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700 | october 2013 | volume 43 | number 10 | journal of orthopaedic & sports physical therapy
[ research report ]
The human foot is often classified into 3 structural categories: high, normal, and low arch, based on its anatomical alignment89 and the height of the medial longitudinal arch.27 Classification in these 3 categories is typically based on cutoff values determined
from the distribution of data (standard deviations65,93,102 or percentiles15,16) from measurements taken on a large popula-tion. The interest in such classification is the belief that nonneutral foot morphol-ogy, such as a high or low arch (flatfoot), may lead to less than optimal foot func-tion and be associated with the develop-ment of lower extremity and low back injuries.23,28,29,59
A review of the literature provides conflicting evidence on the potential re-lationship between foot type and lower extremity injuries. Although a number of published reports have found no rela-tionships between nonneutral foot types and lower extremity injuries,40,94,96,99 the authors of a recent systematic review concluded that both high- and low-arch foot types were associated with running-related injuries.14 The results of this sys-tematic review,14 which did not include a meta-analysis and effect-size estimates, contrast those of a few qualitative re-views that failed to demonstrate a rela-tionship between foot type and future lower extremity injuries.4,8,20,70 This lack of consensus in the literature could be at-tributed, in part, to the variation in the operational definition of foot type among investigators.4,70
A large variety of methods have been developed to classify the foot based on structure and alignment. These
TT STUDY DESIGN: Systematic literature review with meta-analysis.
TT OBJECTIVES: To investigate the association between nonneutral foot types (high arch and flatfoot) and lower extremity and low back injuries, and to identify the most appropriate methods to use for foot classification.
TT METHODS: A search of 5 electronic databases (PubMed, Embase, CINAHL, SPORTDiscus, and ProQuest Dissertations and Theses), Google Scholar, and the reference lists of included studies was conducted to identify relevant articles. The review included comparative cross-sectional, case-control, and prospective studies that reported qualitative/quantitative associations between foot types and lower extremity and back injuries. Quality of the selected studies was evaluated, and data synthesis for the level of association between foot types and injuries was conducted. A random-effects model was used to pool odds ratio (OR) and standardized mean difference (SMD) results for meta-analysis.
TT RESULTS: Twenty-nine studies were included for meta-analysis. A significant association between nonneutral foot types and lower extremity injuries was determined (OR = 1.23; 95% confidence interval [CI]: 1.11, 1.37; P<.001). Foot posture index (OR = 2.58; 95% CI: 1.33, 5.02; P<.01) and visual/physical examination (OR = 1.17; 95% CI: 1.06, 1.28; P<.01) were 2 assessment methods using distinct
foot-type categories that showed a significant association with lower extremity injuries. For foot-assessment methods using a continuous scale, measurements of lateral calcaneal pitch angle (SMD, 1.92; 95% CI: 1.44, 2.39; P<.00001), lateral talocalcaneal angle (SMD, 1.36; 95% CI: 0.93, 1.80; P<.00001), and navicular height (SMD, 0.34; 95% CI: 0.16, 0.52; P<.001) showed significant effect sizes in identifying high-arch foot, whereas the navicular drop test (SMD, 0.45; 95% CI: 0.03, 0.87; P<.05) and relaxed calcaneal stance position (SMD, 0.49; 95% CI: 0.01, 0.97; P<.05) displayed significant effect sizes in identifying flatfoot. Subgroup analyses revealed no significant associa-tions for children with flatfoot, cross-sectional studies, or prospective studies on high arch.
TT CONCLUSION: High-arch and flatfoot foot types are associated with lower extremity injuries, but the strength of this relationship is low. Although the foot posture index and visual/physical exami-nation showed significance, they are qualitative measures. Radiographic and navicular height mea-surements can delineate high-arch foot effectively, with only anthropometric measures accurately classifying flatfoot.
