Quantifying the Quasi-static Angle and Base of Gait

A Preliminary Investigation Comparing Footprints and a Clinical Method

Sarah A. Curran, BSc (Hons)* Dominic Upton, PhD Ian D. Learmonth, FRCS

Although the angle and base of gait are useful parameters commonly measured in podiatric medical practice, a standardized procedure has yet to be defined. Static footprints and clinical tracings of the perimeters of both feet were investigated in 25 asymptomatic subjects (17 women and 8 men). The intrarater reliability of each measurement condition was assessed using intraclass correlation coefficients and ranged from 0.965 to 0.981 for the angle of gait and from 0.979 to 0.986 for the base of gait. Both sets of data were compared using paired t-tests and demonstrated no significant differences (P > .001) for the angle and base of gait. The results suggest that footprint data and a simple clinical tracing of the foot are similar, providing a useful clinical tool for static assessment of the angle and base of gait. (J Am Podiatr Med Assoc 96(2): 125-131, 2006)

Static and dynamic assessments are fundamental components of the evaluation of patients with musculoskeletal pathologies. Although dynamic assessment serves as an informative functional component of the overall assessment process, the importance of static assessment should not be underestimated. Most people have their feet and lower limbs in a relatively favorable static position most of the time.1 Such a phenomenon reveals certain characteristics of the
*Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff, Cardiff, Wales. Department of Psychology, University of Wales Institute, Cardiff, Cardiff, Wales. Department of Orthopaedic Surgery, University of Bristol, Level 5 Bristol Royal Infirmary, Bristol, England. The present article represents a continuation of a developmental study of a clinical technique. A previously published article (Ref. 25) focused predominantly on dynamic assessment. The present article discusses the concept of asymmetrical and symmetrical static stance. Corresponding author: Sarah A. Curran, BSc (Hons), Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff, Western Ave, Cardiff, CF5 2YB, Wales.

individual from physiologic, psychological, and pathologic perspectives and echoes the similar characteristics displayed during bipedal gait. For example, discomfort of the body can be associated with the position assumed during static stance. Quoting the earlier work of Mosher published in 1931, Zacharkow2 commented that correct posture depends on the positioning of the feet during standing. Essentially (as a rule for most people), body weight during standing is directed toward the heel, as opposed to the forefoot. During standing, individuals commonly use two types of stance. First, one may stand symmetrically (referred to as standing at ease), whereby the shoulders are level, with extension of the hips and slight flexion of the knees (approximately 6). Both feet are level compared with one another and assume an anteroposterior direction, with the center of gravity placed midway between both feet, resulting in equal amounts of weightbearing on each limb.3-5 In contrast, asymmetrical stance is reported to be the most common type of stance. The main feature of asym-

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metrical stance is the positioning of the body with one foot slightly in front of the other, thus enabling one foot to carry most of the bodys weight (up to 80%90%) while the contralateral foot carries minimal weight and simply maintains balance.3, 6, 7 For example, to a certain degree, during asymmetrical stance, the right foot is placed anterior and lateral to the left foot. The left knee is more or less fully extended compared with the right knee, and the pelvis is tilted, which results in the center of mass passing downward and forward in a right-handed direction. As a result, during asymmetrical standing, the magnitude and direction of the force that affects the supporting foot is greater than that affecting either foot during symmetrical standing. More proximally, the left shoulder is lower than the right shoulder.3, 6, 8 Such comments are further supported by an elegant and illuminating study by Smith3 entitled The Act of Standing. Smith3 observed 250 spectators attending a croquet match and reported an asymmetrical stance position as a dominant finding, with subjects altering their posture, on average, every 30 sec. Smith3 provided a further rationale for the concept of asymmetrical stance by integrating the notion concerning the amount of relatively constant stress acting on joints and other musculoskeletal structures during standing. Gamble and Yale9 remarked that during clinical and radiographic examination, great care should be exercised on posing the patient in his natural base and angle of stance because this position coincides within acceptable limits with foot position during the midstance phase of walking gait. Perlman et al10 and Bryant11 expressed similar sentiments by adding that this position represented a standardized method for establishing a natural stance position, as opposed to a contrived stance position. However, although this method facilitates standardization, it does not capture the naturalism of static stance, with Rozendal6 commenting that everyday stance would appear to be asymmetrical. This discussion can be considered further by using the term quasi-static, whereby such measurements entail movement and are used in a pragmatic manner, thus enabling the potential for data collection to be recorded using a standardized method and approximating the natural stance of that individual. It is apparent from previous discussion that many authors support the concept of static measurement. Over time, the angle and base of gait have been used and reported by many authors as useful clinical measurements.12-22 A variety of studies10, 11, 23 reported the recording of angle and base of gait parameters from a static perspective. Although this seems to be a common and useful parameter, limited methodologic

