A comparison of hallux valgus angles assessed with computerised plantar pressure measurements, clinical examination and radiography in patients with diabetes

The vertical mobility of the first tarsometatarsal joint during demi-plié with forced turnout in ballet dancers

The forced turnout has a perceived risk of development of hallux valgus (HV) in ballet dancers. We determined how the forced turnout affects the sagittal mobility of the first tarsometatarsal (TMT) joint, which is one of the pathogenic factors of HV development. Seventeen female ballet dancers (body mass index: 18.2 ± 1.8 kg/m2) were included and performed demi-plié in control, functional turnout, and forced turnout conditions. Ultrasound imaging synchronized with a three-dimensional motion analysis system was used for measuring the vertical locations of the first metatarsal and medial cuneiform (MC) to evaluate the first TMT joint mobility. Plantar displacement of MC and the first TMT joint mobility in the forced turnout were the greatest among the 3 conditions. Multiple regression analysis indicated that the greater extent of the forcing angle might increase the displacement of MC and the first TMT joint mobility. Evaluating the sagittal mobility of the first TMT joint in the forced turnout can assist in understanding the association between inappropriate techniques including the forced turnout and HV development in ballet dancers. Since the excessive mobility of the first TMT joint is a factor in HV development, the acquirement of adequate active turnout may have the potential to prevent HV development in ballet dancers.

Comparison of foot function and physical performance between women with and without bilateral painful hallux valgus

BACKGROUND

We aimed to investigate whether foot function and physical performance differ between women with and without bilateral painful hallux valgus (HV).

METHODS

Forty-four women with bilateral painful HV and forty-three controls were included. The Foot Function Index, American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Joints Scale, and Manchester-Oxford Foot Questionnaire were used. The time while walking 10 m-walkway at maximum speed and ascending and descending ten stairs as fast as possible also single-limb stance time were measured.

RESULTS

All self-reported and performance-based measures showed that women with HV had poorer foot function and physical performance than controls (p < 0.05). Women with mild HV had better self-reported foot function than those with moderate HV or severe HV (p < 0.05), but physical performance did not differ (p > 0.05).

CONCLUSIONS

Women with bilateral painful HV exhibited poorer self-reported foot function and performance-based physical function than those without HV.

LEVELS OF EVIDENCE

Level III.

Validity and reliability of hallux valgus angle measurement on smartphone digital photographs

BACKGROUND

This prospective study aimed to test the reliability and validity of hallux valgus angle (HVA) measurement on smartphone digital photographs compared with the standard radiographic evaluation.

METHODS

Twenty Seven female patients (45 feet) with forefoot deformity were evaluated with weight-bearing anteroposterior foot radiographs and smartphone photographs. Radiographic hallux valgus angle (rHVA) was measured on digital radiographs. Two different photographic HVA measurement methods were used. In the first, the longitudinal axes of the first metatarsal and proximal phalanx were determined, and the angle between these axes was measured (pHVA), similar to the radiographic method. In the other method, the angle of the margo medialis pedis was measured on the photograph (pMMP). Two independent observers performed all measurements twice on two different occasions. Reliability analysis was performed using the interclass correlation coefficient. Agreement between the measurements was tested using Bland-Altman analysis.

RESULTS

The repeated rHVA, pHVA and pMMP measurements showed excellent intra and inter-observer reliability, with ICC values above 0.900. The mean rHVA, pHVA, and pMMP were statistically similar (p:0.929, 27.03°±8.7°, 27.11°±8.8° and 26.5°±9.0° respectively). The mean difference between the rHVA and pHVA was - 0.07°±5.1° (range, --9.67 to 9.56°), and the mean difference between the rHVA and pMMP was 0.53°±4.4° (range, -9.76° to 8.22°). There was a strong positive correlation between both photographic methods and radiographic measurements (rho = 0.809, p = 0.001 and rho = 0.872, p = 0.001). In the Bland Altman plot, the upper and lower LOAs (95%CI) ranged from - 10.11° to 9.93° for rHVA and pHVA, and from - 8.26° to 9.33° for rHVA and pMMP. Linear regression analysis showed a proportional bias for pHVA but not for the pMMP (p:0.010 versus p:0.633, respectively). The range of the mean difference (prediction interval) between the pMMP and rHVA was 17.59° and 20° for pHVA and rHVA. Simple linear regression showed that the rHVA was predicted by the following equation: rHVA = 4.73 + 0.84 × pMMP (r2 = 0.761, p < 0.001).

