Lower extremity kinematics in children with and without flexible flatfoot: a comparative study

Ability of a multi-segment foot model to measure kinematic differences in cavus, neutrally aligned, asymptomatic planus, and symptomatic planus foot types

BACKGROUND

Multi-segment foot models (MFMs) provide a better understanding of the intricate biomechanics of the foot, yet it is unclear if they accurately differentiate foot type function during locomotion.

RESEARCH QUESTION

We employed an MFM to detect subtle kinematic differences between foot types, including: pes cavus, neutrally aligned, and asymptomatic and symptomatic pes planus. The study investigates how variable the results of this MFM are and if it can detect kinematic differences between pathologic and non-pathologic foot types during the stance phase of gait.

METHODS

Independently, three raters instrumented three subjects on three days to assess variability. In a separate cohort, each foot type was statically quantified for ten subjects per group. Each subject walked while instrumented with a four-segment foot model to assess static alignment and foot motion during the stance phase of gait. Statistical analysis performed with a linear mixed effects regression.

RESULTS

Model variability was highest for between-day and lowest for between-rater, with all variability measures being within the true sample variance. Almost all static measures (radiographic, digital scan, and kinematic markers) differed significantly by foot type. Sagittal hindfoot to leg and forefoot to leg kinematics differed between foot types during late stance, as well as coronal hallux to forefoot range of motion. The MFM had low between-rater variability and may be suitable for multiple raters to apply to a single study sample without introducing significant error. The model, however, only detected a few dynamic differences, with the most dramatic being the hallux to forefoot coronal plane range of motion.

SIGNIFICANCE

Results only somewhat aligned with previous work. It remains unclear if the MFM is sensitive enough to accurately detect different motion between foot types (pathologic and non-pathologic). A more accurate method of tracking foot bone motion (e.g., biplane fluoroscopy) may be needed to address this question.

Dynamic Gait Analysis in Paediatric Flatfeet: Unveiling Biomechanical Insights for Diagnosis and Treatment

BACKGROUND

Flatfeet in children are common, causing concern for parents due to potential symptoms. Technological advances, like 3D foot kinematic analysis, have revolutionized assessment. This review examined 3D assessments in paediatric idiopathic flexible flat feet (FFF).

METHODS

Searches focused on paediatric idiopathic FFF in PubMed, Web of Science, and SCOPUS. Inclusion criteria required 3D kinematic and/or kinetic analysis during posture or locomotion, excluding non-idiopathic cases, adult feet, and studies solely on pedobarography or radiographs.

RESULTS

Twenty-four studies met the criteria. Kinematic and kinetic differences between FFF and typical feet during gait were outlined, with frontal plane deviations like hindfoot eversion and forefoot supination, alongside decreased second peak vertical GRF. Dynamic foot classification surpassed static assessments, revealing varied movement patterns within FFF. Associations between gait characteristics and clinical measures like pain symptoms and quality of life were explored. Interventions varied, with orthoses reducing ankle eversion and knee and hip abductor moments during gait, while arthroereisis normalized calcaneal alignment and hindfoot eversion.

CONCLUSIONS

This review synthesises research on 3D kinematics and kinetics in paediatric idiopathic FFF, offering insights for intervention strategies and further research.

Comparison of Foot Kinematics Between Normal Arch and Flexible Flatfoot Using the Oxford Foot Model: A Matched Case-Control Study

Background

Symptomatic flexible flatfoot causes alterations in gait, but exactly how this condition affects the intersegmental motion of the foot during the gait cycle remains unclear. Previous studies have examined the kinematics, yielding inconsistent findings. Therefore, the objective of this study was to investigate how flexible flatfoot deformity, defined as Johnson and Strom classification staging II, affects the intersegmental motion of the foot during fast walking based on a comparison with the matched control group.

Methods

Eleven participants with symptomatic flexible flatfoot and 11 healthy matched control participants were recruited using a foot screening protocol incorporated through a foot physical examinations and radiographic measurements. All demographic characteristics exhibited comparable profiles between the groups. During controlled walking, kinematic outcomes pertaining to the hallux, hindfoot, forefoot, and tibia were collected using the multisegmental Oxford Foot Model.

Results

All spatiotemporal parameters were comparable between the groups. In comparison to the control group, individuals with symptomatic flexible flatfoot demonstrated increased hallux valgus and plantarflexion, increased forefoot abduction, heightened hindfoot eversion, and internal rotation. Notably, no significant major differences were observed in the tibia motion segment. Further, significant correlations were identified between static foot measurements and the extent of the maximum deviation observed during dynamic kinematic assessments.

Conclusion

Compared with age- and gender-matched controls, participants with symptomatic flexible flatfoot exhibited significant gait pattern deviations. A significant correlation also exists between static foot deformity measurements and dynamic kinematic deviations. Collectively, these findings have implications for developing targeted therapeutic interventions to address flexible flatfoot.

Level of evidence

Level III, diagnostic study.

Clinical reliability and validity of a video-based markerless gait evaluation method

Objective

To explore the reliability and validity of gait parameters obtained from gait assessment system software employing a human posture estimation algorithm based on markerless videos of children walking in clinical practice.

Methods

Eighteen typical developmental (TD) children and ten children with developmental dysplasia of the hip (DDH) were recruited to walk along a designated sidewalk at a comfortable walking speed. A 3-dimensional gait analysis (3D GA) and a 2-dimensional markerless (2D ML) gait evaluation system were used to extract the gait kinematics parameters twice at an interval of 2 h.

