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Orthopaedics & Traumatology: Surgery & Research xxx (2020) xxx–xxx

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Orthopaedics & Traumatology: Surgery & Research

journal homepage: www.elsevier.com

Original article

What is the most reliable radiographic method to evaluate the

longitudinal foot arch? Application in subjects with Adolescent
Idiopathic Scoliosis
Georges Mjaess , Aya Karam , Chris Labaki , Mohammad Karam , Ziad Bakouny ,
Joe Ghanimeh , Renee Maria Saliby , Aren Joe Bizdikian , Ismat Ghanem , Ayman Assi ∗
Faculty of Medicine, University of Saint-Joseph in Beirut, Lebanon

a r t i c l e i n f o a b s t r a c t

Article history: Background: The foot arch is known to be altered in subjects with postural malalignment. Foot arch mor-
Received 3 July 2019 phology can be studied simultaneously with body’s balance by measuring foot radiographic parameters
Accepted 19 November 2019 on full-body biplanar x-rays. There is no consensus on which is the most reliable method to use to draw
Available online xxx
the foot axes. The aim was to determine the most reliable methods to draw the main foot axes and apply
these findings in order to study the difference of foot parameters between AIS and control subjects.
Keywords: Hypotheses: (1) distant and clear anatomical landmarks are needed to draw the foot axes accurately; (2)
Adolescent Idiopathic Scoliosis
foot longitudinal arch parameters differ between AIS and controls.
3D reconstruction
Foot arch
Methods: Ninety AIS patients and 36 controls have undergone full body biplanar X-rays from which 3D
Posture spino-pelvic and postural parameters were collected for each patient. Six radiological foot angles were
Repeatability evaluated on the 2D lateral radiographs: calcaneal pitch (CPA), talar declination (TDA), first metatarsal
declination (FMDA), talo-calcaneal (TCA), calcaneal first metatarsal (CFMA) and Meary. Angles were cal-
culated based on three major axes of the foot: talar, calcaneal, and first metatarsal. Two to three methods
were used to draw each axis and the reliability of each method was assessed (three operators, 2-times
each). Then, differences of the foot parameters between AIS and controls, and determinants of these
differences among 3D spino-pelvic and postural parameters were evaluated.
Results: The most reliable methods for drawing the three axes of the foot were those using distant and
clear anatomical landmarks on talus, calcaneum and first metatarsal and used for the subsequent analysis.
The AIS group showed a significantly lower TDA (22◦ vs. 24◦ , p = 0.014) and CFMA (141◦ vs. 144◦ , p = 0.045),
and higher FMDA (18◦ vs. 15◦ , p = 0.008) and Meary’s angle (−5◦ vs. −9◦ , p = 0.005) when compared to
controls. Differences were found to be determined mainly by the center of auditory meatus sagittal
plumbline.
Discussion: This is the first study to evaluate the most reliable method to draw foot axes on the lateral
radiograph of biplanar X-rays in order to assess radiological foot arch parameters. AIS patients were
shown to have more elevated foot arch compared to controls.
© 2020 Elsevier Masson SAS. All rights reserved.

1. Introduction longitudinal foot arch is evaluated based on radiological parame-

The foot arch plays a key role in maintaining body balance
and supporting body weight [1]. Studying the radiographic foot
arch morphology relies on both weight-bearing lateral and antero-
posterior (cranio-caudal) standard radiographs of the foot [2]. The
∗ Corresponding author at: Laboratory of Biomechanics and Medical Imaging, Fac-
ulty of Medicine, University of Saint-Joseph, Campus of Innovation and Sport, PTS,
Damascus street, Beirut, Lebanon.
E-mail addresses: ayman.assi@gmail.com, ayman.assi@usj.edu.lb (A. Assi).
ters measured on the lateral radiograph, and these parameters are
assessed by the drawing of three foot main axes: talar, calcaneal,
and first metatarsal axes [3]. Different methods to draw the same
axis have been suggested in the literature [2–5] and the reliability
of each method was separately studied on standard X-rays [6,7].
More recently, studying the full body’s posture and balance
necessitates full body biplanar X-rays from head to feet [8], which
help in the evaluation of global spinal sagittal balance and its rela-
tionships with the pelvis and the lower limbs [9]. In these biplanar
radiographs, patients stand with one leg slightly shifted in front
of the other one to avoid superimposition of the lower limbs’

https://doi.org/10.1016/j.otsr.2019.11.024
1877-0568/© 2020 Elsevier Masson SAS. All rights reserved.