CONCLUSIONS

Although measuring HVA through smartphone photographs is reliable, it is not a valid prediction method.

LEVEL OF EVIDENCE

Level II, diagnostic assessment.

Correlation analysis between foot deformity and diabetic foot with radiographic measurement

Background

Foot deformity is a risk factor for diabetic foot ulcer. This study was aimed to investigate the relationship between hallux valgus (HV) and diabetic foot through the radiographic measurement.

Methods

The patients with diabetic foot hospitalizing in the Department of Endocrinology, the First Affiliated Hospital of Chongqing Medical University from September 2016 to June 2020 were selected. Then the foot plain X-ray radiographs were completed, and the size of HV angle (HVA) was measured. Their clinical data were collected, and the ulcer recurrence rate, amputation rate and mortality rate of the patients were followed up.

Results

A total of 370 patients were included. According to HVA, patients were divided into non-HV group (HVA<15°), and mild (15°≤HVA ≤ 20°), moderate (20°40°) HV groups. The age, height, BMI, smoking history and glycosylated hemoglobin level among the non-HVA, mild, moderate, and severe HV group (P<0.05), while smoking history, HbA1c, eGFR and autonomic neuropathy were significantly lower in HV group than those in non-HV group (P<0.05). The ulcer area in patients with moderate HV was larger than that in non-HV patients, and the severity of infection in patients with severe HV was significantly higher than that the other three groups (P<0.05).

Conclusion

The occurrence of HV is not only related to age and BMI, but also to the creatinine and eGFR level, autonomic neuropathy, lower limb arteriosclerosis occlusion, coronary heart disease and hypertension. Therefore, more attention should be paid to renal function screening, neuropathy screening and evaluation of lower extremity vascular lesions in patients with diabetes, especially those with moderate or higher HV.

Correlations of Sesamoid Bone Subluxation with the Radiologic Measures of Hallux Valgus and Its Clinical Implications

Background and Objectives: Hallux valgus is one of the most common chronic foot complaints, with prevalences of over 23% in adults and up to 35.7% in older adults. However, the prevalence is only 3.5% in adolescents. The pathological causes and pathophysiology of hallux valgus are well-known in various studies and reports. A change in the position of the sesamoid bone under the metatarsal bone of the first toe is known to be the cause of the initial pathophysiology. Purpose: The relationships between the changes in the location of the sesamoid bone and each radiologically measured angle and joint congruency in the hallux valgus remain as yet unknown. Therefore, this study investigated the relationships of sesamoid bone subluxation with the hallux valgus angle, intermetatarsal angle, and metatarsophalangeal joint congruency in hallux valgus patients. The goal is to know the hallux valgus angle, the intermetatarsal angle, and metatarsophalangeal joint congruency's correlation with hallux valgus severity and prognosis by revealing the relationship between each measured value and sesamoid bone subluxation. Materials and Methods: We reviewed 205 hallux valgus patients who underwent radiographic evaluation and subsequent hallux valgus correction surgery in our orthopedic clinic between March 2015 and February 2020. Sesamoid subluxation was assessed using a new five-grade scale on foot radiographs, and other radiologic measurements were assessed, such as hallux valgus angle, the intermetatarsal angle, distal metatarsal articular angle, joint congruency, etc. Conclusions: Measurements of the hallux valgus angle, interphalangeal angle, and joint congruency exhibited high interobserver and intraobserver reliabilities in this study. They also showed correlations with sesamoid subluxation grade.