Results

The two measurements of the children's kinematic gait parameters revealed no significant differences (P > 0.05). Intra-class correlation coefficients (ICC) were generally high (ICC >0.7), showing moderate to good relative reliability. The standard error of measurement (SEM) values of all gait parameters measured by the two walks were 1.26°-2.91°. The system software had good to excellent validity compared to the 3D GA, with ICC values between 0.835 and 0.957 and SEM values of 0.87°-1.71° for the gait parameters measured by both methods. The Bland-Altman plot analysis indicated no significant systematic errors.

Conclusions

The feasibility of the markerless gait assessment method using the human posture estimation-based algorithm may provide reliable and valid gait analysis results for practical clinical applications.

Effect of Dynamic Taping versus Kinesiology Taping on Pain, Foot Function, Balance, and Foot Pressure in 3 Groups of Plantar Fasciitis Patients: A Randomized Clinical Study

BACKGROUND Biomechanical dynamic tape supports muscles, joints, and ligaments and is used in ankle and foot injuries. Kinesiology tape (KT), also known as elastic tape, is widely used in sports medicine. Plantar fasciitis, due to inflammation of the plantar fascia, is a common cause of heel pain. This study aimed to compare the effects of dynamic taping and KT on pain, function, and balance in 3 groups of patients with plantar fasciitis. MATERIAL AND METHODS Sixty-nine patients with plantar fasciitis were randomly assigned to the dynamic taping with physical therapy (PT) group, the KT with PT group, and the control group (23 each). All groups received conservative physical therapy. Dynamic taping and KT were performed twice a week for 4 weeks, and the taping was removed after 12 h of application. Patients' pain, foot function, and balance were assessed using the visual analog scale (VAS), foot function index (FFI), and Y-balance test (YBT), respectively, before and immediately after the intervention. RESULTS In the FFI and YBT, the treatment provided to the dynamic taping with PT group with PT showed a greater effect than in the KT with PT group with PT (P<0.05), and the control group showed the lowest effect. Dynamic taping and KT with PT did not show significant differences in VAS and foot pressure, but both were more effective than the control group (P<0.05). CONCLUSIONS The results of this study suggest that dynamic taping with PT is the most effective method for FFI and YBT in patients with plantar fasciitis, and that dynamic taping and KT with PT are effective methods for treating pain and foot pressure.

Morphological and evolutionary insights into the keystone element of the human foot's medial longitudinal arch

The evolution of the medial longitudinal arch (MLA) is one of the most impactful adaptations in the hominin foot that emerged with bipedalism. When and how it evolved in the human lineage is still unresolved. Complicating the issue, clinical definitions of flatfoot in living Homo sapiens have not reached a consensus. Here we digitally investigate the navicular morphology of H. sapiens (living, archaeological, and fossil), great apes, and fossil hominins and its correlation with the MLA. A distinctive navicular shape characterises living H. sapiens with adult acquired flexible flatfoot, while the congenital flexible flatfoot exhibits a 'normal' navicular shape. All H. sapiens groups differentiate from great apes independently from variations in the MLA, likely because of bipedalism. Most australopith, H. naledi, and H. floresiensis navicular shapes are closer to those of great apes, which is inconsistent with a human-like MLA and instead might suggest a certain degree of arboreality. Navicular shape of OH 8 and fossil H. sapiens falls within the normal living H. sapiens spectrum of variation of the MLA (including congenital flexible flatfoot and individuals with a well-developed MLA). At the same time, H. neanderthalensis seem to be characterised by a different expression of the MLA.

Effect of Different Foot Orthosis Inverted Angles on Walking Kinematics in Females with Flexible Flatfeet

Background

Although the inverted technique was shown to be more effective compared to other orthotic designs for the treatment of flatfeet, the biomechanical mechanisms underlying the therapeutic effect of the inverted angle orthoses is still unclear. Therefore, the aim of this study was to examine the effect of different inverted angles of foot orthoses on walking kinematics in females with flexible flatfeet.

Methods

Thirty-one female adults with flexible flatfeet aged 18-35 years old participated in this study. Kinematic data of the hip, knee, and ankle were collected via BTS motion-capture system during walking under three test conditions in random order: with shoes only; with 15° inverted orthoses; and with 25° inverted orthoses.

Results

Compared to the shoes only condition, both the 15° and 25° inverted orthotic conditions significantly decreased the maximum ankle plantarflexion angle during loading response, maximum ankle dorsiflexion angle during mid-stance, maximum ankle external rotation angle, and maximum ankle internal rotation angle. The maximum ankle plantarflexion angle at toe-off showed a significant decrease with the 25° inverted angle orthosis compared to both the 15° inverted angle and shoes only conditions. No significant differences were found in the knee kinematic variables, maximum hip extension angle, and maximum hip adduction angle between test conditions.

Conclusion

Using inverted orthoses at 15° and 25° inverted angles resulted in significant changes in ankle joint kinematics during walking in female adults with flexible flatfeet. A 25° inverted angle orthosis significantly decreased ankle plantarflexion during push-off, potentially impacting gait mechanics. This suggests that a smaller inverted angle may be more effective for managing flexible flatfeet in female adults.

