MORPHOMETRIC ANALYSIS OF FOOT IN YOUNG ADULT INDIVIDUALS

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1 WORLD JOURNAL OF PHARMACY AND PHARMACEUTICAL SCIENCES Ganapathy et al. SJIF Impact Factor Volume 4, Issue 08, Research Article ISSN MORPHOMETRIC ANALYSIS OF FOOT IN YOUNG ADULT INDIVIDUALS Arthi Ganapathy 1*, Dr. Sadeesh T 2 and Dr. Sudha Rao 3 1,2 Assistant Professor, Department of Anatomy, Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Pondicherry Professor, Department of Anatomy, Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Pondicherry Article Received on 24 May 2015, Revised on 15 June 2015, Accepted on 06 July 2015 *Correspondence for Author Dr. Arthi Ganapathy Assistant Professor, Department of Anatomy, Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Pondicherry ABSTRACT Background: The foot is provided with three bony arches: the medial longitudinal arch, the lateral longitudinal arch and the transverse arch to bear the body weight and propel it during locomotion. Abnormalities in the arches of foot lead to different foot deformities. When diagnosed early in their onset can be corrected by non operative methods and their progression delayed. The present study therefore aims in finding the prevalence of different types of foot in young individuals. Prevalence of different types of foot shapes (Egyptian, Grecian and square type) was also determined. Methods: Two hundred and fifty medical students of Mahatma Gandhi Medical College and Research Institute, Pondicherry, India within the age group of 18-24yrs were included in this study. The foot impression of both right and left feet was taken on white sheets in standing position. The foot prints were visually assessed for different foot types. Plantar arch index and normalized navicular height were calculated for all foot types. Results: The prevalence of flat and high arch feet in the present study was 5.2% and 2% respectively. The range of arch index for normal, flat and high arch feet type were and , and and and for right and left feet respectively. Correlation between arch index and different types of foot was statistically significant (p value = 0.00). Normalized navicular height range observed for normal, flat and high arch feet group were and , and and and for right and left feet respectively. These values significantly correlated with different types of foot (p value <0.05). Conclusion: The range Vol 4, Issue 08,

2 of arch index and normalized navicular height varies significantly for different types of foot hence can be used to accurately delineate the normal, low and high arch foot. INTRODUCTION The foot is constructed of a series of arches formed by the tarsal and metatarsal bones and strengthened by the muscles, ligaments and tendons of the foot. [1, 2] These are medial, lateral longitudinal arches and the transverse arch. These arches are present since birth but in infants, feet appear to be flat because of the presence of fat. The arch becomes prominent when the child starts walking and the foot starts bearing the weight of the body. [3] Pes planus (flat foot) occurs when apex of arch collapses and medial border of foot comes in contact with ground. An excessively high arch foot is called as pes cavus. A variation in the foot posture plays an important role in predisposition to injury [4] which depends on the type of foot and also on the age of the person. Hence there is a need to accurately classify the foot posture and define the normal and potentially abnormal foot types in different age groups. The medial longitudinal arch is very important in maintaining the foot posture and is the most important reference in determining the degree of pes planus and pes cavus. [5, 6] Calculation of medial longitudinal arch height can be used to categorize the foot into high arch, normal or a low arch foot. [7] One of the easy and cost effective means of assessing the Medial Longitudinal Arch is analysis of foot prints. [5] Visual categorization of type of foot posture can be easily done by assessing various parameters on foot prints. Calculating Arch index using foot prints and height of navicular tuberosity from the ground are methods used to delineate the different [8, 6, 7] types of foot. Calculation of the age specific arch index and normalized navicular height and their correlation with the type of foot can give an accurate classification of the foot types. In the present study arch index and navicular height were the parameters used to determine the type of foot posture. They are non invasive and objective measures of medial longitudinal arch. There is also a broad spectrum of classification of foot based on the fore foot shape: Egyptian type, Square type and Grecian type. In Egyptian foot, the first toe is longer than the second. The Greek foot has a longer second toe. In squared foot, toes are of relatively equal length. Vol 4, Issue 08,