detail is provided as to how these authors obtained such parameters.10 This information remains fundamental to the progress of measurement techniques in research and clinical settings and, therefore, should not be underestimated. Although simply drawing a line around the foot reveals no information regarding plantar pressures, Rutherford24 encourages the use of such a method owing to the minimal mess created. Arguably, only McIlroy and Maki23 detailed and schematically presented their method of identifying the base of gait from a clinical perspective. Because of the lack of information, a standard method of recording and analysis is required. Previous research25 has identified a reliable method of measuring angle and base of gait parameters from dynamic and static footprints. This method is now extended to incorporate a quasi-static clinical technique obtained from a simple clinical tracing of the foot and would appeal to clinical practice because of its minimal mess and time taken to obtain recordings. The aim of this study was to assess the differences between measurement techniques using static footprints and a clinical tracing of the foot to calculate the angle and base of gait. The intrarater reliability of both techniques was also investigated.

Materials and Methods

Using a convenience sample, 25 subjects were selected from a university staff and student population. The sample comprised 17 women and 8 men with a mean SD age of 29.04 7.95 years (range, 2046 years), a mean SD body weight of 73.06 16.83 kg (range, 50123 kg), and a mean SD height of 1.69 0.08 m (range, 1.561.88 m). The exclusion criteria included a history of trauma or surgery involving the lower limb in the previous 12 months, an apparent gait disturbance based on visual inspection, and a history of systemic disease that could affect gait. No criteria regarding lower-limb range of motion or posture during dynamic and static activity were established. Ethical approval was granted by the School of the Health and Social Sciences (University of Wales Institute, Cardiff) ethics committee before commencement of the study. Informed consent was obtained from all of the subjects following a verbal and written explanation of the study. Lining paper measuring 1 m long (56 cm wide) was used for the static footprints and clinical tracings. All of the lining paper was affixed with brown heavy-duty paper to prevent any slippage. A 1-cmdeep tray large enough for both feet that contained a composite mixture of black powder paint and talcum powder was used. To assess the reliability of the mea-

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surement for both sets of data, transparent film was placed over the top of each sheet of lining paper and anchored with masking tape, again preventing any slippage during analysis.

Static Footprint Acquisition

Standing barefoot, each subject was asked to step into the tray of colored talcum powder. Standing in the tray, the subjects were instructed to walk in place at their own pace, looking straight ahead, for 20 sec and then were asked to walk forward onto and off of the prepared piece of lining paper. This procedure was repeated until three adequate prints were obtained for each subject. Artists fixative spray was applied to the static footprints to prevent any damage.

left and right feet. Figure 1 illustrates the bisections and lines drawn for the static footprint and the clinical tracing for the angle and base of gait. The angle of gait was calculated for each footprint, and the base of gait was calculated for each footprint pair. To obtain the reliability of the measurement process for both conditions, transparent film was placed over the first footprint from each subject (static footprint and clinical tracing), and the measurements were repeated 1 week later; one investigator (S.A.C.) performed all of the measurements.

Statistical Analysis
Analyses were performed using SPSS version 11.5 for Windows (SPSS Science, London, England). Intrarater reliability of the measurement technique for the angle and base of gait for both conditions was assessed using intraclass correlation coefficients (ICCs); ICCs were further used to evaluate the reliability among the three measurements from each condition. Coefficients of variation were also calculated to express the variation between the measurements as a percentage. Benchmarks recommended by Fleiss27 were used to interpret the ICCs and the Pearson r values (>0.75 = excellent reliability, 0.40.75 = fair-to-good reliability, and <0.4 = poor reliability). To assess differences between the static footprints and the clinical tracings for each parameter (the angle and base of gait), the calculated mean values for the static footprints and the clinical tracings were compared using paired t-tests. Paired t-tests were further used to assess differences in the angle of gait in the right and left feet for both conditions. An = .05 was used for all of the tests of statistical significance. A Pearson product moment correlation was also used to assess the consistency of these measurements.

Clinical Tracing Acquisition

The subjects were asked to walk in place as previously described and were again instructed to stop and to step into a stance position onto a prepared piece of lining paper. The subject maintained this position while the investigator drew a pencil line around the left and right feet, ensuring that the pencil was kept in an upright or vertical position and snug against the foot. The participant was then asked to step forward off of the paper. As with the static footprint method, this process was repeated three times. Inadequate drawings of the heel or forefoot area were rejected, and the process was repeated.