Three-dimensional gait analysis of lower extremity gait parameters in Japanese children aged 6 to 12 years

We aimed to develop gait standards for gait parameters in school-aged Japanese children and assess age-related differences in gait patterns and parameters. Children aged 6–12 years (n = 424) were recruited from two elementary schools. An instrumented three-dimensional gait analysis system was used to record each child's gait kinematics, kinetics, and spatiotemporal parameters. Participants were subdivided into three age groups (Group A, 6–8 years; Group B, 9–10 years; and Group C, 11–12 years). LMS Chartmaker, version 2.54, was used to create a developmental chart for the gait pattern. The non-normalized step and stride lengths were significantly longer, and the cadence was lower in older children; however, the opposite outcome occurred when analyzing normalized data. Ankle moment differed significantly by age, and the maximum ankle moment was higher in older children than that in younger children. Furthermore, the hip and knee flexion angles during gait and the normalized spatiotemporal parameters of Japanese children aged 6–12 years differed by age and from those of children from other countries. The centile chart of the gait pattern is a useful tool for clinicians to assess developmental changes in the gait pattern and detect gait abnormalities in children.

Flexible Flat Foot, Short Tendo-Achilles, and Altered Gait

Background

Pediatric patients often present with vague complaints involving the anterolateral foot and ankle, the medial knee, the lower back, and the hip. In our experience, closer examination of these patients reveals a constellation of symptoms that involve pathology in the ankle, knee, back, and hip. This study aimed to detail the identification and treatment of patients with the triad of flexible flat feet, tight Achilles complex, and altered gait, and their clinical course over time.

Methods

All patients of age 18 years or younger who presented to our urban academic center outpatient clinic with foot, ankle, patellar, low back, or hip pain or pathology were included. Patients with identified tarsal coalitions, accessory naviculars, malalignment syndrome, bone cysts or tumors, soft tissue tumors, arthropathy, neuropathy, infection, limb length inequality, patellar subluxation or dislocation, or spinal pathology were excluded. For each patient, demographic information, symptom description, treatment, and clinical course, including the Foot and Ankle Outcome Score (FAOS) was recorded.

Results

A total of 62 patients were included in our study. Patients mostly presented with low back pain (n=24, 38.7%), medial patellar pain (n=36, 58.1%), anterolateral ankle pain (n=35, 56.5%), and vague foot pain (n=13, 21.0%). Overall, 53.8% of patients with back pain at the initial visit, 35.0% of patients with knee pain, 44.4% of patients with ankle pain and 80.0% of patients with foot pain improved at final follow up. While patient-reported sports and recreation subscale scores demonstrated a significant improvement at the final follow-up compared to baseline scores (p=0.02), all other scores did not significantly differ compared to baseline scores. At final follow-up, 12 of 26 (46.2%) patients reported being able to return to play in their desired sport.

Conclusion

Complaints of back, hip, knee, ankle, or foot pain in the pediatric population can be early markers for a constellation of conditions that include low back pain, flexible flat feet, Achilles contracture, and altered gait due to increased lateral subluxation of the patella and hip flexion.

Effect of Plano-Valgus Foot on Lower-Extremity Kinematics and Spatiotemporal Gait Parameters in Children of Age 5–9

Aim of the study was to see how a definition of the flexible flat foot (FFF) influences the results of gait evaluation in a group of 49 children with clinically established FFF. Objective gait analysis was performed using VICON system with Kistler force platforms. The gait parameters were compared between healthy feet and FFF using two classifications: in static and dynamic conditions. In static condition, the ink footprints with Clarke’s graphics were used for classification, and in dynamic condition, the Arch Index from Emed pedobarograph while walking was used for classification. When the type of the foot was based on Clarke’s graphics, no statistically significant differences were found. When the division was done according to the Arch Index, statistically significant differences between flat feet and normal feet groups were found for normalized gait speed, normalized cadence, pelvic rotation, ankle range of motion in sagittal plane, range of motion of foot progression, and two parameters of a vertical component of the ground reaction force: FZ2 (middle of stance phase) and FZ3 (push-off). Some statically flat feet function well during walking due to dynamic correction mechanisms.

Effect of Systematic Corrective Exercises on the Static and Dynamic Balance of Patients with Pronation Distortion Syndrome: A Randomized Controlled Clinical Trial Study

Background:

The purpose of this study was to determine the effect of systematic corrective exercises on the static and dynamic balance of students with pronation distortion syndrome.

Methods:

In this randomized controlled clinical trial study, 30 volunteers were selected and randomly divided into the control and experimental groups (15 subjects per group). The experimental group performed systematic corrective exercises for 12 weeks, while the control group performed the routine exercise. Static and dynamic balance was evaluated before and after the interventions. The data were analyzed using independent and paired t-tests (P < 0.05).

Results:

The results showed significant improvement (P < 0.05) in the static and dynamic balance in the experimental group, but not in the control group. A significant difference was evident between the experimental and control groups in terms of static and dynamic balances, in static balance including Flamingo balance test (42.26 ± 5.35 vs. 10.13 ± 1.92) stabilometr (1.23 ± 0.48 vs. 3.71 ± 1.02), and in dynamic balance including star excursion balance test (anterior direction 82.4 ± 6.2 vs. 66.7 ± 6.9, Posterior-internal direction 87.8 ± 4.7 vs. 69.6 ± 6.3, posterior-external direction 86.06 ± 6.93 vs. 67.2 ± 6.2), stabilometr (3.8 ± 0.6 vs. 11.18 ± 1.8) (P < 0.05 for all variables).

