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References....................................................................................................................... 312
Summary
7,9,10,11,16
There exists a wide variety of foot shapes and foot arch structures, and these morphological
3,6,11,12, 15, 16,20
differences are considered normal. In young children, variations are reported to be greater due
2,6,7,8, 15,18,20
to physiological changes, and can be considered developmental profiles. A low arch or flat foot
15
has been traditionally regarded as undesirable. Flexible flatfoot is a common finding in children under the
age of 6 years and is a developmental variation. A small minority of children will have flat feet by the age 10
21
years. Pes Planus rarely leads to gait problems or chronic pain if it persists into adulthood. Pathological
forms include the flexible type that falls outside the normal range, as well as the flat foot that is due to a
structural abnormality, such as is found in tarsal coalition. Structural flat feet usually show some stiffness and
15
can cause disability.
15,24
The evolution of the normal foot arch, classification of foot morphology and testing procedures are
1,3,7,10,13,16,19
reported as topics of some debate in the literature. The controversy existing over different
techniques is not adressed in the present document. The selected assessment tools are recognized as
methods that can be used effectively for screening studies and for individual assessments in a clinical
7,10 6,7,9,13,14,15, 16
setting. These testing procedures are used to define and categorize arch structure in children
3 9,10
or calcaneal position. However, no methods have been universally established and recorded values from
13
each method will vary and are not directly comparable.
CLINICAL ASSESSMENT
The MLA and calcaneal position can be measured by two quantitative methods:
Footprint Analysis Anthropometric Measurements
296 Part 5: The Foot
FOOTPRINT ANALYSIS
ANTHROPOMETRIC MEASUREMENTS
Anthropometric measurements consist in analyzing parameters in reference to bony landmarks and the
supporting surface. Two methods are presented:
The Navicular Height (NH) is a direct bony measurement of the navicular, considered the keystone of
7, 23
the MLA. Findings showed no significant difference in the NH between gender and body weight
7
demonstrating that NH may prove to be a more universal measurement for the pediatric population.
It is reported as being a more discriminative tool regarding age difference, suggesting it provides a
7
useful and easily obtained clinical measure.
The Relaxed Calcaneal Stance Position (RCSP) indicates the position of the calcaneus in the frontal
11
plane. The RCSP does not affect the height of the MLA and, in asymptomatic subjects, wide
14
ranges were recorded.
Part 5: The Foot 297
4 years to Moderate to
n = 29 Poor
Evans et al. 6 years poor More reliable in adolescents
5
(2003) but not in young children.
8 years to
n = 30 Good Moderate
15 years
1.2 Measurements
The plantar arch index establishes a relationship between central and posterior regions of the
footprint and is the measurement of the support width of the central region to the foot (A) and of the
22
heel region (B) in millimeters.
SAI is obtained by calculating the ratio of the width in the mid-foot region, (isthmus) (A), with the mid-
4,15, 22
heel region, called the heel width (B), obtained by footprints (Fig. 5.2).
PRE-TEST
Non-slip material is placed under the podograph for safety reasons.
TEST
Testing position and measurements for the SAI are presented in Table 5.4.
Results are compared to the normative reference values in Figure 5.6.
Part 5: The Foot 299
15
TABLE 5.4. STAHELI’ S ARCH INDEX
Testing Position
Dynamic footprints : In the present study, dynamic footprints were recorded. The child stepped in
powdered chalk and then took a step on a sheet of paper. In order to conform to these testing
procedures, and since the foot is a dynamic structure that undergoes changes during a step, it is
suggested to record dynamic footprints by having the child take a step on the podograph. (Fig. 5.3).
Static footprints : However many studies have calculated the SAI by using static footprints (Fig.
10, 12, 17
5.4). The suggested method is to have the child take a step with the non-tested foot onto
one side of the podograph, followed by the placement of the tested foot onto the inked mat. The
non-tested foot is then slightly raised from the supporting surface and placed back on the ground.
17
The child walks off the podograph by clearing the tested foot first.
Figure 5.6
15
©Staheli, Chew, and Corbett, p. 428.
Authors’ Conclusion
The longitudinal arch of the sole of the foot usually develops during childhood and there is no
evidence that flexible flat foot of any degree produces disability.
