|Year : 2020 | Volume
| Issue : 3 | Page : 101-107
A new approach for medial longitudinal arch estimation by “foot print”: A comparative study
Vedi Neeraj1, Dulloo Puja2, Gandotra Achleshwar3
1 Assistant Professor, Department of Anatomy, PSMC, Karamsad, Gujarat, India
2 Professor, Department of Physiology, PSMC, Karamsad, Gujarat, India
3 Professor and Head, Department of Anatomy, SBKSMIRC, Vadodara, Gujarat, India
|Date of Submission||29-Jun-2020|
|Date of Decision||02-Aug-2020|
|Date of Acceptance||14-Sep-2020|
|Date of Web Publication||15-Oct-2020|
Department of Anatomy, PSMC, Karamsad, Gujarat
Source of Support: None, Conflict of Interest: None
Background: Medial longitudinal arch (MLA) is important as per the anatomical aspect of individual's foot. Its elastic properties reduce the risk of musculoskeletal wear and impairment. Various methods of its estimation have been presented by researchers. With this basis the aim of the study is to find the value of MLA by the devised mid-footprint planter angle method and compare it with the standard navicular height method. Methodology: Purposive analytical and comparative study done on 1st year health professional students of Sumandeep Vidyapeeth University (2015–2016 batch). MLA was estimated by the navicular height method and mid-footprint planter angle method on footprint after collecting their demographic and anthropometric data. The calculated values of MLA for both feet were compared by correlation coefficient by two different methods and Kruskal–Wallis test for the comparison as per body mass index (BMI) of participants. Results: Statistical significance was observed for right (−3.57 ± 0.85; P < 0.0001) and left (−6.4 ± 0.91; P < 0.0001) foot for MLA values by two methods, with higher level of Kappa agreement for right (0.755) and left (0.794) foot. Higher to middle level of correlation was observed for both the feet as per the two methods. Statistical significance as per gender was observed for left foot by navicular height method. While, no statistical significance was observed for MLA values as per BMI for both feet as per two methods. Conclusion: MLA values estimated by mid-footprint planter angle and compared by the standard navicular height method concludes that this method can be used in place of the gold standard in day-to-day basis, but extensive work needs to be done before considering it as a replacement, specifically in terms of sample size.
Keywords: Body mass index, footprint method, medial longitudinal arch, navicular height method
|How to cite this article:|
Neeraj V, Puja D, Achleshwar G. A new approach for medial longitudinal arch estimation by “foot print”: A comparative study. Natl J Clin Anat 2020;9:101-7
|How to cite this URL:|
Neeraj V, Puja D, Achleshwar G. A new approach for medial longitudinal arch estimation by “foot print”: A comparative study. Natl J Clin Anat [serial online] 2020 [cited 2021 Apr 22];9:101-7. Available from: http://www.njca.info/text.asp?2020/9/3/101/298160
| Introduction|| |
The civilizations gone by in the past have left foot print on the face of the Earth. Foot print is one which reflects the individual organism. It may vary from that of a sparrow to Orangutan. We as humans are unique by the virtue of having bipedal gait and the evolution of thought process hence called Homosapiens-sapiens. Just like the uniqueness in the face of a person and his/her hand print; so, we can say about foot print too. The ancient civilizations were experts in using the arch mechanism for the construction of building which still remains core architectural aspect in the modern world. In order to have an effective bipedal gait the arch mechanism evolved; specifically, the planter arches. These arches enable us to participate in various competitive sports, fight or flight as is well depicted in ancient Greek. The importance of planter arch is well presented by researchers toward the field of the sports and dance.,, Although, Tudor et al concluded that children with flat or 'normal' feet were equally successful at various motor tests.
The human foot is an intricate web of bones, joints, tissues, ligaments, tendons, and arches. The foot is like a steady chain that is in constant communication with other joints like the knee and hip.
Talus is the key stone of the foot. The planter arch is more accentuated on the medial side and can be viewed with the naked eye. However, the basic support of this arch is on the lateral side of the foot which is in contact with the ground. Therefore, to have the effective transmission of body weight, the foot behaves like a tripod with anterior, posterior, and lateral aspect being directly in contact. Standring S has well explained the three main arches of the foot, mainly the medial longitudinal arch (MLA), the lateral longitudinal arch, and the transverse arches. The shock absorption by the longitudinal arches can well be observed by the springiness of MLA of the foot by the runner on the toes.