Assessment Technique for Footprints and Clinical Tracings

Both sets of data were analyzed using a previously described technique that was modified for static assessment.26 To obtain a longitudinal bisection of the foot, a transparent grid was placed over each foot. All of the measurements were made using a fine (0.5-mm) nonpermanent marker pen; the angle of gait was measured in degrees using a standard tractograph, and the base of gait was measured in centimeters. The assessment technique outlined by Wilkinson et al26 and further employed by Curran et al25 had to be modified for the static footprint. In the dynamic assessment technique, the heel bisection is connected to the next bisection of the heel of the same foot. As such, assessment cannot be undertaken for the static method. The bisection of the heel was marked, and a line was drawn in a distal direction from the heel parallel to that of the lined paper on which the footprint was produced. The line of progression was calculated by dividing the distance of the heel bisection for the

Results
Twenty-five sets of raw data were collected. Each subject generated three prints each for the static and clinical conditions. In total, 150 footprints and tracings were produced. The mean values obtained for the angle and base of gait for each condition are summarized in Table 1.

Reliability of the Measurement Technique for Footprints and Clinical Tracings

Intrarater reliability for each measurement condition was excellent, demonstrating ICC values of 0.972 and 0.981 for the clinical angle of gait in the left and right feet, respectively. The ICC values for the static foot-

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Static Footprint

Clinical Method

Figure 1. Schematic representations of the angle of gait (A, C) and the base of gait (B, D) for the static footprint and the clinical method. (Parts A and B reprinted with permission from Curran et al. 25)

print angle of gait for the left and right feet were 0.965 and 0.977, respectively. The ICC values for the clinical and static footprint base of gait were 0.986 and 0.979, respectively.

tion coefficient of variation between mensurations for each measurement condition and parameter are given in Table 2.

Intrarater Reliability of Measurements

The ICC values for the reliability of the three mensurations for each measurement condition for the right foot (the angle and base of gait) were excellent, ranging from 0.81 to 0.89. However, the ICC for the angle of gait in the left foot during the static state was fair to good at 0.72 (95% confidence interval [CI], 0.540.85). The values obtained from three separate mensurations for each measurement condition indicate that linearly based parameters do not significantly differ between mensurations for all of the measurement conditions and for each parameter. Coefficients of variation were small for all of the measurement conditions and ranged from 2.8% to 3.9% for the angle of gait and from 3.6% to 3.9% for the base of gait, indicating that measurements could be expected to vary little from one foot to the next. The ICC and correla-

Comparisons Between the Static Footprints and the Clinical Tracings

Angle of Gait. Analysis of the angle of gait for the left foot demonstrated no significant differences between the two measurement conditions (static and clinical) (t = .050; df = 24; P = .960). The difference between the mean values of both conditions was 0.01% (95% CI, 0.53200.5586). A Pearson product moment correlation coefficient of 0.88 suggests that these results were consistent. The angle of gait for the right foot also demonstrated no significant differences between the two conditions (t = .134; df = 24; P = .895). The difference between the mean SD static (13.72 4.24) and clinical (13.66 4.68) measurements was very small at 0.05% (95% CI, 0.77000.8767). The consistency of these results was calculated as 0.905 using the Pearson product moment correlation. Figures 2 and 3 illustrate the correlations between the

Table 1. Angle and Base of Gait Values for Both Measurement Conditions Range Angle of gait () Left foot Right foot Base of gait (cm) 616 828 8.223.1 Static Footprints Mean SD 10 2.5 13.7 4.4 14.3 3.8 Range 618 426 7.022.1 Clinical Tracings Mean SD 10 3.0 13.7 4.8 13.8 3.5

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Table 2. Intrarater Reliability for the Angle and Base of Gait for the Three Mensurations for Each Measurement Condition Angle of Gait, Left Foot ICC (95% CI) CV (%) Static footprint Clinical tracing 0.72 (0.540.85) 0.81 (0.680.90) 3.9 3.3 Angle of Gait, Right Foot ICC (95% CI) CV (%) 0.81 (0.670.90) 0.87 (0.760.93) 3.0 2.8 Base of Gait ICC (95% CI) CV (%) 0.89 (0.810.94) 0.84 (0.720.92) 3.6 3.9

Abbreviations: ICC, intraclass correlation coefficient; CI, confidence interval; CV, coefficient of variation.