3 With the following study the prevalence of these types of foot shapes in young individuals [9, 10] was determined. METHODOLOGY Two hundred and fifty medical students of Mahatma Gandhi Medical College and Research Institute, Pondicherry, India within the age group of 18-24yrs [11] were included in this study. The volunteers were made to sit on a chair and the foot brought in contact with the foot impression ink pad. Each individual foot impression of both right and left feet was taken on white sheets in standing position. Footprints of the 250 volunteers were analyzed for plantar arch index and normalized navicular height by the following methods. CALCULATION OF PLANTAR ARCH INDEX The plantar arch index was calculated using Staheli s method in this study. First a line was drawn from the medial forefoot edge to the mid heel region. The midpoint of this line was calculated. From this midpoint, a perpendicular line was drawn, crossing the foot print. This was taken as the mid foot width [A]. From the mid heel point another perpendicular line was drawn crossing the foot print. This was the measurement of the mid heel width [B]. AI= A/B. Figure 1: Calculation of plantar arch index CALCULATION OF NORMALIZED NAVICULAR HEIGHT Navicular height is the distance between the navicular tuberosity and the supporting surface.the most prominent point of the navicular tubercle was marked with a fine line on the skin. Navicular height [H] was then obtained by measuring, to the nearest millimeter, the distance between the supporting surface at a 90 angle to the line drawn on the navicular tubercle. Vol 4, Issue 08,

4 Figure 2: Calculation of normalized navicular height Normalized navicular height The distance between the supporting surface and the navicular tuberosity was measured [H]. Foot length was then truncated by measuring the perpendicular distance from the 1st metatarsophalangeal joint to the most posterior aspect of the heel [L]. Normalised navicular height truncated was calculated by dividing the height of the navicular tuberosity from the ground (H) by the truncated foot length (L) i.e. Normalised navicular height truncated = H/L 6 (Fig 2). Figure 3 shows footprints of different types of foot. The data collected was analyzed using SPSS software version Correlation of the study group with various parameters was done using Chi square test and ANOVA for calculating the statistical significance. Vol 4, Issue 08,

5 RESULTS The age and sex distribution of all the subjects is represented in table 1 and figure 4 respectively. Table 1: Age wise distribution of subjects AGE NO. OF SUBJECTS (n=250) (%) (43.6%) 141(56.4%) Figure 4: Showing sex distribution of participants Figure 5: Showing distribution of different types of foot in the participants The distribution of different types of foot along with sex distribution is depicted in Figure 5 In the present study different types of foot was correlated with arch index of right and left footprints. Vol 4, Issue 08,

6 Correlation of arch index with different types of foot (Right and Left) Analysis of the right foot prints of the study group (n=250, M=109,F=141) showed the mean AI of 0.55± 0.28 with the maximum and minimum of 1.87 and 0 respectively and that of left foot prints showed a mean arch index of 0.54 ± 0.26 with the maximum and minimum of 1.51 and 0 respectively. The mean AI of the right foot of participants who had normal foot (n=232, M=99, F=133) was 0.51± 0.18 with the maximum and minimum of 0.98and 0.15 respectively, and left foot it was 0.51± 0.19 with the maximum and minimum of 0.96 and 0.11 respectively. For those who had flat foot (n=13, M=8, F=5) it was 1.38 ± 0.24 with the maximum and minimum of 1.87 and 0.96 respectively for right and 1.29 ± 0.12 with the maximum and minimum of 1.51 and 1.11 respectively for left foot. In high arch foot group (n=5, M=2, F=3) it was 0.09 ± 0.12 with the maximum and minimum of 0.28 and 0 respectively for right and 0.14 ± 0.11 with the maximum and minimum of 0.26 and 0 respectively for left foot. This difference in AI for different types of foot was statistically significant (p value = 0.00) (Table 2). Table 2: AI of different types of foot on standing DIFFERENT AI OF DIFFERENT TYPES OF FOOT ON STANDING TYPES OF RIGHT LEFT FOOT MEAN SD MIN MAX P-VALUE MEAN SD MIN MAX P-VALUE NORMAL (232) FLAT (13) HIGH ARCH (5) Normalized navicular height (NNHt) of the 250 volunteers was calculated by measuring the navicular height and truncated foot length from their footprints In standing position. Further the values were correlated with the different foot types. Correlation of NNHt with different types of foot (Right and Left) Analysis of the foot prints of the study group (n=250, M=109,F=141) showed the mean NNHt of 0.29± 0.04 with the maximum and minimum of 0.41 and 0.15 respectively for right and 0.28 ± 0.04 with the maximum and minimum of 0.43 and 0.16 respectively for left foot. Vol 4, Issue 08,