Please cite this article in press as: Mjaess G, et al. What is the most reliable radiographic method to evaluate the
longitudinal foot arch? Application in subjects with Adolescent Idiopathic Scoliosis. Orthop Traumatol Surg Res (2020),
https://doi.org/10.1016/j.otsr.2019.11.024
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Fig. 1. Definition of foot angles on lateral radiographs.
anatomical landmarks on the sagittal view, such as condyles and
malleoli [10]. While these biplanar radiographs have a low radi-
ation dose compared to standard X-rays, studying both global
posture and foot morphology using this single imaging modal-
ity minimizes even more the radiation dosage to the patient.
Compared to conventional X-rays which feature each foot apart,
biplanar radiographs feature both feet slightly superimposed.
Rungprai et al. have demonstrated the reliability and validity of
biplanar radiographs in the assessment of lateral foot parameters
used to evaluate the longitudinal foot arch in adults, and this by
using only a single drawing method for each parameter [11]. While
many methods exist in the literature for the drawing of foot param-
eters, we do not know which method is the most reliable to use on
biplanar full-body radiographs, where feet are slightly superim-
posed.
On the other hand, spinal deformities are known to affect global
posture and balance [12] and may have repercussions on the
foot arch [13]. In the case of adolescent idiopathic scoliosis (AIS),
which is a 3D deformity of the spine that affects the spino-pelvic
alignment [14], the relationship between AIS and foot deformities
remains unclear. An epidemiological study based on patients’ foot-
prints and a clinical diagnosis of scoliosis has shown a significant
relationship between idiopathic scoliosis and pes cavus [15]. There
are no studies that evaluate the radiographic morphology of the
lateral foot arch in patients with AIS.
Therefore, the aim of this study was to determine the most
reliable methods to draw the main three foot axes on the lateral
radiograph of biplanar X-rays, and apply these findings in order to
study the difference of foot parameters between AIS and control
subjects.
The hypotheses of this study were:
• distant and clear anatomical landmarks are needed to draw the
foot axes accurately;
• foot longitudinal arch parameters differ between AIS and con-
trols.
2. Patients and methods
2.1. Patients
This retrospective study was approved by the IRB committee of
our institution (CEHDF#742) and all patients had previously signed
a written informed consent form.
Please cite this article in press as: Mjaess G, et al. What is the most reliable radiographic method to evaluate the
longitudinal foot arch? Application in subjects with Adolescent Idiopathic Scoliosis. Orthop Traumatol Surg Res (2020),
https://doi.org/10.1016/j.otsr.2019.11.024
An AIS group (> 10 years old, Cobb angle > 10◦ ) with a lower limb
discrepancy < 1 cm and a control group of adolescents without any
musculoskeletal alterations or orthopedic history were included in
the study.
3. Methods
Demographic parameters for each subject (age, sex, weight,
height) were collected. All subjects had previously undergone full-
body biplanar X-Rays using the EOS system (EOS Imaging® , Paris,
France) and were asked to stand in the free-standing position [10],
the right foot slightly shifted forward [16]. A well-trained opera-
tor performed 3D reconstructions of the spine and lower limbs for
all patients using the SterEOS® software (version 1.8.99.20R, EOS
Imaging® , Paris, France).
From these reconstructions, classic spino-pelvic and lower limb
parameters were collected in 3D [10,17]. The type of scoliotic curva-
ture was collected: major thoracic, thoraco-lumbar or lumbar [18].
In addition, global postural parameters were also collected (in mm):
shoulder discrepancy (ShD), center-of-auditory-meatus plumbline
(CAM-plumbline) to the middle of the hip-axis on sagittal radio-
graphs, C7 to central sacral line (C7-CSL) as the frontal deviation
between C7-plumbline and the center of the sacral plate, and the
sagittal vertical axis (SVA) [19].
Six foot-related parameters were measured in 2D for both
AIS and control groups bilaterally on the lateral radiographs:
Calcaneal pitch angle (CPA), talar declination angle (TDA), first
metatarsal declination angle (FMDA), talo-calcaneal angle (TCA),
Meary’s angle, and calcaneal first metatarsal angle (CFMA) (Fig. 1).
These 6 angles were based on the three major axes of the foot: Talar
Axis, Calcaneal Axis, and First Metatarsal Axis. Several methods
were used to draw these axes (Fig. 2).
In order to determine the most reliable foot axis, upon which
are based foot angle measurements, a repeatability assessment
was conducted. A power analysis was performed with the aim
of determining the number of operators, subjects and repetitions
required to obtain an error on the repeatability calculation infe-
rior to 5% [20]. Consequently, a subsample of 40 subjects (20 AIS
age and sex matched to 20 controls) was chosen arbitrarily from
the initial population and was included in the repeatability study.
Three trained-operators measured the 3 axes of the foot, for each
patient, bilaterally, 2 times each at 1-week interval. A foot axis
angle, defined as the angle between each axis and the horizontal,
was then calculated for each method.
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Fig. 2. Methods used in order to draw the 3 major axes of the foot: talar axis, calcaneal axis and first metatarsal axis.