Elastic properties of MLA allow the soft tissues spreading over the ground thus creating contact reaction forces over a longer period of time and reducing the risk of musculoskeletal wear or impairment. This also allows the storage of the energy so that these forces, can be returned at the next step, in turn, reducing the cost of walking and principally, running, where vertical forces are higher.
Navicular bone height determines the height of a person's arch. Collapse of longitudinal arches, results in flat foot where standing and walking of the person will be with their feet in a pronated position, thus foot everts or rolls inward. This makes the person susceptible to heel pain, arch pain, and plantar fasciitis.
People having high longitudinal arch or a cavus foot tend to walk and stand in the supinated position where the foot inverts or rolls outward. High arches cause the plantar fascia to be stretched away from the calcaneus or the heel bone by increasing the power on the forefoot, leading to plantar fasciitis.
Literature has indicated that injuries in the lower extremity are inclined due to height of MLA.,, Researchers have presented different ways to determine the values of MLA for normal, cavus, and planus foot with varied techniques such as navicular landmark measurement directly or by digital photography, footprint measurements, radiographs, and ultrasonography.,,,,,,
The aim of the present study was to find the value of MLA by navicular height method and correlating it with the chosen morphological characteristics (mid-footprint planter angle) by footprint in medical and health science students of Sumandeep Vidyapeeth University (SV University).
- To find the value of MLA considering the standing navicular height of a subject
- To provide a method of measuring and identifying MLA using footprints
- To compare and correlate the findings from the footprint data of mid-footprint planter angle with that of standing navicular height as per difference in gender and body mass index (BMI).
| Methodology|| |
Observational, purposive, nonrandomized, analytical and comparative study was commenced after receiving ethical approval from the Institutional Ethical Committee (SVIEC/ON/Medi/BNPG14/D/15107, dated September 18, 2015). First year medical, dental, and physiotherapy students of batch 2015–2016 were included for the study for the duration of 6 months. Participant information sheet was explained to all the 1st-year students of SV University and students who volunteered for the study were selected. A consent form was signed by all the voluntary participants in the presence of a witness, since few participants age was <18 years. Students having any gross foot deformity or injury or having a history of lower extremity injury within the past 6 months or foot or ankle surgery were excluded from the study.
The sample size estimation was based on the number of students in SV University, under the guidance of a qualified statistician posted in SBKS Medical Institute and Research Center. The number of undergraduate students in SV at the time of initiation of the study was 2000. At confidence interval 95%, power 80% taking P (prevalence as 20%) the sample size calculated on open Epi software was 193. Out of 310, only 200 1st year undergraduate students' voluntaries gave their consent to participate in the study, out of which data from 184 voluntary participants were incorporated as per the inclusion criteria.
An anthropometric measurement with personal information about age (17–21 years, 17 year = 27, 18 years = 108, 19 years = 38, 20 years = 10, and 21 years = 1) and gender (male = 90; female = 94) were collected. BMI was calculated as per the criterions of Asian-Pacific cutoff point.,
Measurement of medial longitudinal arch by navicular height method
The test measurements were conducted firstly on the right foot and then on the left foot. The participant stood in an upright position, toes pointing straight forward, with the right foot behind the left with the left heel and right toe on the same transverse plane as mentioned by Soren Spörndly-Nees et al. and Vedi et al., The participants were allowed to hold a metal bar for support. The clinician marked the tip of the first metatarsal, then the navicular tuberosity, and finally a point at the Calcaneum using a metric scale.
- The tubercle of navicular bone (C)
- Most prominent posterior portion of calcaneum (B)
- Most prominent medial end of 1st metatarsal (A).
The truncated foot length and arch height are taken using a metric scale and set-square. Height of the MLA was taken by dropping a perpendicular from the point “C” to ground on line “AB” at point “D.” With the help of these four measurements, the triangle was constructed and angles (angle ACD, DCB and ACB) were measured and recorded using Natural Sines, cosines, and tangents, i.e., Trigonometric-ratio table (T-ratio) [Figure 1]a and [Figure 1]b.
|Figure 1: Estimating medial longitudinal arch by the navicular height method. (a) To estimate truncated foot length; (b) To estimate arch height|
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Measurement of medial longitudinal arch using footprint
Footprints of all the 200 participants were obtained using the simple blue ink print method. The feet of the participants were cleaned with the soap and dried with a towel. The subject was asked to sit on the chair comfortably. A thick sponge-based roller of 7 cm diameter was rolled over the dry feet of the subject one at a time, after rolling it over the blue ink pad. The sponge absorbs the ink from the ink-pad and when the foot is placed, the ink sticks on the surface of the foot, without dripping. The subject was then asked to stand by placing his/her feet on a clean white sheet A-3 size to mark the footprint for both the feet with full load.