Analysis of hallux valgus angles automatically extracted from 3D foot scans taken in North America, Europe, and Asia

The forefoot is the foot part most affected by ill-fitting shoes. Footwear fitting considers the measurements of length, width, and arch length. Toe shape has not yet been used in sizing feet and fitting shoes. This study aims to investigate the variation in toe shape, as measured by the hallux valgus angle. An automatic and reproducible hallux valgus angle measuring method using 3D foot scans with no palpation markers is proposed and applied to about half a million samples collected across North America, Europe, and Asia. The measuring method is robust and can detect the medial contour along the proximal phalanx even in extreme cases. The hallux valgus angle has a normal distribution with long tails on both sides in the general population. Large dispersions of HVA values were observed for both genders and in all three geographical regions. Practitioner summary: The hallux valgus angle has a broad distribution in the general population. Females have larger hallux valgus angles than males, and people from Asia have larger hallux valgus angles than people from North America and Europe. Shoe toe boxes should be designed to fit the actual shapes of shoppers' toes. The proposed method for measuring HVA opens a new opportunity to study the causal relationship between shoe wearing habits and HVA on a large scale.

Alignment of the metatarsal heads affects foot inversion/eversion during tiptoe standing on one leg in demi-pointe position: A cross-sectional study on recreational dancers

Classical ballet dancers stand on tiptoe in the demi–pointe position where the ankle is plantarflexed, and the toes extend around a mediolateral axis passing through the second metatarsal head. Foot sickling, the foot inversion/eversion when the forefoot is grounded, should be avoided to achieve esthetics and prevent injuries during tiptoe standing. The foot inversion/eversion angle may change depending on the metatarsal heads through which the toe extension axis passes. This study investigated the relationship between metatarsal alignment in both load positions and foot inversion/eversion angle during tiptoe standing. Nine recreational female ballet dancers performed tiptoe standing on a single leg in the demi–pointe position. The foot inversion/eversion angle, the centre of pressure (COP) positions, and angles between adjacent metatarsal heads in the horizontal plane were investigated using motion–capture data and magnetic resonance imaging of the forefoot. As the angle between the second and adjacent metatarsal heads became more acute during tiptoe standing on the non-dominant leg, the dancers everted the foot more and significantly loaded the first toe–side more, and vice versa (r = −0.85 and −0.82, respectively). Then, the load positions were distributed on the distal side of the second metatarsal head. These were not seen during standing on the dominant leg with COPs more proximal to the second metatarsal head. In conclusion, dancers load the distal part of the second metatarsal head during tiptoe standing on the non–dominant leg. When the angle at the second metatarsal head was acute, within the triangle formed by the first, second, and third metatarsal heads, even slight mediolateral shifts of load positions altered the toe extension axis around that metatarsal head; the dancers loaded medial to the second metatarsal head and everted the foot and vice versa. Therefore, the angle between the second and adjacent metatarsal heads influenced the foot inversion/eversion angle.

The Impact of Hallux Valgus on Adolescent Ballet Dancer Balance and Health-Related Quality of Life Scores

BACKGROUND

It is well-known that hallux valgus (HV) alters foot biomechanics. In different populations, HV and postural stability has been studied, but HV and the adolescent ballet dancer has not been studied. The aims of this study were to explore the effect of HV on adolescent ballet dancers' balance and to assess the health-related quality of life (HRQOL) of adolescent ballet dancers with HV.

METHODS

Female ballet dancers aged 8 to 16 years were screened prospectively and divided into two groups: those with HV (group 1) and those without HV (group 2). The HV diagnosis was made clinically. The groups were compared according to balance parameters and HRQOL questionnaires.