mean static and clinical measurements for the angle of gait in the left and right feet, respectively. Comparisons Between Left and Right Foot Angle of Gait for Each Measurement Condition. The relationship between the left and right feet for the angle of gait was examined by comparing the mean value for each foot for the static footprints and the clinical tracings (Table 1). For the static footprint, a difference of 3.70 (37%) was noted for the

20 18 16 14 12 10 86420

right foot compared with the left foot. A paired t-test demonstrated that this was a significant difference (t = 5.53; df = 24; P < .001). A difference of 3.66 (36.7%) was also noted between the right foot and the left foot for the clinical measurement condition. Again, further analysis using a paired t-test supported the statistical significance of this increase (t = 5.38; df = 24; P < .001). Base of Gait. Analysis of the base of gait revealed no significant differences between the two measurement conditions (t = 1.026; df = 24; P = .50), with the mean difference being small between the two conditions and the mean SD base of gait for the footprint (14.3 3.8) being slightly higher (0.5 cm) than that for the clinical tracing (13.8 3.5). A Pearson product moment correlation again demonstrated good-to-excellent consistency for these results. Figure 4 presents the correlation between the mean static footprint and the mean clinical tracing for the base of gait.

Clinical

Discussion
2 4 6 8 10 Static 12 14 16 18

Figure 2. Correlation between the mean static footprint and the mean clinical measurement for the angle of gait for the left foot.

Although many biomechanical measurements in the clinical setting occur during static conditions, few if any research reports have addressed a consistent, reliable, and valid method of recording the angle and base of gait. The present study provides clinicians

30 25 Clinical Clinical 20 15 10 50 5 10 15 Static 20 25 30

25 20 15 10 50 5 10 Static 15 20 25

Figure 3. Correlation between the mean static footprint and the mean clinical measurement for the angle of gait for the right foot.

Figure 4. Correlation between the mean static footprint and the mean clinical measurement for the base of gait.

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and researchers with a one-step method for evaluating the angle and base of gait from a quasi-static measurement condition and as such is used in a pragmatic manner. Excellent reliability of the measurement technique for the angle and base of gait was noted for both measurement conditions (static footprint and clinical tracing), yielding correlation values consistently greater than 0.9. Such results substantiate the use of this technique in the clinical and research settings when a single investigator undertakes such measurements. Furthermore, a strong correlation of the repeated measures (three measurements per subject for each condition) illustrated by the ICC values suggests that the angle and base of gait can be calculated reliably, thus allowing for comparative analysis across time. Operator error while tracing each foot during data collection for the clinical measurement could have produced inaccurate representations of the foot, although the risk was recognized and minimized by the investigator by consistently holding the pencil vertical and close to the foot. The data collected and analyzed during this study demonstrate mean values of 6 to 28 for both conditions for the angle of gait. These values are similar to those reported by Saltzman et al,28 who recorded an angle of gait that ranged from 7 to 22, and McIlroy and Maki,23 who detailed angle of gait values of 13 to 52. However, slightly smaller values for the angle of gait were reported more recently by Bryant,11 who recorded values of 0 to 15. The angle of gait for the right foot was consistently higher than that for the left foot for both conditions. Such results echo the findings of Bryant11 and McIlroy and Maki,23 who clinically recorded the angle of gait in their respective investigations. Such asymmetries displayed for the angle of gait may have a central role in outlining the characteristics of stance,19 supporting the concepts previously highlighted by Smith3 on the attitude of standing. Furthermore, although it was not recorded during data collection, anecdotal observations of static stance (footprint and clinical) demonstrated forward advancement of the right foot compared with the left foot. Such an observation provides not only a rationale for an increased angle of gait for the right foot but also succinct documentation of the characteristic asymmetrical stance. Dominance of one limb over the contralateral limb could be a factor. Therefore, establishing whether participants were right- or left-handed/footed by having them catch and kick a ball would have added further clarity to this issue. In addition, such investigation can be further explored by assessing trends in static stance in patients with certain musculoskeletal pathologies, such as osteoarthritis of the knee or hip.

Comparative assessment of the base of gait during this study can also be compared with previously highlighted investigations. In this study, the base of gait values ranged from 7 to 23 cm, similar to values described by McIlroy and Maki23 (628 cm) and Bryant11 (515 cm).