TT LEVEL OF EVIDENCE: Prognosis, level 2a. J Orthop Sports Phys Ther 2013;43(10):700-714. Epub 11 June 2013. doi:10.2519/jospt.2013.4225
TT KEY WORDS: flatfoot, high arch, injuries
1Physical Education and Sports Science Academic Group, National Institute of Education, Nanyang Technological University, Singapore. 2Allied Health Specialties, KK Women’s and Children’s Hospital, Singapore. This study was funded by the National Institute of Education Academic Research Fund. The authors certify that they have no affiliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed in the article. Address correspondence to Dr Pui W. Kong, Physical Education and Sports Science Academic Group, National Institute of Education, Nanyang Technological University, 1 Nanyang Walk 637616 Singapore. E-mail: [email protected] T Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy®
JASPER W.K. TONG, MSc1,2 • PUI W. KONG, PhD1
Association Between Foot Type and Lower Extremity Injuries: Systematic
Literature Review With Meta-analysis
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journal of orthopaedic & sports physical therapy | volume 43 | number 10 | october 2013 | 701
methods include radiographic mea-surements,31,36,83 qualitative and semi-quantitative visual appraisal,19,54,92 direct anthropometric measurements,7,60,74 foot-print analysis,1,9,15,17-19,30,42,43,55,57,64,69,71,103 and analysis of captured images.58,75,100 Although radiographic evaluation is the widely accepted gold standard for assess-ing foot and medial longitudinal arch alignment,58,60,62,74,76 exposure to ionizing radiation is neither practical nor war-ranted, considering its potential negative side effects.76,78,90
Based on the current literature, it remains unclear whether foot type is associated with the incidence of lower extremity injuries and what the most acceptable and accurate method of as-sessing foot type may be. Therefore, the primary purpose of this literature review was to provide an evidence-based sum-mary, via meta-analysis, on whether foot
type is associated with the incidence of lower extremity injuries. A secondary purpose was to identify the most appro-priate method of assessing foot type. The results of this literature review may help clinical practice by determining the value of assessing foot type and implementing preventive and/or corrective strategies based on such evaluation. Also, they may inform clinical practice and research ef-forts by potentially identifying the best methods to assess foot type.
METHODS
Data Sources and Search
A search for titles and abstracts in PubMed (1966-2011), Embase (1974-2011), CINAHL (1983-2011),
SPORTDiscus (1985-2011), and ProQuest Dissertations and Theses electronic data-bases was performed on April 11, 2012.
No search limits were used for the year, language of publication, and study design in an effort to include as many published articles as possible for initial screening. The first reviewer (J.W.K.T.) performed the search after agreement on the search terms (APPENDIX A, available at www.jospt.org) was reached with the second review-er (P.W.K.).
Study SelectionBased on the title and abstract, poten-tially relevant articles for inclusion in the review were selected if they met the following criteria: published in English; cross-sectional, case-control (retrospec-tive), or prospective cohort study design; subjects either screened or assessed in weight bearing or self-reported foot structure/type at the beginning of the study; comparative groups identified at the beginning of the study; injuries to the lower extremities or low back report-ed for the study period; and qualitative or quantitative analyses reporting on the association between foot structure/type and injuries to the lower extremities or low back.
The search process was conducted independently by 2 reviewers (J.W.K.T. and P.W.K.). Any disagreement over the selected abstracts for inclusion for full-text review was deliberated and resolved through mutual consent. Subsequently, full-text papers were retrieved for further review, and the reference lists of those articles were also searched by hand for relevant publications. The reviewers also performed searches in Google Scholar us-ing key words.
Methodological Quality Assessment and Data ExtractionThe methodological quality of each se-lected full-text article was assessed in-dependently by both reviewers (J.W.K.T. and P.W.K.), and scoring was based on 6 criteria modified from those proposed by Barnes et al4 (TABLE 1). Both reviewers initially agreed on the definition of the 6 methodological quality assessment ques-tions before undertaking scoring of the
TABLE 1
Criteria for Methodological Quality Assessment of the Studies and Interrater
Agreement for the Rating of Each Question (56 Studies Included for Full-Text Review)4
*Values are kappa (P<.001).