Conclusions:

It can be concluded that systematic corrective exercises improve static and dynamic balance in students with pronation distortion syndrome and it could be recommended as modalities for these people.

Anomalous gait feature classification from 3-D motion capture data

The gait kinematics of an individual is affected by various factors, including age, anthropometry, gender, and disease. Detecting anomalous gait features aids in the diagnosis and treatment of gait-related diseases. The objective of this study was to develop a machine learning method for automatically classifying five anomalous gait features, i.e., toe-out, genu varum, pes planus, hindfoot valgus, and forward head posture features, from three-dimensional data on gait kinematics. Gait data and gait feature labels of 488 subjects were acquired. The orientations of the human body segments during a gait cycle were mapped to a low-dimensional latent gait vector using a variational autoencoder. A two-layer neural network was trained to classify five gait features using logistic regression and calculate an anomalous gait feature vector (AGFV). The proposed network showed balanced accuracies of 82.8% for a toe-out, 85.9% for hindfoot valgus, 80.2% for pes planus, 73.2% for genu varum, and 92.9% for forward head posture when the AGFV was rounded to the nearest zero or 1. Multiple anomalous gait features were detectable using the proposed method, which has a practical advantage over current gait indices, including the gait deviation index with a single value. The overall results confirmed the feasibility of using the proposed method for screening subjects with anomalous gait features using three-dimensional motion capture data.

Comparison of 3D Hip Joint Kinematics in People with Asymptomatic Pronation of the Foot and Non-Pronation Controls

Background

The impact of asymptomatic pronation on proximal joints during motion has not been well understood, and research on it remains limited. Therefore, the current study determines the effect of asymptomatic pronation of the foot on hip joint kinematics during gait.

Methods

Forty participants were recruited for the study (20 with asymptomatic pronated feet and 20 with non-pronated feet). Foot assessment was conducted by navicular drop and rear-foot angle tests. Hip joint kinematics were measured via MVN Xsens system 3D-motion capture from sagittal, frontal and transverse planes during gait. An independent t-test was used to identify differences in kinematic variables.

Results

Both groups were similar in characteristics, and there were no significant differences between the groups in age (P = 0.674) and BMI (P = 0.459). However, there was a significant difference in arch height (P = 0.001) and rear-foot angle (P = 0.001). Our findings showed there were insignificant differences between the asymptomatic pronated foot and non-pronated foot control groups in hip joint kinematics of sagittal (P = 0.618), frontal (P = 0.276), and transverse (P = 0.337) planes during a full gait cycle.

Conclusion

Patients with asymptomatic pronation of the foot and non-pronation of the foot showed similar movement patterns of hip kinematics in all three planes. The findings of the present study highlight the need for clinicians to consider foot alignment when examining patients with asymptomatic pronation of the foot and non-pronation of the foot.

Fatigue in Children with Pronated Feet After Aerobic Exercises

BACKGROUND

Sports have a strong influence on current society. Foot posture has been postulated to be a risk factor for overuse injuries; however, the link between foot posture and injuries is unclear. This study aimed to determine whether children with pronated feet become more fatigued after participating in sports tests than those with normal feet.

METHODS

One hundred five children aged 10 to 12 years (mean ± SD age, 10.46 ± 0.78 years) participated in the sports tests, which were aerobic-type resistance exercises with six stations at which each child remained for 30 sec. The posture of the foot was evaluated via the Foot Posture Index and the plantar footprint via the arch index and the Clarke angle before and after aerobic-type resistance exercises. Perceived tiredness was evaluated with the Pictorial Children's Effort Rating Table (PCERT) and whether there was pain during or after physical activity.

RESULTS

The variables used to measure foot posture and the plantar arch changed more in the pronated feet, suggesting that the feet undergo more pronation after physical exercise. The neutral feet obtained a mean ± SD PCERT score of 5.46 ± 1.89 and the pronated feet a score of 7.60 ± 1.92.

CONCLUSIONS

Children with pronated feet showed more fatigue and foot pain during and/or after physical exercise than those with neutral feet. Foot type could be responsible for the lack of enthusiasm of children toward undertaking healthy activities, and this problem might be solved via appropriate orthopedic treatment.

The development of the medial longitudinal arch in the intrauterine period

In this study, we aimed to reveal whether the medial longitudinal arch is formed in the intrauterine period and the structural features of the medial longitudinal arch. The study was conducted on 146 feet of 73 fetuses (38 male, 35 female) aged between 15 and 40 weeks of gestation. The fetuses were grouped by trimesters. The footprints taken were photographed with a millimeter ruler, and the development of the medial longitudinal arch was examined on footprints based on the Clarke index, Chipaux-Smirak index, and Staheli index. In Clarke index and Staheli index, it was observed that the arch height was normalized in the transition from the second trimester to the third trimester, the arch decreased in the transition to full-term, and the rate of pes planus increased. All indices detected pes planus by 81.81% in the full-term period. The rate of pes planus determined according to Clarke index and Staheli index, especially in the third trimester period, was 6.94% and 11.11%, respectively. We have provided a perspective on how the development of the medial longitudinal arch is shaped in the intrauterine period. Based on the results of study, we consider that the data on the medial longitudinal arch, especially in the third trimester period, may be more significant. In the evaluations made from the footprints of premature infants in the intrauterine third trimester period in the future, a study, in which infants detected with pes planus can be followed up and the development of their medial longitudinal arch is evaluated, can be conducted.