Conclusion
Objective and reliable clinical measurements of the lower extremity are fundamental prerequisites for clinicians and researchers involved in the management of musculoskeletal pathologies. To date, there is no accepted gold standard measure of the angle and base of gait in the podiatric, physical therapy, and orthopedic literature. The results of this study indicate that a simple reliable clinical tracing of the foot seems to correlate with static footprint data. Further research is required to clarify the use of this method of measuring static stance and the angle of gait. Using patients with musculoskeletal pathologies should provide additional insight into the collective contribution to the effects of certain pathologies on the musculoskeletal chain. The clinical measurement assessment for the angle and base of gait presented in this study is a feasible and acceptable method that can be incorporated easily into the clinical examination of patients. Acknowledgment. Eric Lee, BSc (Hons), for reviewing and providing constructive criticism of this report. This study was supported by a research fellowship from Health Professions Wales, Cardiff (S.A.C.).

References
1. RYS M, KONZ S: Standing. Ergonomics 37: 677, 1994. 2. ZACHARKOW D: Posture, Sitting, Standing, Chair Design and Exercise, Charles C Thomas, Springfield, IL, 1988. 3. SMITH JW: The act of standing. Acta Orthop Scand 23: 159, 1954. 4. PERRY JE: Gait Analysis: Normal and Abnormal Pathological Function, Slack, Thorofare, NJ, 1992. 5. W HITTLE MW: Gait Analysis: An Introduction, Butterworth & Heinemann, Oxford, 2002. 6. ROZENDAL R: Biomechanics of Standing and Walking, in Disorders of Posture and Gait, ed by W Bles, T Brandt, p 3, Elsevier, Amsterdam, 1986. 7. O ATIS CA: Kinesiology: The Mechanics and the Pathomechanics of Human Movement, Lippincott Williams & Wilkins, Philadelphia, 2003. 8. G EURSEN JB, A LTENA D, M ASSEN CH, ET AL : A model of the standing man for the description of his dynamic behaviour. Agressologie 17: 63, 1976. 9. GAMBLE F, YALE I: Clinical Foot Roentgenology, Krieger, New York, 1975. 10. P ERLMAN PH, D UBOIS P, S ISKIND V: Validating the process of taking lateral foot x-rays. JAPMA 86: 317, 1996.

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11. BRYANT J: A comparison of radiographic foot measurements taken in two different positions. JAPMA 91: 234, 2001. 12. D OUGAN S: The angle of gait. Am J Phys Anthropol 7: 275, 1924. 13. MORTON DJ: The angle of gait: a study based upon the examination of feet of Central African natives. J Bone Joint Surg 4: 741, 1932. 14. FUKUSHIMA T: Angle and distance between steps. J Bone Joint Surg Am 37: 1311, 1975. 15. MURRAY MP, KORY RC, CLARKSTON BH: Walking patterns in healthy old men. J Gerontol 24: 169, 1969. 16. M URRAY MP, K ORY RC, S EPIC SB: Walking patterns of normal women. Arch Phys Med Rehabil 51: 637, 1970. 17. MURRAY MP, SEPIC SB, GARDNER GM, ET AL: Walking patterns in men with Parkinsonism. Am J Phys Med 57: 278, 1978. 18. R OBINSON JL, S MIDT GL: Quantitative gait evaluation in the clinic. Phys Ther 61: 351, 1969. 19. RIGAS C: Spatial parameters of gait related to the position of the foot to the ground. Prosthet Orthot Int 8: 130, 1984.

20. K ERNOZEK TW, R ICARD MD: Foot placement angle and arch type: effect on rearfoot motion. Arch Phys Med Rehabil 71: 988, 1990. 21. SGARLATO TE: The angle of gait. JAPA 55: 645, 1965. 22. SCRUTTON DS, ROBSON P: The gait of 50 normal children. Physiotherapy 54: 363, 1968. 23. MCILROY WE, MAKI BE: Preferred foot placement of the feet during quiet stance: development of a standardized foot placement for balance testing. Clin Biomech 12: 66, 1997. 24. R UTHERFORD A: Footprints. J Audiov Media Med 6: 80, 1983. 25. CURRAN SA, UPTON D, LEARMONTH ID: Dynamic and static footprints: comparative calculations for angle and base of gait. The Foot 15: 40, 2005. 26. WILKINSON MJ, MENZ HB, RASPOVIC A: The measurement of gait parameters from footprints. The Foot 5: 84, 1995. 27. FLEISS JL: The Design and Analysis of Clinical Experiment, John Wiley & Sons, New York, 1986. 28. S ALTZMAN CL, BRANDSER EA, BERBAUM KS, ET AL: Reliability of standard foot radiographic measurements. Foot Ankle Int 15: 661, 1994.

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