7 The mean NNHt of the right foot of participants in normal foot group (n=232, M=99, F=133) was 0.28 ±0.04 with the maximum and minimum of 0.41 and 0.15 respectively, and for left foot it was 0.28 ± 0.04, with the maximum and minimum of 0.43 and 0.15 respectively. For those who had flat foot (n=13, M=8,F=5) it was 0.24± 0.04 with the maximum and minimum of 0.31 and 0.16 respectively for right and 0.25± 0.04 with the maximum and minimum of 0.32 and 0.16 respectively for left foot. High arch foot group (n=5,m=2,f=3) showed a mean of 0.29 ± 0.02 with the maximum and minimum of 0.32 and 0.26 respectively for right foot and 0.29 ± 0.03 with the maximum and minimum of 0.31 and 0.25 respectively for left foot. This difference in NNHt for different types of foot was statistically significant both on right (p value = 0.005) and left side (p value = 0.014) (Table 3). Table 3: NNHt of different types of foot on standing DIFFERENT NNHt OF DIFFERENT TYPES OF FOOT ON STANDING TYPES OF RIGHT LEFT FOOT MEAN SD MIN MAX P-VALUE MEAN SD MIN MAX P-VALUE NORMAL (232) FLAT (13) HIGH ARCH (5) There is also a broad spectrum of classification of foot based on the fore foot shape: Egyptian type, Square type and Grecian type [9, 10].With the present study the prevalence of these types of foot in young individuals was determined. Analysis of the 250 participants foot prints revealed that 134(53.6%) had Egyptian foot, 115(46%) had Grecian foot and 1 (0.4%) had Square foot (Fig 6). 1 (0.4%) 115 (46%) 134 (53.6%) Figure 6: showing percentage distribution of different shapes of foot Vol 4, Issue 08,

8 Figure 7: showing different types of foot shapes DISCUSSION The AI and NNHt are parameters frequently used to quantify the medial longitudinal arch and to delineate different types of foot. Literature review showed lack of studies regarding the age specific reference values for these parameters. The range of AI and NNHt was determined in the study group for use in research and to assist in screening of foot types during clinical practice. Prevalence of various types of foot shows difference based on the population studied and their geographic location. Chou et al(2009). [12] in their study in school children within the age group of 6-12 yrs belonging to Taichung county of China showed the prevalence of flat foot 13.88% and that of high arch foot 1.32%. Vergara E et al. [13] (2011) showed an overall prevalence of flat foot to be 15.74% in their study on 940 children in the age group of 3-10yrs in two districts Bogota and Barnequilla. The above mentioned studies show minor variations in the prevalence of flat foot but the prevalence is definitely much higher than what was seen in the present study. Prevalence of flat foot noted in the present study was 5.2% and high arch foot was 2%. This difference in the prevalence noted can be attributed to age of the study group. The above studies were done in children between the age group of 3-12yrs while the age group in the present study ranged from 18-24yrs. Literature review clearly suggests age as an important determinant of prevalence of different types of foot. T.Abolarian et al (2011). [14] in their study on 560 Nigerian children in the age group of 6 to 12 yrs showed age as a significant predictor of flat foot (p <0.05). The Vol 4, Issue 08,