Impressions of the footprint combined with clinical evaluation provide a practical means to
document the configuration of the foot.
Part 5: The Foot 303
Figure 5.7
15
©Staheli, Chew, Corbett, p. 427.
4
Consistency of Measurements: Prior to this study, Engel and Staheli (1974) analyzed the
evolution of torsion in the lower limbs in childhood. Reproducibility of measurements was
evaluated on five children on two separate occasions and the median and range of the differences
between the two sets of values were determined:
For the arch width, the median difference was 1 mm and the range was 0 to 5 mm;
For the heel width, the median difference was 1 mm and the range was 0 to 6 mm.
304 Part 5: The Foot
2.2 Measurements
NH is the distance between the navicular tuberosity and the supporting surface (Fig. 5.8).
PRE -TEST
Prior to the assessment, if need be, have the child stand on the platform so he becomes familiar with
the testing position. The child is instructed that he will have to stay upright during the assessment
and that no stepping is allowed.
TEST
Testing position and measurements are presented in Table 5.7.
Results are compared to the normative reference values for NH measurements in Table 5.8.
7
© Gilmour, Burns, p. 495.
Comments
Internal and external validity including sample size (n =84 to 96 in each group) seems good and the
use of results as a trend for clinical guidelines is appropriate.
Part 5: The Foot 307
3.2 Measurements
RCSP is the angle formed by the posterior aspect of the calcaneus to the supporting surface in
stance position, measured with a standard goniometer (Fig. 5.12).
PRE-TEST
Prior to the assessment, if need be, have the child stand on the platform so he becomes familiar with
the testing position. The child is instructed that he will march in place, then be asked to stop and
remain in a relaxed stance position. No stepping is allowed.
TEST
Two testers are needed. One to stabilize the ankle and foot in neutral position while the other marks
the skin with the pen.
Testing position, goniometer alignment and measurements are presented in Table 5.9.
Results are compared to the normative reference values in Figure 5.13.
308 Part 5: The Foot
Figure 5.10: In prone, bisection of the posterior Figure 5.11: In standing, comfortable angle and
aspect of the calcaneus. (© IRDPQ-2008). base of stance achieved. (© IRDPQ – 2008).
Goniometer Alignment and Measurements
The movable arm is aligned on the calcaneal
bisection line.
The stationnary arm is aligned parallel to the
supporting surface.
RCSP is the angle formed by the bisection of
the posterior aspect of the calcaneus to the
14
supporting surface during relaxed standing.
Note: 95% of children had a RCSP between 1° varus and 12° valgus. 14
Figure 5.13 :
14
© Sobel, Levitz, Caselli, Tran, Lepore, Lilja, …and Wain, p. 262.
8-year-old girl : RCSP = - 4°. This angle is not within the normal ra nge of her age group and
indicates important varus of the calcaneus.
Authors’ Conclusion
Reliability and normal values for RCSP were determined in a non clinic population of healthy
adults and children ranging in age from 5 to 36 years.
The RCSP demonstrated wide ranges from 6° varus to 12° valgus in children.
The values reported in the present study correspond with the results of other empirical studies; the
theoretical normal value for the relaxed calcaneal stance position of 0° (± 2°) would be invalid.
The RCSP was found to be a reliable measurement when used by the same examiner (intra-tester
reliability).
Inter-tester reliability of RCSP was less than intra-tester reliability but was of 2.5° between teste rs,
showing that intra-tester measurements demonstrate reasonable reliability for clinical
measurements.
The theoretical normal values of 0° (± 2°) as an i ndicator of pathology was not found and thus
should not be used as an indicator of pathology.
Comments
Internal validity seems good. However, sample size is small in two age-categories (8-and 10-year-
olds) and data must be interpreted with caution. For the others categories the use of results as a
trend for clinical guidelines is appropriate.
Intra class correlation coefficient would have been a better indication to examine inter-tester
reliability.
312 Part 5: The Foot
References
Research Articles
1. Cavanagh, P. R., & Rodgers, M. M. (1987). The arch index: a useful measure from footprints.
Journal of Biomechanics, 20, 547-51.
2. Churgay, C. A. (1993). Diagnosis and treatment of pediatric foot deformities. American Family
Physician, 47, 883-889.
