Kinematic differences between normal and low arched feet in children using the Heidelberg foot measurement method

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Abstract

The purpose of this study was to investigate the kinematics of normal arched and low arched feet in children and use this data to quantify the differences between the two foot types during walking gait. Multi-segment foot motion was measured, using the Heidelberg foot measurement method (HFMM), for 25 normal arched feet and 27 low arched feet in 9–12-year-old children. The kinematic differences in the foot between the two groups during walking were relatively small, except for the medial arch and forefoot supination angles. The magnitude of the medial arch angle was approximately 10° greater in the low arched group than the normal arched group throughout the gait cycle. There was a significant difference found in the forefoot supination angle (p < 0.03), relative to the midfoot, between the two groups at initial heel strike, and maximum and minimum values throughout the gait cycle. The values for the normal group were significantly higher in all these angles indicating that the forefoot of the low arched foot remains less pronated during the gait cycle. There was no significant difference in the motion of the rearfoot between the two foot types. The results of this study provide normative values for children's feet and highlight the mechanical differences in flexible flat feet in this age group. This data contributes to knowledge on foot kinematics in children and will be valuable for future research on the structure, function and potential treatment of the flexible flat foot.

Introduction

Three-dimensional (3D) gait and motion analysis have advanced rapidly in the last decade to the point where multi-segment analysis of the paediatric foot is possible and of interest to scientists and clinicians [1], [2], [3], [4], [5], [6], [7]. Children are an important target population for 3D motion analysis of the foot because of the specific primary effects of musculo-skeletal and neuromuscular pathologies on children's feet (e.g., equinovarus deformities in cerebral palsy or flat feet) the related functional impairment on gait and the need to develop evidence-based approaches to their clinical management. The majority of work in 3D foot analysis has been carried out on adult populations, with a few exceptions [1], [5], [8]. In their study of adolescent feet, MacWilliams et al. [8], demonstrated the capability of their model to analyse smaller, younger feet, and hence provided a normative database of kinematic and kinetic data for adolescent feet. Stebbins et al. [5] proposed a model for use with children that had already been validated for adult feet and found the kinematic patterns were consistent with results from adults. Both of these studies were carried out on healthy normal feet.

Until recent years, those analysing the low arched or flexible flat foot relied on simple foot measurement and two-dimensional analysis. Many theories regarding the structure and function of the low arched foot have been based on static footprints or the change in position of the navicular during dynamic movement [9], [10], [11], [12], [13], [14]. The limitations of two-dimensional analyses and the extrapolation of these results to the younger foot have not been established. Therefore, in vivo three-dimensional measurement of foot motion in children that allows for the analysis of the movement of the unconstrained foot is necessary to understand factors contributing to flat feet, their effects on gait, classification of foot abnormalities, and planning of suitable interventions in symptomatic patients. Recent developments in foot biomechanic measurement [5], [6], [8] produce more information than previously about the motion of the midfoot, particularly its motion relative to the adjacent segments of the forefoot and rearfoot.

Studies of the adult flat foot [15] and pathological posterior tibial tendon dysfunction (PTTD) [16], [17], [18], [19] have reported an increased hindfoot eversion in PTTD during the loading response [16], [17], with differences attributable to variations in the reference position. Hunt and Smith [15] looked at the mechanics of the flat versus normal foot, but was limited to an adult population and the stance phase of gait. Their study failed to reveal the expected biomechanical differences between low and normal arched feet, and found a restraint in motion rather than excessive motion. Differences in motion of the rearfoot have often been associated with structural misalignments of the forefoot, particularly during the stance phase of gait [20]. However, this was recently challenged by Cornwall et al. [21] who reported no relationship between rearfoot motion and forefoot alignment during walking in a healthy adult population. There is currently no reported data on this relationship in the flat foot. Even though the range of motion of the hallux has not been specifically reported for flat feet, deformities such as hallux valgus have identified flat foot as an intrinsic factor [22], [23]. Ledoux and Hillstrom [24] reported that flat feet had significantly more force under the hallux than normal arched feet and suggested that it would indicate mechanical changes in hallux motion.

The purpose of this study was to investigate the kinematics of the foot in normal and low arched feet in children, and quantify the differences in multi-segment foot motion between the two foot types. Firstly, it was hypothesized that similar to previous findings in the adult flat foot there would be restraint rather than excess of rearfoot frontal plane motion in children with low arched feet. It was further hypothesized that the motion of the forefoot relative to the midfoot would be different between the low and normal arched foot when measured in both the frontal and transverse planes by the HFMM. Finally, there were no expected differences in the motion of the hallux or in stride length and cadence. Additionally, the kinematic data presented in this paper can provide a reference for comparison to pathological feet in future work.

Section snippets

Participant information

Participants were recruited from a group of ninety-four 9–12-year-old children who had been previously categorized into high, normal and low arched foot groups, using both static and dynamic two-dimensional measurements of the medial longitudinal arch (Supplementary A). The 94 children had been recruited to a larger study and were asymptomatic, pre-pubescent, and had the ability to perform the required tasks. To facilitate the investigation of the natural foot, a history of lower limb injury or

Differences in range of motion

Significant differences were observed between the low and normal arch groups for the medial arch angle, forefoot supination and abduction angles and hallux flexion and abduction using repeated measure ANOVAs (Table 2). The pattern and range of motion of the rearfoot was similar for the normal and low arched foot. There were no significant differences (p > 0.05) between initial, maximum or minimum values of subtalar joint motion between the two foot types. However, a 5.8% difference in the timing

Discussion

This study contributes to knowledge on foot kinematics in children and provides a comprehensive account of the differences between the kinematics of normal and low arched feet in children. Relatively few kinematic differences were observed between normal and low arched feet in the sample of asymptomatic children studied. In this study decreased forefoot pronation was the only kinematic variable associated with the lower arch, unlike previous studies [16], [18], [19], where increased rearfoot

Acknowledgements

The authors wish to acknowledge the assistance of Deborah Vickers and Leanne Dwane during data collection.

Conflict of interest

The authors declare that there is no conflict of interest.

References (32)

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