9 prevalence of flat foot decreases as the age advances. Vergara E et al. [13] in their study have shown a higher prevalence of flat foot in the age group of 3-6yrs (38.3%) which reduced to 27.5% in children above the age of 6yrs. higher rates of prevalence of flat foot occur in children because the longitudinal arch of the sole of the foot usually develops during childhood. With walking there is loss of subcutaneous fat and reduction of laxity of the joints and the arch becomes prominent. [19] Previous studies carried out on adults show a lesser prevalence of different types of foot compared to that done on children. Ukoha u et al (2012). [15] studied 649 adults of Nigeria in the age group of 18-27yrs and reported the prevalence of pes planus to be 13.9% with a prevalence of 6.8% among males and 7.1% among females. Dreya Atamturk [16] (2009) have studied 516 Turkish adults in the age group of 18-83yrs and found the prevalence of flat foot and high arch foot to be 4.1% and 1.2% respectively. The findings were in accordance to the prevalence noted in the present study. Calculating the AI using Staheli s method in the foot prints is one of the methods used by many researchers to delineate the different types of foot. Huang et al. [17] compared the AI of 23 subjects having flat foot with an equal number of subjects having normal arch. The age of the participants ranged from 13-61yrs. The mean AI of the right foot of the normal arch group observed by them was 0.66 ± 0.11 and that of flat foot group was and 1.29 ± The mean AI of the left foot of the normal arch group and flat foot group were 0.65 ± 0.12 and 1.36 ± 0.17 respectively. Gross et al. [18] have used Staheli s AI to quantify the type of foot and assessed the association of flat foot with ipsilateral knee pain in case of 1903 older patients with a mean age group of 65 ± 9 yrs. They reported the AI of all the patients ranged from AI of 0.00 was categorized as pes cavus foot and that which ranged from as pes planus foot. In their study Staheli et al. [19] (1987) gave a normal range of AI. The age of the study subjects ranged from 1yr to 80 yrs. According to their study the normal value of AI ranged from 0.70 to 1.35 during infancy and 0.3 to 1.0 from middle of childhood to adulthood. The AI values were not specified for high arch and flat foot types. Vol 4, Issue 08,

10 As prevalence of different types of foot changes with the age, the referral values of AI should also be age specific. Previous studies have been done on subjects over a wide age range which varied from children to older group. In addition not many studies have given the AI range for high arch foot. Hence in the present study the age of the study population was restricted to young adult age group that is 18-24yrs. AI was calculated for different foot types in standing position so as to give wider reference values and it was found to be statistically significant(p <0.05). The AI for normal arch foot type (n= 232) were as follows. For right foot it ranged from 0.15 to For the left foot values were 0.11 to In flat foot type group (n= 13) the AI for right foot ranged from 0.96 to For left foot it was 1.11 to For the high arch foot type (n= 5) the AI for the right foot ranged from 0.00 to For the left foot the values were 0.00 to The next parameter calculated was NNHt which is the ratio of vertical height of navicular tuberosity from the ground and truncated foot length. NNHt also gives a good estimate of medial longitudinal arch and hence used in many studies to assess the different types of foot. Bhatia et al. [20] (2010) studied the right feet of 60 children of in the age group of 10-12yrs and reported a mean value of NNHt to be 0.256± In their study they have not classified the foot types as normal, low arch and high arch. Murley et al. [21] (2009) studied 91 asymptomatic adults of Australia. The age of the participants ranged from 18 to 47 years. Among them 32 participants were classified as having normal arch and 31 as flat foot. Mean values of NNHt reported by them were 0.18 ± 0.04 for flat foot group and 0.27 ± 0.03 for normal foot group. Xiong et al. [6] (2010) studied the medial longitudinal arch of the right feet of 48 adults with a mean age of 23yrs. The participants belonged to Hongkong Chinese community. The value of NNHt observed by them for the different types of feet were 0.165± 0.02 for high arch, ± 0.02 for normal arch and ± 0.02 for low arch.verma et al. [22] (2011) studied 100 healthy subjects with a mean age of 24.28± 2.08 yrs. According to them the mean values Vol 4, Issue 08,