RESULTS

In group 1 (n = 31) and group 2 (n = 24), the mean age was 11.6 years and 12.2 years, respectively. Mean first metatarsophalangeal angle was 13.4° (range, 10°-15°) in group 2 and 19.8° (range, 16°-25°) in group 1. A statistically significant difference was found according to the nonparametric Mann-Whitney U test results in the comparison of HV angle between groups. According to Spearman rho correlation analysis, it was determined that the increase in HV angle caused deterioration in the flamingo static balance test (r = 0.552; P = .019). No significant relationship was found between HRQOL questionnaires and the presence of HV (P > .05).

CONCLUSIONS

Adolescent ballet dancers experience static balance impairment due to HV angle increase. Clinical measurement of HV and application of balance parameters made easy without need of set ups to perform evaluation with high numbers of participants in concordance with the literature.

Association between foot posture and tibiofemoral contact forces during barefoot walking in patients with knee osteoarthritis

Background

Accumulating evidence indicates that abnormal foot posture are risk factors for knee osteoarthritis (OA). However, the relationship between foot posture and tibiofemoral contact force (CF) during habitual weight-bearing activities remains unclear. This study aimed to determine the association between tibiofemoral CF and foot posture while walking.

Methods

In total, 18 patients with knee OA and 18 healthy individuals participated in this cross-sectional study. Foot parameters were evaluated by Foot Posture Index (FPI), Staheli Arch Index (SAI), hallux valgus angle, calcaneus inverted angle relative to the floor as a static rearfoot posture, navicular height, and toe grip strength. In addition, all participants underwent kinetic and kinematic measurements during a self-selected speed gait. The measurement device used was the three-dimensional motion analysis system with a sampling rate of 120 Hz. The musculoskeletal model, which has 92 Hill-type muscle–tendon units with 23 degrees of freedom, was used to calculate tibiofemoral CF. Partial correlations was used to investigate the association between foot parameters and total, medial, and lateral tibiofemoral CF of the first and second peaks while controlling for gait speed.

Results

A significant negative correlation was observed between Walking SAI and first peak medial tibiofemoral CF in control participants (r = -0.505, p = 0.039). SAI was also significantly positively correlated with first peak medial tibiofemoral CF in patients with knee OA (r = 0.482, p = 0.042).

Conclusions

Our findings revealed a correlation between the medial first peak tibiofemoral CF and the SAI. This study indicates that people with knee OA and flatfoot have excessive first medial tibiofemoral CF during walking.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05624-y.

Displacement of the Metatarsal Sesamoids in Relation to First Metatarsophalangeal Joint Extension

Background:

Quantifying normal sesamoid movement in relation to first metatarsophalangeal joint (MTPJ1) motion is essential to identifying aberrant kinematics and understanding how they may contribute to forefoot pain and dysfunction. The present study aims to report sesamoid displacement in relation to MTPJ1 extension and to compare sesamoid displacement with MTPJ1 range of motion (ROM) from several imaging modalities.

Methods:

Using 10 fresh frozen cadaveric feet, sesamoid displacement was evaluated during simulated MTPJ1 extension. The ability of 3 MTPJ1 measurement techniques (goniometry, fluoroscopy, and unloaded cone beam computed tomography [CBCT]) in predicting sesamoid displacement were compared. Kinematics were expressed in a coordinate frame based on the specimen-specific first metatarsal anatomy, and descriptive statistics are reported.

Results:

In the sagittal plane in both neutral and maximally extended positions, the tibial sesamoid was located on average more anteriorly than the fibular sesamoid. The angular displacement of the tibial and fibular sesamoids in the sagittal plane were 30.2 ± 14.3 degrees and 35.8 ± 10.6 degrees, respectively. In the transverse plane, both sesamoids trended toward the body midline from neutral to maximum extension. The intersesamoidal distance remained constant throughout ROM. Of the 3 measurement techniques, MTPJ1 ROM from CBCT correlated best (R² = 0.62 and 0.81 [P < .05] for the tibial and fibular sesamoid, respectively) with sagittal plane sesamoid ROM.

Conclusion:

The sesamoids were displaced anteriorly and medially in relation to increasing MTPJ1 extension. CBCT was the most correlated clinical imaging technique in relating MTPJ1 extension with sesamoid displacement.