Morphological variations of the human talus investigated using three-dimensional geometric morphometrics

INTRODUCTION

The shape of the talus determines the positional and kinematic features of the subtalar, talonavicular, and talocrural joints during walking. Thus, detailed knowledge of the pattern of sexual dimorphism of the human talus may be useful for revealing the pathogenetic mechanism of foot and knee disorders, which are more prevalent in females. The aim of this study was to characterize and visualize the three-dimensional shape variations of the talus in relation to sex and age using geometric morphometrics.

MATERIALS AND METHODS

Computed tomography images of 56 feet without talar injuries or disorders were used in this study. Thirty-seven anatomical landmarks were identified on a bone model of the talus to calculate principal components (PCs) of shape variations among specimens. PC scores were compared between sexes, and their correlations with age were also investigated.

RESULTS

The female talus had a longer neck and narrower head width than the male talus. The superior trochlea was tilted more laterally in the frontal plane in females. Furthermore, the female talar head was more twisted and was more elongated in the dorsoplantar direction.

CONCLUSIONS

Morphological features of the talus in females could alter the subtalar and talonavicular joint kinematics during walking and could be a structural factor in the pathogenetic mechanism underlying foot and knee disorders. This study contributes to the comprehensive understanding of shape variations in the human talus.

Sex- and age-related morphological variations in the talar articular surfaces of the calcaneus

BACKGROUND

The prevalence of foot pathologies, such as flatfoot deformity and hallux valgus, is higher in women and increases with age. It has been reported that these types of foot disorders may also be linked to excessive mobility of the subtalar joint to the eversion direction during weight bearing. Given that the mobility of the joint is determined by its articular morphology, sex- and age-related variations in the subtalar articular surface morphology are possible. The purpose of this study was to investigate the orientation and the curvature radii of the talar articular facets of the calcaneus in relation to age and sex using three-dimensional computer tomography.

METHODS

Fifty-six feet without subtalar injuries or disorders were included in this study. The orientations of the talar articular surfaces of the calcaneus were quantified in the sagittal and coronal planes. The curvature radii of the articular surfaces of the calcaneus were also assessed based on the approximations of the sphere surfaces.

RESULTS

The talar articular surface was oriented more anteriorly and medially in the females than in the males. The curvature radius of the calcaneal posterior facet in the females exhibited a positive correlation with age, indicative of increased articular surface flattening.

CONCLUSIONS

The morphological features of the female calcaneus could induce excessive eversion and could lead to a higher prevalence of foot disorders, including flatfoot and hallux valgus, in elderly females. This study contributes to an understanding of the sexual dimorphism of the articular surfaces of the calcaneus and provides insight into the mechanisms that underline various foot disorders.

Association of quadriceps angle with plantar pressure distribution, navicular height and calcaneo-tibial angle

OBJECTIVE

The aim of study was to analyze the association between Quadriceps Angle (QA) and plantar pressure, navicular height (NH), and calcaneo-tibial angle (CTA).

METHODS

A total of 64 volunteers (mean age: 22.25 ± 2.54 (range:19-33)) participated in this cross sectional study. EMED-m (Novel GmbH, Germany) electronic pedobarograph was employed for dynamic plantar pressure measurement using two step protocol. The angle between the vertical axis of calcaneus and the long axis of Achilles tendon for CTA. The height of navicular tubercle from the ground was measured while the subject was standing on both feet for NH. QA was measured while the subject was standing in a relaxed posture where both feet bearing equal weight.

RESULTS

There were significant negative correlations between QA and maximum force (MxF) under the 4th. metatarsal head (MH4). The QA was also significantly correlated with MxF and force-time integral (FTI) under the bigtoe (BT). FTI under the 3rd. metatarsal head (MH3), MH4 and 5th. metatarsal head (MH5) were significantly negatively correlated with QA. Pressure-time integral (PTI) under the MH4 and MH5 were found to be significantly negatively correlated with QA. A significant correlation was also found between QA and NH (p < 0.0001), whilst there was no correlation between QA and CTA. Regression analysis showed that NH was appeared as the major contributor for the QA (β = -0.49, p < 0.001) in the dynamic condition, followed by BT-FTI (β = 0.37, p < 0.001) and MH5-MxF (β = -0.21, p < 0.037).

CONCLUSION

These findings may imply that the NH which can at least be controlled by appropriate shoe inserts may affect QA. This way, loading pattern of both plantar region and whole lower extremity may be altered.

LEVEL OF EVIDENCE

Level III, Diagnostic Study.

Kinematic differences between neutral and flat feet with and without symptoms as measured by the Oxford foot model

BACKGROUND

Flatfoot is a common presentation in children. It is usually asymptomatic, though a small number of children experience pain. Foot function during flatfoot walking is rarely considered, yet as an activity that places significant demands on the feet, this could explain the differences in terms of symptoms.

RESEARCH QUESTION

This paper investigates walking patterns in neutral and flat feet, with and without symptoms, to determine which kinematic parameters are associated with symptomatic flat feet.

METHODS

This is a retrospective study in which one hundred and six children between five and 18 years old were assessed by a physiotherapist for foot posture. Each foot was classified into one of four groups, giving 98 asymptomatic neutral, 47 asymptomatic mild flat, 29 asymptomatic flat, and 38 symptomatic flat feet with complete data for analysis. Using Plug-In-Gait and Oxford-Foot-Model markers, walking kinematics were measured, along with ground reaction forces. Median values of 14 lower limb joint angles were calculated at foot strike, midstance, and foot off. Each foot was treated as an independent sample. ANOVA and ANCOVA (with the speed-related variable relative stride length as the covariate) and post-hoc tests were used to assess whether angles differed between groups.