11 NNHt for different foot types were 0.21 for low arch, 0.26 for normal arch and 0.32 for high arch foot. In present study, the mean values of NNHt for normal foot group for right and left feet in standing were 0.28 ±0.04. The present study showed decreased value of mean NNHt for flat foot group (mean NNHt = 0.24 ± 0.04 and 0.25 ± 0.04 right and left respectively) compared to normal foot group as was observed in the previous studies. The mean NNHt for high arch group observed in the present study was 0.29 (± 0.02), (higher than flat foot group and marginally higher than normal foot group), similar to study done by Verma et al. [22] The mean NNHt for high arch foot reported by them was 0.32 (higher when compared to flat and normal foot group). Hence the mean NNHt value is higher for high arch foot groups, followed by normal foot groups and lower for flat foot groups and in the present study it was observed to be statistically significant (p <0.05). This pattern of difference correlated well with the above mentioned studies. However there was difference in actual values of mean NNHt for flat, high, normal group in the studies mentioned above probably due to age factor and different geographical locations of the population studied. Prevalence of different foot types based on fore foot shape i.e. Egyptian, Grecian and Square type was also determined in the present study. In Egyptian foot, the first toe is longer than the second. The Greek foot has a longer second toe. In squared foot, toes are of relatively equal length. [9,10] Riegerova et al. [10] in their study on 268 students of Sternberk, Ostrava, found commonest foot shape was Egyptian type (70.99%) followed by Ancient or Grecian type (26.18%) and least common variety found was square or quadratic variety (2.83%). Most common type of foot shape found in the present study was Egyptian type (53.6%) followed by Grecian foot (46%) and the least common type found was Square foot (0.4%). Findings were similar to that reported by Riegerova et al. The variations observed in the actual prevalence could be attributed to the different ethnic groups studied. CONCLUSION Based on the results and the methodology employed, we have concluded that 1) In the present study on 250 medical students between the ages of 18 to 24 yrs the prevalence of flat and high arch foot observed bilaterally is 5.2% and 2% respectively. Vol 4, Issue 08,

12 The male: female ratio of Flat foot is 1.6: 1 and High arch foot is 0.6:1 (statistically not significant p value = 0.4). 2) A strong correlation is observed between arch index and different types of foot which is statistically significant (p value = 0.00). 3) The range of arch index for different types of foot Different foot types Right Left Normal Flat High arch ) Normalized navicular height of subjects also correlates significantly with different types of foot (p value <0.05). 5) The range of normalized navicular height for different types of foot: Different foot types Right Left Normal Flat High arch The prevalence of different foot types in the young individuals is lower compared to the prevalence in children. Arch index and normalized navicular height are significant parameters to accurately delineate the normal, low and high arch foot. REFERENCES 1. Basmajian JV, Stecko G: The role of muscles in arch support of foot- an electromyographic study. The Journal of Bone and Joint Surgery, 1963; 45- A (6): Faher M: Finger, toes palmar and plantar arches. Aust. J.Physiother, 1974; XX (4): Gore AJ, Spencer JP: The newborn foot. American Family Physician, 2004; 69(4): Williams DS, Mc Clay IS: Measurements used to characterize the foot and the medial longitudinal arch: reliability and validity. Physical therapy, 2009; 80(9): Yalcin N, Esen E, Kanatali V, Yetkin H: Evaluation of medial longitudinal arch: a comparison between the dynamic plantar pressure measurement system and radiographic analysis. Acta Orthop Traumatol Turc, 2010; 44(3): Xiong S, Goonetilleke RS, Witana CP, Weera Singhe TW, Au EYL: Foot arch characterization- a review, a new metric and a comparison. J Am Podiatr Med Assoc, 2010; 100(1): Vol 4, Issue 08,

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