Clinical Significance:

This study advances our understanding of the biomechanical function of the sesamoids, which is required for both MTPJ1 pathology interventions and implant design. These findings support the use of low-dose CBCT as the information gathered provides more accurate detail about bone position compared with other imaging methods.

A Comparison Between X-ray Imaging and an Innovative Computer-aided Design Method Based on Weightbearing CT Scan Images for Assessing Hallux Valgus

With the development of recent technology, radiographs can be saved digitally, and angular measurements can be processed using various software packages. We developed an innovative computer-aided design method with Materialize Interactive Medical Image Control System software to measure hallux valgus angle (HVA), the intermetatarsal angle (IMA), and the distal metatarsal articular angle (DMAA) and assessed its concordance with traditional X-ray imaging methods. All measurements were carried out on 42 feet from 26 adult patients diagnosed with hallux valgus who were prospectively selected from July 2016 to April 2018. Standing X-ray radiograph and weightbearing computed tomography scans were conducted on all patients, and HVA, IMA, and DMAA were generated using both a traditional X-ray method and our innovative method. Two different observers assessed measurements for each patient. Finally, statistical analyses were conducted to assess the reliability of the measurements. Both X-ray imaging and our innovative method had strong interobserver and test-retest reliability. The ICC of X-ray imaging was 0.945, p < .001, and the ICC of the innovative method was 0.915, p < .001. There was no statistical difference between the 2 methods for HVA and IMA measurements (p > .05); however, a difference was detected for DMAA (p < .05). Bland-Altman analyses demonstrated a high degree of agreement between the 2 methods for HVA and IMA, but a significant difference for DMAA. From the results, we concluded that our innovative computer-aided design method is a feasible, reliable way to quantitatively assess HVA, IMA, and DMAA, and it is likely more accurate for measuring DMAA.

Radiographic measurements have limited effect in dynamic plantar pressures in hallux valgus patients

PURPOSE

Radiographic measurements are the gold standard in the management for preoperative surgical planning of hallux valgus deformity. Plantar pressure technology is a tool that is not commonly used to evaluate and manage hallux valgus patients, and few studies have reported the correlation of plantar pressure measurements and radiography.

METHODS

A prospective cohort study was designed to analyze plantar pressure measurements and radiographic variables. The inclusion criteria were age over 18 years old, and diagnosis of hallux valgus requesting surgical correction because of discomfort, pain or difficulty with shoe wear. Plantar pressure measurements were performed using a platform. Radiographic data were obtained according to the guidelines of the AOFAS Committee on Angular Measurements.

RESULTS

A total of 114 patients met the inclusion criteria. Mean age of the patients was 50 years, and 94 patients (82.5%) were women. We found significant correlations between dynamic plantar pressure measurements and HVA, DMAA, and MDA. Mean pressure under third metatarsal head was the most associated plantar pressure measurement with hallux valgus angle and metatarsal declination angle. However, this association showed signs of weakness.

CONCLUSION

Hallux valgus angle and metatarsal declination angle had a minimal influence on plantar-loading parameters. Pressure values did not discriminate the magnitude of HV deformity. Others factors responsible for the observed plantar pressures pattern should be addressed.

Vulnerability of the foot's morphological structure to deformities caused by foot loading paradigm in school-aged children: a cross-sectional study

The study aimed to assess the association between the key predictive foot structure variables and its loading paradigm in 625 school-aged children. Clinical appraisal relied primarily on having the plantar parts of their feet comprehensively assessed with Podoscan 2D Foot CAD, and a dynamometer platform, the research tools of choice widely acknowledged for their overall accuracy and reliability, with a view to determining the distribution of respective foot loads, as well as addressing both balance and gait issues. The Clarke's angle, Wejsflog index, length and width of the feet, regardless of gender, proved the key predictive variables for the foot-loading paradigm. Notably the Clarke's angle, construed the most sensitive variable in assessing flat-footedness, offered an extra added value in overall investigative effort. The actual design of the study protocol effectively complements a standard clinical assessment procedure, whereas by comprehensively addressing those variables, it is also believed to aid clinicians in gaining an extra, hands-on, diagnostic potential, so that any teenagers exposed to the highest risk of developing foot deformities could effectively be identified through pertinent screening tests, and consequently offered a task-oriented, therapeutic management, specifically aimed at preventing potential postural complaints in later life.