Table 1
Reproducibility for each method of foot axis angle determination.

Talar Axis Calcaneal Axis First Metatarsal Axis

Method 1 Method 2 Method 3 Method 1 Method 2 Method 1 Method 2 Method 3

ICC 0.834 0.976 0.701 0.962 0.983 0.979 0.945 0.954

SR (◦ ): mean ± sd 4.0 ± 1.7 1.7 ± 0.8a 7.1 ± 3.2 2.1 ± 1.4 1.6 ± 0.8a 1.0 ± 0.6a 2.2 ± 0.9 1.5 ± 0.9
Between-method comparisons (p-value) < 0.001 0.001 < 0.001
a
Significantly lower value; sd: standard deviation.

3.1. Statistical analysis
Age, weight, height and gender ratio were compared between
both groups (Student t-test, Chi2 test).
In order to assess the reliability of each foot axis drawing
method, the intraclass correlation coefficient (ICC) (2, k) model [21]
and the repeatability variance (SR , norm ISO 5725-1:1994 [22]),
including both intra and inter-operator repeatability, were calcu-
lated for each method of foot axis angle. ICC > 0.80 indicates very
high reliability, 0.60–0.80 moderately high reliability, 0.40–0.59
moderate reliability and < 0.40 low reliability [23].
SR was then compared between methods for each major axis
of the foot, using either a Friedman test (followed by Nemenyi
multiple-comparisons) or a Wilcoxon test. The most repeatable
methods to draw the foot axes were then used in the rest of the
analysis.
Differences in spino-pelvic, lower limbs and global postu-
ral parameters between AIS and controls were evaluated using
Mann–Whitney test.
In order to evaluate differences in foot parameters between
AIS and controls, while including both feet, mixed repeated mea-
sures analysis of variance (RM-ANOVA) models were computed
and the between-subject effects of this model were evaluated.
In order to assess the possible determinant factors that could
account for these differences, multivariate RM-ANOVA models
were computed. The dependent variables were foot parameters
which had been found to be significantly different between AIS
and controls; the independent variables were spino-pelvic, lower
limbs and postural parameters as well as the type of curvature in
AIS.
Statistics were performed using Xlstat® (version 2018.1, Addin-
soft, Paris, France). The level of significance was set at 0.05.

Please cite this article in press as: Mjaess G, et al. What is the most reliable radiographic method to evaluate the
longitudinal foot arch? Application in subjects with Adolescent Idiopathic Scoliosis. Orthop Traumatol Surg Res (2020),
https://doi.org/10.1016/j.otsr.2019.11.024
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Table 2
Comparison of spino-pelvic, lower limbs and global postural parameters between AIS and controls.

Parameter AIS Controls p-value

Spino-Pelvic Parameters
Cobb(◦ ) 38.12 ± 13.62 3.98 ± 3.96 <0.001a
AVR (◦ ) 17.61 ± 8.46 1.80 ± 2.36 <0.001a
T1/T12 kyphosis (◦ ) 34.38 ± 12.15 43.17 ± 9.55 <0.001a
L1/S1 lordosis (◦ ) 59.11 ± 10.69 57.56 ± 8.44 0.50
Pelvic Incidence PI (◦ ) 49.98 ± 12.24 44.19 ± 10.11 <0.001a
Sacral Slope SS (◦ ) 39.99 ± 8.16 36.56 ± 6.07 0.001a
Pelvic Tilt PT (◦ ) 9.95 ± 8.55 7.59 ± 7.00 0.02a
Frontal pelvic obliquity (mm) 6.37 ± 3.70 4.30 ± 3.83 <0.001a
Pelvic axial rotation (◦ ) 3.22 ± 2.46 3.39 ± 2.24 0.35
Lower LimbsParameters
Neck shaft angle (◦ ) 130.41 ± 4.17 131.44 ± 4.82 0.25
Tibial Torsion (int [-], ext [+]) (◦ ) 28.43 ± 7.12 28.32 ± 6.93 0.79
Knee Varus (-)/Valgus (+) (◦ ) 0.53 ± 2.48 0.81 ± 2.31 0.40
Knee flexion (+)/extension (−) (◦ ) −2.54 ± 5.39 −3.19 ± 5.28 0.39
HKS(◦ ) 4.22 ± 1.14 3.71 ± 1.07 0.001a
Femoral anteversion (int [+], ext [-]) (◦ ) 17.22 ± 10.47 16.70 ± 10.31 0.72
Global Posture
Shoulder discrepancy (mm) 0.05 ± 0.51 0.12 ± 0.48 0.26
CAM plumbline (post [-], ant [+]) (mm) −29.83 ± 23.75 −17.79 ± 28.24 <0.001a
C7-CSL (mm) 12.20 ± 9.11 7.32 ± 6.44 <0.001a
Sagittal Vertical Axis (post -], ant [+]) (mm) −20.12 ± 21.72 −13.51 ± 23.67 0.12
a
Statistically significant.