During weight transmission, the area of the foot in contact with the ground determined the integrity of the arches of foot. Three major foot imprints components were considered:
- Anteriorly ⅓ is formed due to the metatarsal head which remains constant mostly
- Posteriorly ⅓ of the foot print also remains constant which is formed due to the calcaneus bone
- Middle ⅓ concavity part is variable reflecting the height of the arch indicated by the width of the area of contact with ground on the lateral side.
The angles were measured by joining the medial most point anteriorly due to metatarsal head with the point of maximum concavity on the medial side of the foot while posteriorly due to calcaneus bone forming a triangle with this angle for the study, i.e., angle which is the mid-footprint planter angle (termed as Gandotra Angle) [Figure 2].
|Figure 2: Mid-footprint planter angle (Gandotra angle) for the right and left foot|
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The data were collected analyzed as per mean ± standard deviation (SD), correlation coefficient, and Kruskal–Wallis as per the variation in BMI.
The Cronbach's Alpha reliability value for the data collected for the four items of the MLA estimation by different methods in two feet is 0.878, which implies high reliability of collected data.
[Table 1] shows mean and SD for the data collected for MLA estimation by navicular height method and Gandotra Angle by the footprint method in the right and left foot. The data show statistical significance (P < 0.001) for the value of MLA estimation by the navicular height method and Gandotra Angle on the footprint for the right or left foot.
|Table 1: Descriptive statistics for the medial longitudinal arch by two methods for both feet (right and left)|
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[Table 2] shows Kappa agreement of 0.755 for the right foot and 0.794 for the left which shows value at the higher level of agreement with statistically significant results by two different methods (P < 0.0001)*.
|Table 2: Kappa agreement test for right and left foot for medial longitudinal arch estimation by the gold standard Navicular height method and Gandotra angle footprint method (n=184)|
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[Table 3] shows that Spearman's rho correlation coefficient for measuring MLA by navicular height and Gandotra Angle on footprint. Higher level of correlation is observed between MLA estimation in the right and left foot by two different methods (navicular height and Gandotra Angle of footprint method; 0.754 and 0.820). Middle level of correlation is observed between MLA estimation in the left and right foot by the footprint method (0.492) as well as between right foot MLA estimation by Gandotra Angle by footprint and left foot for navicular height method (0.578); showing statistical significance at all the levels.
|Table 3: Nonparametric Spearman's rho correlations test for identifying the correlation coefficient between two methods of MLA estimation in both feet|
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[Table 4] shows statistical significance (P < 0.05) of MLA estimation in the left foot by navicular height method only as per gender variability while for other test no gender variability has been identified as per MLA estimation.
|Table 4: Comparing medial longitudinal arch values for both feet by navicular height method and Gandotra angle on footprint method as per gender|
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[Table 5] shows the Kruskal–Wallis one-way ANOVA results indicating no statistical significance in the MLA estimation as per the BMI (underweight, normal, over-weight, and obese) by either method for any feet. For the right foot-Navicular height method: χ2 (3, n = 184) = 3.896, P = 0.273; right foot-gandotra angle footprint method: χ2 (3, n = 184) = 2.676, P = 0.444; left foot-navicular height method: χ2 (3, n = 184) = 3.291, P = 0.349; while the value for left foot-gandotra angle footprint method: χ2 (3, n = 184) = 2.339, P = 0.505.
|Table 5: Kruskal–Wallis test for assessing the significance as per the body mass index for both the feet with both the methods of medial longitudinal arch estimation (n=184)|
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This implies that there is no difference in the MLA estimation values as per BMI of the participants, estimated by any method.
| Discussion|| |
At present, various methods for the evaluation of MLA both static and dynamically have been conducted.,,, However, footprint analysis is one of the most popular, cheap, and easily reproducible method for assessing the MLA. Although footprints have been widely used by several authors for the analysis and description of the MLA, there is not a universally accepted method till date.,
Staheli et al. defined the arch index as “the ratio of the width of the foot in the area of arch to that of heel”. Chen et al. reported that sub arch angle showed significant correlation with radiographic parameters in children with flat feet and could be easily and accurately obtained from a capacitive force plate. In line with these researchers work, the authors tried to introduce a new parameter of footprint for estimating MLA (termed as Gandotra Angle) and compared it to the navicular height method, which is considered as the standard. [Table 1] shows the descriptive statistics for the MLA estimation by two different methods in the right and left foot. The present study exhibits slight variations in footprint dimensions were the left footprint has slightly lesser values than the right footprint.