3. Cubukcu, S., Alimoglu, M. K., Balci, N., & Beyazova, M. (2005). Plantar arch type and strength
profile of the major ankle muscle groups: a morphometric-isokinetic study. Isokinetics and
Exercise Science, 13, 217-222
4. Engel, G. M., & Staheli, L. T. (1974). The Natural History of torsion and other factors
influencing gait in childhood: A study of the angle of gait, tibial torsion, knee angle, hip rotation,
and development of the arch in normal children. Clinical Orthopaedics and Related Research,
99, 12-17.
5. Evans, A. M., Copper, A. W., Scharfbillig, R. W., Scutter, S. D., & Williams, M. T. (2003).
Reliability of the foot posture index and traditional measures of foot position. Journal of the
American Podiatric Medical Association, 93, 203-213.
6. Forriol, F., & Pascual, J. (1990). Footprint analysis between three and seventeen years of age.
Foot & Ankle, 11, 101-104.
7. Gilmour, J. C., & Burns, Y. (2001). The measurement of the medial longitudinal arch in
children. Foot & Ankle International, 22, 493-498.
8. Gould, N., Moreland, M., Trevino, S., Alvarez, R., Fenwick, J., & Bach, N. (1990). Foot growth
in children age one to five years. Foot & Ankle, 10, 211-213.
9. Igbigbi, P. S., & Msamati, B. C. (2002). The footprint ratio as a predictor of pes planus: a study
of indigenous Malawians. The Journal of Foot and Ankle Surgery, 41, 394-397.
10. Kanatli, U., Yetkin, H., & Cila, E. (2001). Footprint and radiographic analysis of the feet. Journal
of Pediatric Orthopedics, 21 (2), 225-228.
11. Kanatli, U., Gözil, R., Besli, K., Yetkin, H., & Bolukbasi, S. (2006). The relationship between the
hindfoot angle and the medial longitudinal arch of the foot. Foot & Ankle International, 27, 623-
627.
12. Maes, R., Dojcinovic, S., Andrianne, Y., & Burny, F. (2004). Étude rétrospective sur les
corrélations entre des paramètres podométriques et l’angle de Djian-Annonier dans l’étude de
la voûte plantaire. Résultats d’une série de 158 cas. Médecine et chirurgie du pied, 20, 11-16.
doi : 10.1007/s10243-040-0003
13. Nikolaidou, M., & Boudolos, K. (2006). A footprint-based approach for the rational classification
of foot types in young schoolchildren. The Foot, 16, 82-90. doi:10.1016/j.foot.2006.02.001
14. Sobel, E., Levitz, S. J., Caselli, M. A., Tran, M., Lepore, F., Lilja, E.,…Wain, E. (1999).
Reevaluation of the relaxed calcaneal stance position. Reliability and normal values in children
and adults. Journal of the American Podiatric Medical Association, 89, 258-264.
Part 5: The Foot 313
15. Staheli, L. T., Chew, D. E., & Corbett, M. (1987). The longitudinal arch. A survey of eight
hundred and eighty-two feet in normal children and adults. The Journal of Bone and Joint
Surgery, 69, 426-428.
16. Stavlas, P., Grivas, T., Michas, C., Vasiliadis, E., & Polyzois, V. (2005). The evolution of foot
morphology in children between 6 and 17 years of age: A cross-sectional study based on
footprints in a mediterranean population. The Journal of Foot and Ankle Surgery, (44) 6, 424-
428. doi:10.1053/j.jfas.2005.07.023
17. Urry, S., & Wearing, S. (2005) Arch indexes from ink footprints and pressure platforms are
different. The Foot, (15) 2, 68-73. doi:10.1016/j.foot.2005.02.001
18. Welton, E. A. (1992). The Harris and Beath footprint: interpretation and clinical value. Foot &
Ankle, 13, 462-468.
Research abstracts
19. Chu, W. C., Lee, S. H., L., Wang, W. T. J., & Lee, M. C. (1995). The use of arch index to
characterize arch height: a digital image processing approach. Biomedical Engineering, 42,
1088-1093.
Reference books
20. Staheli, L. T. (2003). Fundamentals of pediatric orthopedics, (3rd ed.), Philadelphia: Lippincott
Williams & Wilkins.