4. Results CAM-plumbline (p = 0.01) were found to be determinant factors for

4.1. Demographics
Ninety AIS subjects (15 ± 2 years old; 72F/18 M; 42 major tho-
racic, 34 major thoraco-lumbar and 14 major lumbar scoliosis) with
a mean Cobb angle of 38 ± 13◦ (minimum: 20, maximum: 81.6),
height of 160 ± 10 cm and weight of 53.7 ± 11.1 kg, and 36 con-
trol subjects (16 ± 4 years old; 24F/12 M) with a mean height of
160 ± 20 cm and weight of 57.5 ± 19 kg, were included in the study.
No statistical differences were found for age, weight, height and sex
between both groups (all p > 0.05).
the differences in FMDA between AIS and controls. CAM-plumbline
(p = 0.028) was found to be a determinant factor for the differences
in Meary’s angle between AIS and controls. Pelvic axial rotation
(p = 0.022) and CAM-plumbline (p = 0.01) were found to be determi-
nant factors for the differences in CFMA between AIS and controls.
In all three previous angles, CAM-plumbline had the largest sum of
squares when compared to the other determinant factors. The type
of scoliotic curve, the magnitude of Cobb angle, weight and height
were not determinant factors.
5. Discussion

4.2. Repeatability
The results of ICC and SR for each method of foot axis angle deter-
mination were presented in Table 1. SR was statistically different
(p < 0.001) between all of the suggested methods. In the case of
the talar axis, T2 showed the highest ICC (0.976) and the lowest SR
(1.75◦ , p < 0.001). In the case of the calcaneal axis, C2 showed the
highest ICC (0.983) and the lowest SR (1.64◦ , p = 0.001). In the case
of the first metatarsal axis, M1-1 showed the highest ICC (0.979)
and the lowest SR (1.04◦ , p < 0.001). Therefore, T2, C2 and M1-1
were used and the SR of foot parameters were as follow: talar dec-
lination angle (1.75◦ ), calcaneal pitch angle (1.64◦ ), first metatarsal
declination angle (1.04◦ ), talo-calcaneal angle (2.4◦ ), Meary’s angle
(2◦ ), and calcaneal first metatarsal angle (2.1◦ ).
4.3. AIS vs. Controls
The results of the comparisons between the two groups were
presented in Table 2. The AIS group showed an altered spino-pelvic,
global postural and knee alignment when compared to controls.
The AIS group showed a significantly lower TDA (22◦ vs. 25◦ ,
p = 0.014) and CFMA (141◦ vs. 144◦ , p = 0.045), and larger FMDA (18◦
vs. 15◦ , p = 0.008) and Meary’s angle (−5◦ vs. −9◦ , p = 0.005) when
compared to controls (Fig. 3). Differences between AIS and controls
were larger than the repeatability variance of each parameter.
The regression analysis showed no significant determinant
factors for the differences in TDA between AIS and controls
(p > 0.05). Pelvic tilt (p = 0.045), pelvic axial rotation (p = 0.025) and
Studying the longitudinal arch of the foot relies on three main
axes: talar, calcaneal, and first metatarsal axes. There is no consen-
sus in the literature for the most reliable methods when drawing
these axes in order to assess radiographic lateral foot parameters on
full-body radiographs. This is the first study to determine the most
reliable method to use practically in order to evaluate these three
axes in AIS and controls. The method that represented the talar axis
as the line joining the middles of two segments, the first represent-
ing the largest thickness of the talus body, and the second joining
the highest and lowest points of the talus head (T2), presented the
highest ICC and the lowest SR values, and was therefore consid-
ered as the most reliable method to draw the talar axis. This could
be explained by the fact that T1 takes into consideration only one
segment of the calcaneum and could be drawn differently between
operators, as in T3, the second segment is drawn randomly and is
too close to the first segment, thereby increasing the probability of
errors in measurement. In contrast, T2 utilizes two precise distant
segments representing the geometry of the whole talus. In the case
of the calcaneal axis, the method that represented the calcaneal axis
as the line joining the middles of two segments — the first repre-
senting the largest thickness of the calcaneal body, and the second
joining the highest posterior point of the talo-calcaneal joint and
the lowest point of the calcaneo-navicular joint, —C2 showed the
highest repeatability. This might be due to a process similar to the
one found in the talar axis, since C2 was based on joining the mid-
lines of two distinct and distant lines presenting the entirety of
the calcaneus, compared to C1, where only one segment was taken
into account. In the case of the first metatarsal axis, the method that

