in MLA from that age on. This is mainly
due to the fact that it is a subjective variable that depends on
the experience of tester in evaluating children feet and with
few available parameters to identified subtle changes in con-
formation and classification of MLAs. The recommendation
to complement this assessment by other anthropometrical
method is thus reinforced.
We confirmed that MLA maturation is depicted similarly
by the different indexes and that low MLA ratio is also sim-
ilar for most indexes in every age group. Moreover, indexes
showed good correlation between them. Meanwhile, the dis-
tribution in low, normal and high MLA in every age group
points to a great divergence in the assessment and classifica-
tion methods used in this study. Most comparisons between
indices showed similarities in several age groups, neverthe-
less in a non-consistent way. It is remarkable that the SI
was found to be quite different than CSI, AA and AI. These
divergences should be considered in the interpretation and
comparison of studies that use these indices since one simi-
lar population can show variations in the distribution of MLA
depending on the elected method for its evaluation.
The lack of concordance between methods can be due to
differences in criteria established by each author for MLA
classification. The normal MLA classification in SI included
the values within two standard errors, to one side or the other
of the mean value, considering the sample of this study and
after the descriptions of Staheli et al. [8]. Thus, for the SI there
was a higher prevalence of normal MLA even in younger
children.
On the other hand, for AI classification we considered the
limited values for the different MLAs depicted by Cavanagh
and Rodgers [38]. These authors considered as normal the
MLA values to those between the first and third quartile cal-
culated for a population of adults that showed MLAs more
accentuated in relation to children. In this way, the tendency
148 A.N. Onodera et al. / The Foot 18 (2008) 142–149
was that most children’s feet were classified as low ALM.
The AI, after revised literature, was the index most employed.
Nevertheless, it requires the use of specific equipment for the
irregular area calculation which makes its use difficult for
large-scale clinical practice.
When using AA, it is difficult to determine the mid-foot
apex concavity in an over-accentuated or lowered MLA,
which can make the measure less precise. Small children
can show an inversion of that curve being even more diffi-
cult. Thus, the AA is not the most indicated index to assess
children’s feet.
We found that the CSI has the advantage of having five
classifications, and three of them are used to depict lowered
MLAs, different from that which Nikolaidou and Boudo-
los [33] discussed in their paper. Having in mind that most
children’s feet are included in these groups, such a CSI vari-
able would make possible the most precise follow-up of
MLA evolution. Moreover, the CSI calculation does not need
specialized equipment, being easily applied. So, its use in
pediatric populations can be recommended.
Despite of the divergences in the classification and
methodologies among indexes, it was observed an agreement
about the tendency of MLA’s development between 3 and 10
years old, being statistically notorious the moment of MLA’s
formation between 4 and 5 years old. It is interesting to note
that this moment occurs even with the generous fat pad usu-
ally present above the feet of the children, and frequently is
a confounding factor in estimating the arch height.
Conflict of interest
None.
Acknowledgements
The authors express their gratitude for all the subjects for
their voluntary involvement in the present paper. Also, we
wish to acknowledge FAPESP 03/00839-9 in the funding of
this research.
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