RESULTS

The symptomatic flat feet showed significant differences from asymptomatic groups (most commonly the neutral feet) in terms of hip flexion, knee flexion and varus, hindfoot inversion-eversion, and forefoot abduction-adduction. Increased forefoot abduction occurred throughout stance phase in symptomatic flatfooted participants compared to all asymptomatic groups.

SIGNIFICANCE

The results suggest that foot motion in the transverse plane is closely associated with the presence of symptoms in flat feet and that this is accompanied by changes in the kinematics of the ankle, knee, and hip.

Short-term effects of customized arch support insoles on symptomatic flexible flatfoot in children: A randomized controlled trial

BACKGROUND

Limited evidence is available regarding the effects of insoles on pediatric flexible flatfoot because of the heterogeneity and low methodological quality of previous studies. The purpose of this prospective trial is to examine the short-term effects of customized arch support insoles on symptomatic flexible flatfoot in children by using the International Classification of Functioning, randomized controlled Disability, and Health (ICF) framework.

METHODS

This study was conducted in a rehabilitation outpatient clinic of a teaching hospital. Fifty-two children with symptomatic flexible flatfoot were included. The children in the treatment group wore customized arch support insoles for 12 weeks, whereas those in the control group did not wear the insoles. Both clinical and radiographic measurements, including the navicular drop, foot posture index, Beighton hypermobility score, talonavicular coverage angle, calcaneal inclination angle, and calcaneal-first metatarsal angle, were used for diagnosing flexible flatfoot. Physical activity (10-m normal and fast walking, stair ascent, stair descent, and chair rising), physical function, and psychometric properties (Pediatric Outcome Data Collection Instrument and Pediatric Quality of Life Inventory) were evaluated at the baseline and 12 weeks after the intervention.

RESULTS

Compared with the control group, the treatment group exhibited significant improvement in pain/comfort (P = .048), physical health (P = .035), stair ascent time (P = .015), upper extremity and physical function (P = .016), and transfer and basic mobility (P = .042) during the intervention period.

CONCLUSION

Children with flexible flatfoot who wore customized arch support insoles for 12 weeks exhibited significantly improved pain/comfort, physical health, stair ascent time, upper extremity and physical function, and transfer and basic mobility. These variables belong to the domains of body functions and structures and activity and participation in the ICF framework. However, because the groups were not comparable, additional studies with larger sample sizes should be conducted.

Arch index and running biomechanics in children aged 10-14 years

BACKGROUND

While altered foot arch characteristics (high or low) are frequently assumed to influence lower limb biomechanics and are suspected to be a contributing factor for injuries, the association between arch characteristics and lower limb running biomechanics in children is unclear.

RESEARCH QUESTION

Therefore, the aim of this study was to investigate the relationship between a dynamically measured arch index and running biomechanics in healthy children.

METHODS

One hundred and one children aged 10-14 years were included in this study and underwent a biomechanical investigation. Plantar distribution (Novel, Emed) was used to determine the dynamic arch index and 3D motion capture (Vicon) to measure running biomechanics. Linear mixed models were established to determine the association between dynamic arch index and foot strike patterns, running kinematics, kinetics and temporal-spatial outcomes.

RESULTS

No association was found between dynamic arch index and rate of rearfoot strikes (p = 0.072). Of all secondary outcomes, only the foot progression angle was associated with the dynamic arch index (p = 0.032) with greater external rotation in lower arched children.

SIGNIFICANCE

Overall, we found only few associations between arch characteristics and running biomechanics in children. However, altered foot arch characteristics are of clinical interest. Future studies should focus on detailed foot biomechanics and include clinically diagnosed high and low arched children.

Three-dimensional innate mobility of the human foot bones under axial loading using biplane X-ray fluoroscopy

The anatomical design of the human foot is considered to facilitate generation of bipedal walking. However, how the morphology and structure of the human foot actually contribute to generation of bipedal walking remains unclear. In the present study, we investigated the three-dimensional kinematics of the foot bones under a weight-bearing condition using cadaver specimens, to characterize the innate mobility of the human foot inherently prescribed in its morphology and structure. Five cadaver feet were axially loaded up to 588 N (60 kgf), and radiographic images were captured using a biplane X-ray fluoroscopy system. The present study demonstrated that the talus is medioinferiorly translated and internally rotated as the calcaneus is everted owing to axial loading, causing internal rotation of the tibia and flattening of the medial longitudinal arch in the foot. Furthermore, as the talus is internally rotated, the talar head moves medially with respect to the navicular, inducing external rotation of the navicular and metatarsals. Under axial loading, the cuboid is everted simultaneously with the calcaneus owing to the osseous locking mechanism in the calcaneocuboid joint. Such detailed descriptions about the innate mobility of the human foot will contribute to clarifying functional adaptation and pathogenic mechanisms of the human foot.

Prevalence of Flexible Flat Foot in Adults: A Cross-sectional Study

INTRODUCTION

Flat foot (pes planus) is a commonly observed disorder in clinical practice. The height of Medial Longitudinal Arch (MLA) determines the degree of pes planus. Majority of the previous studies on prevalence of flexible flat foot were done among children.