Please cite this article in press as: Mjaess G, et al. What is the most reliable radiographic method to evaluate the
longitudinal foot arch? Application in subjects with Adolescent Idiopathic Scoliosis. Orthop Traumatol Surg Res (2020),
https://doi.org/10.1016/j.otsr.2019.11.024
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Fig. 3. Comparison of the foot radiological parameters between AIS and controls.

Fig. 4. Difference in the shape of the lateral foot arch between AIS and controls: the role of CAM-plumbline.

represented the first metatarsal axis as the line joining the middles
of two segments representing respectively the largest thicknesses
of the proximal and distal extremities of the first metatarsal (M1-1)
was the most repeatable for the same reasons as the talar axis.
All three methods which were found as the most reliable pre-
sented an ICC > 0.8 which indicates a very high reliability. The
results obtained for ICC are comparable to those found by Rung-
prai et al. (which ranged from 0.927 to 1) [11]. ICC for calcaneal
pitch angle in our study was higher than that found by Bock et al.
(0.983 vs. 0.823) and that could be explained by the precise method
we proposed in order to draw the calcaneal segments compared to
the free-hand method utilized by Bock et al. [7].
Frontal Cobb Angle, PI, SS, PT, C7-CSL, TK, CAM-plumbline and
frontal pelvic obliquity, and HKS, are known to differ between nor-
mal subjects and AIS patients [24], as in the current study. Scoliotic
subjects showed an altered foot morphology compared to controls
(between-subjects effect), with a higher first metatarsal declination
and a lower calcaneal first metatarsal angle, resulting in a more ele-
vated foot arch in AIS patients compared to controls. This difference
was explained by a more posteriorly projected CAM plumbline,
resulting in a lower talar declination (a more horizontalized talus),
thus decreasing stress on the foot arch, especially on the forefoot
(first metatarsal component). This is illustrated by a higher first
metatarsal declination, consequently resulting in a more elevated
plantar arch (lower calcaneal first metatarsal angle). It should be
noted that the calcaneal component of the foot arch did not dif-
fer significantly between AIS and controls, thus not contributing
to the differences observed (Fig. 4). The differences found were
not only due to measurements variability as they were superior
to the repeatability variance SR . These results are consistent with

Please cite this article in press as: Mjaess G, et al. What is the most reliable radiographic method to evaluate the
longitudinal foot arch? Application in subjects with Adolescent Idiopathic Scoliosis. Orthop Traumatol Surg Res (2020),
https://doi.org/10.1016/j.otsr.2019.11.024
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the literature which shows a higher pes cavus prevalence among
AIS patients [15].
This study has some limitations. It did not evaluate the param-
eters of the foot in the horizontal plane, but this was not possible
using EOS® , since the frontal radiological incidence of this imaging
technique, which is antero-posterior, differs from that of the stan-
dard frontal radiograph of the foot which is cephalo-caudal. Future
studies should include horizontal radiographs of the foot and pedo-
barography data in order to better understand foot deformities in
AIS. However, the EOS® imaging technique is considered as a vali-
dated and reliable technique to evaluate sagittal foot radiographic
parameters [11].
6. Conclusion
In conclusion, this study proposed the most repeatable methods
to draw the foot axis on lateral radiographs for the talus, calca-
neus and first metatarsal, that should be used in clinical practice.
This study confirmed the stated hypothesis that axes based on dis-
tant points were more repeatable. The clinical application showed
that AIS subjects had more horizontalized talus due to a posteriorly
projected sagittal alignment, therefore resulting in a higher first
metatarsal declination and a more elevated foot arch compared to
controls.
Disclosure of interest
The authors declare that they have no competing interest.
Funding
This research was funded by the research council of the Univer-
sity of Saint-Joseph in Beirut (Project FM300).
Authors’ contributions
GM, AK, CL, JG, RMS and AA wrote the manuscript.
GM, AK, CL, MK, JG participated to the data collection.
GM, AA, ZB did the statistics and interpretations of the results.
AJB, IG substantially edited the manuscript.
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