[Table 2] shows the higher level of Kappa agreement for the MLA estimation for both the feet considering navicular height method as standardized method, suggesting that gandotra angle of MLA estimation by the footprint angle can be used in place of the gold standard method. [Table 3] shows middle to high level of correlation for MLA measurement by the navicular height method or Gandotra Angle on footprint with statistical significance P < 0.0001 for each foot by any method. Shiang et al. in their study showed a better correlation between the footprint measured values and the normalized navicular height. Queen et al. study showed no correlation of footprint measurements with the navicular height. Vedi et al. showed the positive lower level of correlation (0.435 and 0.461) for right and left foot with statistical significance (P < 0.005) between the navicular height and mid-footprint angle with middle level negative correlation (−0.531 and − 0.500) between Gandotra angle and Clark's angle for the right and left foot with statistical significance (P < 0.001).
[Table 4] shows the MLA dimensions in males having slightly greater value than in females by either method of estimation. Although statistical significance was observed in the left foot by navicular height method of MLA estimation (P < 0.019), and the rest showed no significance difference as per gender. Rohatgi et al. concluded that the gender comparison did not reveal any significant difference (P > 0.05) for arch index in footprint as per BMI. Similar results were concluded by Ashok et al. and Erden et al. showed statistically significant differences between the sexes thus revealing anatomical differences in terms of ankle, hallux, and medial arch structures.
Researchers have identified sexual dimorphism occurring due to genetic and hormonal factors, socio-cultural factors such as gender role in society specifically varied workload manipulating the degree of sexual size dimorphism. Badiye et al. in their study concluded that the breadth dimensions of the foot prints can help in side (right/left) and sex determination. Kanchan et al. and Atamtur concluding from their study that sexual dimorphism in footprint dimensions does exist, although nothing was mentioned as per MLA value differences., Hazzaa et al. also have showed significant statistical correlation as per gender with the incidence of flat foot, with no correlation as per age of the participants using Foot Posture Index-6 score and arch index, rather than MLA values.
The Kruskal–Wallis test [Table 5] for measuring the significance of MLA estimation as per the BMI (Asian Pacific based) showed no statistical significance in the present study when estimated by navicular height or by Gandotra Angle by the footprint method. Similarly, the results were concluded by other researchers showing no clinical relevance or statistical significance comparing BMI with the hours of standing work before the measurement and with that of total years of performing standing work., Singh et al. reported that the BMI did not predict the change in arch height in half marathon runners. Yousefi Azarfam et al. showed weak correlation detected between all calculated indices and angles with BMI. Some researchers showed the positive correlation between excess body weight and level of arch drop in both lower extremities, irrespective of gender.,
Thus, variability has been identified by the researchers for MLA estimation in different settings and methods as per gender or BMI. More work needs to be done to come up to a rightful conclusion. However, the present study does agree for the introduction of new way of estimating MLA using footprint.
| Conclusion|| |
This study has highlighted the innovative, noninvasive, cost-effective, and accurate technique for estimating MLA by the Gandotra Angle using footprint. Its values are significantly correlated to the values estimated through navicular height method, which is considered to be efficient method of its estimation.
The present study shows no statistical correlation for calculating MLA by two different methods as per gender or, for varied BMI ranging from underweight to obese.
More extensive work is required before Gandotra Angle can be considered most authentic, and accurate for calculating MLA of an individual and can be used in outpatient department on day to day basis. Other than this, it can provide a basis for the surgical reconstruction of injured foot and help in designing better external devices for nonsurgical correction. Even, can be use by shoe industry to prepare a customized shoe for pain free, comfortable footwear.
More participants probably might affect the results of the study. Second, the usage of digitalized footprint estimation would have been better. Moreover, the radiological feature comparison with the Gandotra Angle would have added a better dimension to the study.
Special thanks to 1st year medical, dental, and physiotherapy students of batch 2015–2016 for providing their valuable time and support for estimating MLA by two different methods. Thanks to the faculty members of the department of anatomy to support for conducting the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]