AIM

The present study was undertaken to determine the prevalence of flexible flat foot among 18-21-year-old Indian adults using Navicular Drop Test (NDT) which is regarded as reliable and valid method to characterise MLA.

MATERIALS AND METHODS

The present study was a cross-sectional study in which Brody's Navicular Drop Test was performed in five hundred healthy subjects (250 males and 250 females) aged 18-21-year-old. Navicular Drop (ND) of ≥ 10 mm was regarded as flexible flat foot. Statistical analysis was done using SPSS version 23.0.

RESULTS

The prevalence of flexible flat foot was 13.6% (for males-12.8%; for females-14.4%). The median with Inter Quartile Range (IQR) for ND among males was 6 mm (4-8) and 6 mm (4-9) for right and left foot respectively. The median with IQR for ND among females was 6mm (4-10) and 7mm (3-8) for right & left respectively. The correlation of Right Side Navicular Drop (RND) with height and weight was significant, but insignificant correlation was found between RND and BMI. The correlation of Left Side Navicular Drop (LND) with height, weight and BMI of individuals was statistically not significant. The difference between the ND of males and female group was statistically not significant.

CONCLUSION

The present study quantified the prevalence of flexible flat foot and gender wise normative values of ND among 18-21-year-old Indian adults. The information obtained by this study will be useful in the field of orthopaedics.

Influence of Children's Foot Type on Their Physical Motor Performance

BACKGROUND

This cross-sectional study aimed to determine whether normal, flat, or high-arched feet corresponded to better performance of certain motor tests in children.

METHODS

One hundred eighty-seven children (mean ± SD age, 11.15 ± 1.24 years) were recruited and divided into three groups: 96 with normal feet, 54 with high-arched feet, and 37 with low-arched feet. Nine motor trials were selected to assess motor performance: standing long jump, standing triple jump from each foot, standing vertical jump, shuttle run 10 × 5 m, standing-start 20-m sprint, static balance, dynamic balance on a beam of an inverted gym bench, and agility circuit.

RESULTS

There were no significant differences in the trial results between groups, although in eight of the nine trials participants in the high-arched group tended to perform better. Boys performed better than girls in all of the trials except those of balance.

CONCLUSIONS

These results suggest that children with a certain foot type did not achieve better motor performance in the nine trials tested.

The three-dimensional kinematics and spatiotemporal parameters of gait in 6-10 year old typically developed children in the Cape Metropole of South Africa - a pilot study

Background

Functional gait is an integral part of life, allowing individuals to function within their environment and participate in activities of daily living. Gait assessment forms an essential part of a physical examination and can help screen for physical impairments. No three-dimensional (3D) gait analysis studies of children have been conducted in South Africa. South African gait analysis laboratory protocols and procedures may differ from laboratories in other countries, therefore a South African data base of normative values is required to make a valid assessment of South African children’s gait. The primary aim of this study is to describe joint kinematics and spatiotemporal parameters of gait in South African children to constitute a normative database and secondly to assess if there are age related differences in aforementioned gait parameters.

Methods

A descriptive study was conducted. Twenty-eight typically developing children were conveniently sampled from the Cape Metropole in the Western Cape, South Africa. The 3D lower limb kinematics and spatiotemporal parameters of gait were analyzed. The lower limb Plug-in-Gait (PIG) marker placement was used. Participants walked bare foot at self-selected speed. Means and standard deviations (SD) were calculated for all spatiotemporal and kinematic outcomes. Children were sub-divided into two groups (Group A: 6–8 years and Group B: 9–10 years) for comparison.

Results

A significant difference between the two sub-groups for the normalized mean hip rotation minimum values (p = 0.036) was found. There was no significant difference between the sub-groups for any other kinematic parameter or when comparing the normalized spatiotemporal parameters.

Conclusion

The study’s findings concluded that normalized spatiotemporal parameters are similar between the two age groups and are consistent with the values of children from other countries. The joint kinematic values showed significant differences for hip rotation, indicating that older children had more external rotation than younger children.

Are flexible flat feet associated with proximal joint problems in children?

The role of flexible flat feet (FF) in the development of musculoskeletal symptoms at joints proximal to the ankle is unclear. We undertook an observational study to investigate the relationship between foot posture and the proximal joints in children. It was hypothesised that reduced arch height would be associated with proximal joint symptoms and altered gait kinematics and kinetics particularly in the transverse plane at the hip and knee. Ninety-five children between the ages of 8-15 were recruited into this ethically approved study. Foot posture was classified using the arch height index (AHI). The frequency of knee and hip/back pain was documented, and each child underwent three dimensional gait analysis. Reduced arch height was associated with increased odds of knee symptoms (p<0.01) and hip/back symptoms (p=0.01). A flat foot posture was also significantly associated with a reduction in the second peak of the vertical ground reaction force (p=0.03), which concomitantly affected late stance hip and knee moments. A reduced AHI was also associated with increased pelvic retraction and increased knee valgus in midstance. No kinematic and kinetic parameter associated with a flat foot posture related to increased proximal joint symptoms in the FF group. Children with a flatter foot posture are more likely to have pain or discomfort at the knee, hip and back; however, the mechanisms by which this occurs remain unclear. Treating FF without explicit understanding of how it relates to symptoms is difficult, and further work in this area is required.