Questions Score 1 Score 0Interrater
Agreement*
1. Were the inclusion/exclusion criteria clearly defined?
Definition of recruited population and rationale for recruitment are clear and appropriate
Missing or unclear inclusion/exclusion criteria
0.75
2. Were there sufficient subject numbers included?
n100 n<100 0.92
3. Was the level of evidence high?
Well-conducted case-control (retrospective) or prospective cohort studies
Cross-sectional studies, case-control (retrospective) or prospective cohort studies with a high risk of confound-ing or bias
0.89
4. Were the injury and control groups comparable?
Comparable in at least 3 of the following attributes: age, sex, physical characteristics, activity type and level
Data were unavailable for comparison, or comparable in less than 3 of the attributes described
0.79
5. Were methods/measures used to classify foot type appropriate?
Quantitative or semi-quantitative measures (eg, joint angles, arch height, scoring of observ-able signs, and physical assessment)
Missing or unclear classifica-tion methods, or qualitative measure (eg, purely descrip-tive observation and physical assessment)
0.96
6. Were appropriate statistical methods used?
Confounding factors were adjusted either through matching or multivariate regression analysis
Confounding factors were not adjusted
0.73
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[ research report ]
selected studies. Any disagreement on scoring was resolved by discussion and consensus on a score for each question. The maximum possible score for meth-odological quality was 6, and only studies that scored 3 or greater were included in the literature review and meta-analysis. A standardized form was used for data extraction of selected studies, which in-cluded information on study design, par-ticipants, the country where the study was conducted, methods to establish foot classification, and lower extremity and low back injuries considered in the study. In addition, data extraction included re-porting the results of the study along with their related statistical significance. For studies that did not perform any statisti-cal analysis, the results were considered nonsignificant.
Data Synthesis and AnalysisInterrater agreement for each method-ological quality assessment question was assessed with kappa statistics (SPSS; SPSS Inc, Chicago, IL). Meta-analysis was performed with RevMan software (Nordic Cochrane Centre, Copenhagen, Denmark), instituted by the Cochrane Collaboration for systematic review and meta-analysis.32 Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were computed by entering raw dichotomous counts of lower extremity or low back injuries (outcome) for each categorical foot-type classification (ex-posure) into the software. Among the included studies, foot type was classified based on various descriptions; therefore, the reviewers adopted common foot-type definitions, with neutral foot (NF) as the
reference category, and high arch (HA) and flatfoot (FF) as the nonneutral foot-type categories (TABLE 2).
Pooled estimates of the ORs for the relevant studies were analyzed with Mantel-Haenszel test statistics, a meth-od of computing ORs when combining studies.67 For studies that reported the severity of lower extremity or low back injuries based on continuous measures (eg, visual analog pain scale) between the NF and HA or FF groups, results were pooled using standardized mean differ-ences (SMDs) and corresponding 95% CIs to account for the different outcome scales used among studies. Positive effect sizes indicated that the injuries were as-sociated with subjects in the HA or FF group, whereas negative effect sizes indi-cated that injuries were associated with subjects in the NF group.
Similarly, we used SMD to pool stud-ies that reported foot-type assessment as continuous measures when comparing the subjects who had lower extremity or low back injuries to those in the control group. In these cases, because foot assess-ment was an outcome on a continuous scale, we used positive effects to indicate a tendency toward nonneutral foot type for subjects in the injury group. Negative effects indicated a tendency toward an NF foot type for subjects in the control group. Whenever insufficient outcome data were encountered, we contacted the corresponding authors for further clarification.