Correlation between degree of hallux valgus and kinematics in classical ballet: A pilot study

Hallux valgus is a serious medical concern for classical ballet dancers. Although it is well-known that progression of hallux valgus is related to inappropriate movement techniques in classical ballet, the kinematic relationship between the degree of hallux valgus and ballet techniques has not been substantiated. To develop proper training methods that prevent progression of hallux valgus, this study aimed to investigate the relationship between the degree of hallux valgus and movement techniques in classical ballet. Seventeen female classical ballet dancers at the advanced college-level participated in this study. Kinematic analysis of standing and plié in the first position was conducted via video capture technique. The Pearson product-moment correlation analysis was performed to examine the degree of hallux valgus and the following three kinematic variables: (1) the extent to which turnout is forced by other joints in the lower extremity than the hip joint, (2) the direction difference between the knee and toe in the transverse plane, and (3) the pelvis obliquity angle. Among these kinematic variables, we found a significant correlation between the hallux valgus angle and the pelvis obliquity angle during plié (P = .045). The greater the hallux valgus angle, the greater the retroversion of the pelvis, a result which was contrary to our prediction. We present the first evidence that the degree of hallux valgus correlates with kinematics in a very basic technique of classical ballet.

Detailed analysis of the transverse arch of hallux valgus feet with and without pain using weightbearing ultrasound imaging and precise force sensors

Background

Hallux valgus is the most common forefoot deformity and affects the transverse arch structure and its force loading patterns. This study aims to clarify the differences in the transverse arch structure and the force under the metatarsal heads individually, between normal feet and hallux valgus feet, and between hallux valgus feet with pain and without pain. We further test the association between the parameters of the transverse arch and hallux valgus angle and between the parameters and pain in hallux valgus.

Methods

Women’s feet (105 feet) were divided into normal group (NORM) and hallux valgus group (HVG); and further into subgroups: hallux valgus without pain (HV Pain (-)) and hallux valgus with pain (HV Pain (+)). Transverse arch height and metatarsal heads height were measured using weight-bearing ultrasound imaging. Force under the metatarsal heads was measured using force sensors attached directly on the skin surface of the metatarsal heads. The measurements were taken in three loading positions: sitting, quiet standing and 90% weight shift on the tested foot. Differences between the groups were compared using Student t-test and Wilcoxon Exact test. Multivariate logistic analysis with adjustment for physical characteristics was also conducted.

Results

Transverse arch height was significantly higher in HVG than in NORM in all positions; there were no significant differences between HV Pain (+) and HV pain (-). Lateral sesamoid was significantly higher in HVG and HV Pain (+) than in NORM and HV Pain (-) respectively when bearing 90% of the body weight unilaterally. There was a trend of higher forces under the medial forefoot without significant difference. Transverse arch height and lateral sesamoid height were associated with the hallux valgus angle, while lateral sesamoid height was associated with forefoot pain in hallux valgus deformity.

Conclusions

This study shows the differences in the transverse arch structure between normal feet and feet with hallux valgus, and between hallux valgus feet with and without pain. This finding is noteworthy when considering future treatments of painful feet, notably the height of the lateral sesamoid which seems to play a role in forefoot pain.

Clinical Predictors of Dynamic Lower Extremity Stiffness During Running

BACKGROUND

Lower extremity stiffness describes the relative loading and kinematics of the entire lower extremity during ground contact. Previously injured subjects demonstrate altered lower extremity stiffness values. Clinical analysis of lower extremity stiffness is not currently feasible due to increased time and cost.