Web Sites
21. Grueger B. (2009). Footwear for children; Paediatric Child Health,14, 120.
Retrieved from: http://www.cps.ca/English/statements/CP/FootwearChildren.htm
Accessed March 7, 2010.
22. Hernandez, A. J., Kimura, L. K., Laraya, M. H. F., & Favaro, E. (2007). Calculation of Staheli's
plantar arch index and prevalence of flat feet: a study with 100 children aged 5-9 years; Acta
Ortopedica Brasileira, 15 Retrieved from:
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-
78522007000200001&lng=en&nrm=iso&tlng=en Accessed March 9th, 2010.
23. Morrison, S. C., Durward, B. R., Watt, G. F., & Donaldson, M. D. C. (2005). The intra-rater
reliability of anthropometric data collection conducted on the peripubescent foot: A pilot study.
The Foot, 15, 180-184. Retrieved from : http://www.thefootjournal.com/article/S0958-
2592(05)00058-1/abstract Accessed October 26, 2011.
24. Pettengill, M. J., & Richard, M. J. (2006). Inserts offer a new angle on pediatric flat foot
treatment; Biomech, January. Retrieved from:
http://www.biomech.com/full_article_printfriendly/?ArticleID=581&month=1&year=2006&fromdb
=archives Accessed October 26, 2011.
314 Part 5: The Foot
Up to Date References
2011
Footprint measurements ( 2,638 static footprints) of
Chen KC, Yeh CJ, Kuo JF, Hsieh CL, Yang SF, Wang CH.
flatfoot in a population of preschool-aged children ( 3
(2011).Footprint analysis of flatfoot in preschool-aged
children. Eur J Pediatr. May;170(5):611-7. Epub 2010 Oct to 6 years) were analyzed. The Clarke's angle (CA),
Chippaux-Smirak index (CSI), and Staheli arch index
23.
(AI), were used for comparison with clinical diagnosis.
The clinical diagnosis as a gold standard compared
with the results of the CA, CSI, and AI and displayed
in a receiver operating characteristic (ROC). Ratios
were calculated given their cutoff points, and their
pretest/posttest probabilities were plotted as the
Fagan nomogram. The optimal cutoff points for CA,
CSI, and AI were 14.04°, 62.70%, and 107.42%,
respectively, and all of them showed high sensitivity.
In conclusion, this study demonstrated that footprint
analysis methods are suitable for diagnosing flatfoot
in preschool-aged children, and that the most
appropriate cutoffs are as follows: CA ≤ 14.04°, CSI >
62.70%, and AI > 107.42%. The CSI had a predictive
probability of more than 90% and is recommended in
screening for flatfoot in preschool-aged children.
2010-2008
Bosch K, Gerss J, Rosenbaum D.(2010) Development of
In a longitudinal design, 36 healthy German children
healthy children's feet--nine-year results of a longitudinal
were followed over the course of nine years. The
investigation of plantar loading patterns.Gait Posture.
children had a mean age of 14.6 ± 1.8 months at the
Oct;32(4):564-71. Epub 2010 Sep 15.
first appointment and 122.8 ± 2.0 months at the last
appointment. Dynamic foot loading was evaluated
with plantar pressure measurements during walking
and static footprints were taken to determine changes
in foot form. The established database can be used
as comparative values for clinical decisions about the
normal foot development.
Morrison SC, Ferrari J. (2009). Inter-rater reliability of the
30 subjects aged 5 - 16 years were recruited for the
Foot Posture Index (FPI-6) in the assessment of the
research. Two raters independently recorded the FPI-
paediatric foot. J Foot Ankle Res Oct 21;2:26.
6 score for each participant. Almost perfect
agreement between the two raters was identified. The
FPI-6 is a quick, simple and reliable clinical tool which
has demonstrated excellent inter-rater reliability when
used in the assessment of the paediatric foot.
Redmond AC, Crane YZ, Menz HB. (2008) Normative
Studies reporting FPI data were identified by
values for the Foot Posture Index. J Foot Ankle Res., Jul
searching online databases.
31;1(1):6.
A set of population norms for children, adults and
older people have been derived from a large sample.
Foot posture is related to age and the presence of
pathology, but not influenced by gender or BMI. The
normative values identified may assist in classifying
foot type for the purpose of research and clinical
decision making.
Part 5: The Foot 315