Four subgroup analyses were con-ducted. First, pooled data were analyzed separately for HA and FF foot types, so that the association between each foot type and lower extremity or low back injuries could be ascertained. Second, as the intention of this study was also to determine the most appropriate method to classify or assess foot type, a subgroup analysis was conducted across different categorical and continuous measures utilized for foot-type classification or as-sessment. Third, the association between foot type and lower extremity injuries was analyzed for subjects younger than
TABLE 2Foot-Structure Categories With
Corresponding Terms and Definitions Used in the Included Studies
Foot-Structure Category Terms Definition Based on Weight-Bearing Assessment
High arch High arch, pes cavus, cavus feet, varus foot, supinated, underpronat-ing, nonpronating
• Quantitative measures of the medial longitudinal arch that are:- Less than or equal to or greater than or equal to (dependent on
direction of variable) 1, 1.5, or 2 standard deviations from the sample mean; or
- Less than or equal to the lowest or greater than or equal to the highest (dependent on direction of variable) 20th percentile or tertile of sample population; or
- Less than the 25th percentile of sample population; or- Cutoff as determined by Kolmogorov-Smirnov 2-sample test
• Midfoot width divided by heel width equals 0• Examiner is able to insert fingers fully under the arch
Neutral foot Neutral, normal, middle, average arch, rectus, normal foot
• Quantitative measures of the medial longitudinal arch that are:- Within 1, 1.5, or 2 standard deviations from the sample mean; or- Within the middle tertile; or- Within the 20th to 80th percentiles
• Midfoot width divided by heel width, less than or equal to middle tertile (except zero)
Flatfoot Flatfoot, pes planus, flat arch, planus feet, low arch, valgus foot
• Quantitative measures of the medial longitudinal arch that are:- Less than or equal to or greater than or equal to (dependent on
direction of variable) 1, 1.5, or 2 standard deviations from the sample mean; or
- Less than or equal to the lowest or greater than or equal to the highest (dependent on direction of variable) 20th percentile or tertile of sample population; or
- Greater than the 75th percentile; or- Cutoff as determined by Kolmogorov-Smirnov 2-sample test
• Midfoot width divided by heel width, highest tertile• Width of central zone of the foot is at least half the forefoot width
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journal of orthopaedic & sports physical therapy | volume 43 | number 10 | october 2013 | 703
18 years of age and those 18 years of age or older. This analysis was performed because the pediatric population may display different findings compared to adults, based on a still-developing and perhaps more adaptable foot. Finally, a subgroup analysis was also performed based on different study designs (pro-spective cohort, case-control [retrospec-tive], and cross-sectional).
A random-effects model (DerSimo-nian-Laird) was applied to account for the different groups of subjects recruited and the variety of reported lower extrem-ity and low back injuries. Random errors were added to the estimates, so that with-in- and between-study variances could be adjusted and weighted.6 Tests of het-erogeneity among studies were also per-formed with the chi-square test, and the extent of the heterogeneity was assessed with the I2 statistic39 at the outcome level. To assess for publication bias, a funnel plot was generated, in which asymmetry of the plot was interpreted to suggest that positive studies with larger samples tend to be published more readily than stud-ies with smaller samples and/or negative (lack of statistical significance) results.91 For all analyses, significance was set at P<.05.
RESULTS
Study Selection
FIGURE 1 displays the flow diagram of the search strategy and review process, consistent with the PRIS-
MA guidelines.66 The electronic search of the online databases identified 4525 potentially relevant manuscripts. Based on the review of the abstracts, 70 articles were retained for full-text retrieval and analysis. An additional 25 potentially relevant articles were identified after hand searching the reference lists of the 70 selected full-text articles and through Google Scholar. Of these 25 articles, fol-lowing examination of the abstracts, 14 were selected for full-text retrieval and review. After removing 28 dupli-cate articles, assessment and scoring of
methodological quality were performed on 56 full-text articles that met all in-clusion criteria for the review. Of these 56 articles, 34 met the criterion for a minimum methodological quality score of 3 or greater. A qualitative synthesis of these studies was performed, with infor-mation provided in APPENDIX B (available at www.jospt.org).