OBJECTIVE

To determine the clinically identifiable contributors to lower extremity stiffness.

METHODS

In this cross-sectional controlled laboratory study, 92 healthy runners completed a clinical screening involving passive assessment of hip, knee, and ankle range of motion, along with body anthropometrics. The range of motion was predominantly assessed in the sagittal and frontal planes. In the same session, runners completed an overground kinematic and kinetic running assessment at 3.35 m/s (±5%) to obtain lower extremity stiffness. Correlations between lower extremity stiffness and clinical variables were completed. Modifiable variables were included in an all-possible-linear regressions approach to determine a parsimonious model for predicting lower extremity stiffness.

RESULTS

Clinically modifiable measures included in the regression model accounted for 48.4% of the variance of lower extremity stiffness during running. The variables that predicted greater stiffness included greater body mass, less ankle dorsiflexion range of motion with the knee flexed, less hip internal rotation range of motion, and less first-ray mobility.

CONCLUSION

Reduced lower extremity range of motion and greater body mass are associated with greater lower extremity stiffness during running. These variables could be addressed clinically to potentially alter lower extremity stiffness and injury risk. J Orthop Sports Phys Ther 2019;49(2):98-104. Epub 27 Jul 2018. doi:10.2519/jospt.2019.7683.

Footprint as an alternative to X-ray in hallux valgus angle measurement

Background: X- ray images provide accurate and reliable data in different foot pathologies. However, the accompanied complications will limit its use for epidemiological studies and research purposes, especially in children. Therefore, simple, accessible, and cost- effective methods such as footprint, with a good correlation with x-ray images, are needed to help diagnose different foot pathologies. In the present study, the accuracy of footprint technique in assessing hallux valgus angle (HVA) was evaluated based on x-ray images through measuring the angle between the medial border protrusion of the foot and the hallux. Methods: In this cross-sectional study, 42 participants with symptomatic hallux valgus were recruited. HVA was measured by both x-ray imaging and footprint. The differences between the two approaches were identified by applying correlation-coefficient test and reliability, which was assessed using interclass correlation (ICC). Results: A significant correlation was found between the HVA measured by x-ray and HVA by footprints (p< 0.001), and the ICC was upper than 90%. Conclusion: Foot print is a reliable method for measuring HVA, as it was highly correlated with the HVAs obtained by x-ray imaging.

Variation of plantar pressure in Chinese diabetes mellitus

To investigate dynamic changes in plantar pressure in Chinese diabetes mellitus patients and to provide a basis for further preventing diabetic foot. This is a cross-sectional investigation including 649 Chinese diabetes mellitus patients (diabetes group) and 808 "normal" Chinese persons (nondiabetes group) with normal blood glucose levels. All the subjects provided a complete medical history and underwent a physical examination and a 75-g oral glucose tolerance test. All subjects walked barefoot with their usual gait, and their dynamic plantar forces were measured using the one-step method with a plantar pressure measurement instrument; 5 measurements were performed for each foot. No significant differences were found in age, height, body weight, or body mass index between the two groups. The fasting blood glucose levels, plantar contact time, maximum force, pressure-time integrals and force-time integrals in the diabetes group were significantly higher than those in the nondiabetes group (p < 0.05). However, the maximum pressure was significantly higher in the nondiabetes group than in the diabetes group (p < 0.05). No difference was found in the contact areas between the two groups (p > 0.05). The maximum plantar force distributions were essentially the same, with the highest force found for the medial heel, followed by the medial forefoot and the first toe. The peak plantar pressure was located at the medial forefoot for the nondiabetes group and at the hallucis for the diabetes group. In the diabetes group, the momentum in each plantar region was higher than that in the nondiabetes group; this difference was especially apparent in the heel, the lateral forefoot and the hallucis. The dynamic plantar pressures in diabetic patients differ from those in nondiabetic people with increased maximum force and pressure, a different distribution pattern and significantly increased momentum, which may lead to the formation of foot ulcers.