Effect of excessive body weight on foot arch changes in preschoolers a 2-year follow-up study

BACKGROUND

A stable standing posture, and effective and aesthetic gait, depend heavily on correct anatomical construction of the feet, thanks to which they can play their important role. The shape and height of the foot arches are already formed in the preschool and early school years; therefore, abnormalities and disorders in children's feet, and correlations between foot formation and somatic build, are still crucial and interesting issues for orthopedists, pediatricians, physiotherapists, and podiatrists. This study deals with changes in the height of the longitudinal and transverse arches of the foot in 4- to 6-year-old children.

METHODS

A total of 102 boys and 105 girls took part in a 24-month study in which their body weight, height, body mass index, and Clarke's and gamma angles were measured. The analysis also focused on correlations among sex, nutritional status, and changes in foot arch height.

RESULTS

It was discovered that sex did not considerably affect Clarke's and gamma angle values. However, it was found that between ages 4 and 6 years, the proportion of overweight and obese boys and girls increased, and the medial longitudinal arch of the foot had a tendency to collapse in those with excessive body weight. The effect of nutritional status on the transverse arch of the foot is rather dubious.

CONCLUSIONS

In light of these findings, therapeutic programs for preventing foot deformities in children should also focus on body weight control.

The effects of low arched feet on foot rotation during gait in children with Down syndrome

BACKGROUND

In children with Down syndrome (DS) hypotonia and ligament laxity are characteristic features which cause a number of orthopaedic issues, such as flat foot. The aim of this study was to determine if children with flat foot are characterised by an accentuated external foot rotation during walking.

METHOD

Fifty-five children with DS and 15 typically developing children recruited as control group were assessed using three-dimensional gait analysis, using an optoelectronic system, force platforms and video recording. Parameters related to foot rotation were identified and calculated and the participants' foot morphology was assessed using the arch index.

RESULTS

Data obtained in this study showed that while DS children without flat foot displayed the foot position on the transverse plane globally close to controls during the whole gait cycle, the DS children with flat foot were characterised by higher extra-rotation of the foot in comparison with those without flat foot and controls.

CONCLUSIONS

Our results suggest that the presence of flatfoot lead the children with DS to extra-rotate their feet more than the children without flat foot. From a clinical point of view, these results could enhance the rehabilitative programmes in DS.

Relationship between flat foot condition and gait pattern alterations in children with Down syndrome

BACKGROUND

In patients with Down syndrome (DS) one of the most common abnormalities is flat foot which can interfere significantly with normal daily activities, such as gait. The aim of this study was to quantitatively assess the relationship between the flat foot and the gait alterations in DS children.

METHOD

Twenty-nine patients with DS and 15 non-affected subjects were assessed using 3D Gait Analysis, using an optoelectronic system, force platforms and video recording. The degree of flat foot was assessed using the arch index and kinematic and kinetic parameters were identified and calculated from 3D Gait Analysis for each study participant.

RESULTS

Data showed that ankle plantarflexion moment and ankle power during terminal stance were significant to differentiate the patients with and without flat feet: their peak values were significantly lower for the patients with flat foot. In addition, the research for correlation demonstrated that the higher the arch index value, the lower the peak of ankle moment and of the generated ankle power during terminal stance and the minimum of absorbed ankle power.

CONCLUSIONS

Children with flat foot displayed a less functional gait pattern in terms of ankle kinetics than children without flat foot, suggesting that the presence of flat foot may lead to a weaker efficient walking. Then, the increasing flat foot tended to result in lower push-off ability, leading to a less functional walking.

Serial casting for neuromuscular flatfoot and vertical talus in an adolescent with hereditary spastic paraplegia

PURPOSE

The purpose of this report is to explore assessment and serial casting intervention for painful rigid flatfoot deformities with vertical talus in an adolescent girl with hereditary spastic paraplegia who was nonambulatory.

SUMMARY OF KEY POINTS

The participant's right foot underwent 2 phases of casting with correction first toward hindfoot inversion and then dorsiflexion. Because of a vertical talus, her left foot required an intermediate casting toward plantar flexion, inversion, and forefoot adduction prior to casting toward dorsiflexion.

STATEMENT OF CONCLUSIONS

The patient improved despite the underlying progressive neuromuscular disorder. Pain ameliorated and she returned to supported standing and transfers. Spasticity decreased bilaterally and the flexibility of her foot deformities improved to allow orthotic fabrication in subtalar neutral. Results were maintained at 12 and 16 months.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Individualized multiphase serial casting requires further investigation with patients such as those with hereditary spastic paraplegia.

Pediatric flexible flatfoot; clinical aspects and algorithmic approach

Flatfoot constitutes the major cause of clinic visits for pediatric foot problems. The reported prevalence of flatfoot varies widely due to numerous factors. It can be divided into flexible and rigid flatfoot. Diagnosis and management of pediatric flatfoot has long been the matter of controversy. Common assessment tools include visual inspection, anthropometric values, footprint parameters and radiographic evaluation. Most flexible flatfeet are physiologic, asymptomatic, and require no treatment. Otherwise, the physician should treat symptomatic flexible flatfeet. Initial treatment options include activity modification, proper shoe and orthoses, exercises and medication. Furthermore, comorbidities such as obesity and ligamenous laxity should be identified and managed, if applicable. When all nonsurgical treatment options faile, surgery can be considered. Our purpose in this article is to present a clinical algorithmic approach to pediatric flatfoot.