The level of agreement between the 2 reviewers for each question used to assess the methodological quality of the studies ranged from good to excellent (κ = 0.73-0.96, P<.001).51
Study PopulationsThe subject populations of the 34 studies that were qualitative-
Database search results, n = 4525• PubMed, n = 1561• Embase, n = 1292• CINAHL, n = 937• SPORTDiscus, n = 470• ProQuest, n = 265
Articles excluded after abstract review, n = 4466• PubMed, n = 1537• Embase, n = 1288• CINAHL, n = 915• SPORTDiscus, n = 454• ProQuest, n = 261• Hand searched and Google Scholar, n = 11
Full-text articles assessed for eligibility, n = 84• PubMed, n = 24• Embase, n = 4• CINAHL, n = 22• SPORTDiscus, n = 16• ProQuest, n = 4• Hand searched and Google Scholar, n = 14
Additional records identified through hand searching references and Google Scholar, n = 25
Total abstracts screened, n = 4550
Duplicates removed, n = 28Failed methodological quality review, n = 22
Studies included in qualitative synthesis, n = 34
No normal foot category, n = 2No response from authors, n = 3
Studies included in quantitative synthesis (meta-analysis), n = 29
FIGURE 1. Flow diagram of the search and selection process.
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ly synthesized included military/police trainees,1,22,24,46,47,49,50,88,97,104 ath-letes,7,12,13,38,48,52,53,56,65,80,81,101 adults,2,5,10,11,41 elderly persons,3,33,34,63,72,79 and preschool-ers.26 Eleven studies were conducted in the United States,2,3,5,7,22,33,46,47,65,80,101 8 in
Australia,11-13,24,26,56,63,104 4 in Israel,38,49,50,88 2 each in Finland48,53 and Brazil,72,81 and 1 each in Saudi Arabia,1 the UK,79 South Africa,10 Turkey,34 Taiwan,41 Korea,52 and China.97 There were 12 prospec-tive cohort studies,7,13,22,24,46,47,56,65,80,88,97,104
10 case-control (retrospective) stud-ies,1,11,26,38,48-50,52,79,81 11 cross-sectional studies,2,3,5,10,33,34,41,53,63,72,101 and 1 study that included both a prospective cohort and a case-control (retrospective) design.12 In 4 studies, the mean age of the par-
Study (Foot Type/Injury) Weight Odds Ratio (95% Confidence Interval)
Bartosik et al5 (FF) 0.5% 3.44 (0.79, 15.02)
2.0 5.00.50.2 1.0
Favors NF Favors HA or FF
Burns et al11 (HA) 0.9% 4.93 (1.71, 14.17)
Burns et al12 (FF-FPI-Pr) 0.2% 0.47 (0.05, 4.03)
Burns et al12 (FF-FPI-Re) 0.4% 0.67 (0.13, 3.47)
Burns et al12 (FF-VI-Pr) 0.2% 0.61 (0.07, 5.69)
Burns et al12 (FF-VI-Re) 0.2% 0.47 (0.05, 4.35)
Burns et al12 (HA-FPI-Pr) 0.6% 4.89 (1.33, 17.93)
Burns et al12 (HA-FPI-Re) 0.7% 2.00 (0.60, 6.63)
Burns et al12 (HA-VI-Pr) 0.1% 2.46 (0.15, 40.39)
Burns et al12 (HA-VI-Re) 0.1% 1.88 (0.11, 30.86)
Cowan et al22 (FF) 1.6% 0.45 (0.21, 0.95)
Cowan et al22 (HA) 2.0% 1.75 (0.91, 3.36)
Esterman and Pilotto24 (FF, foot pain) 0.4% 0.47 (0.10, 2.27)
Esterman and Pilotto24 (FF, injury) 0.3% 0.18 (0.02, 1.40)
Esterman and Pilotto24 (FF, LE pain) 0.6% 1.23 (0.34, 4.42)
Esterman and Pilotto24 (HA, foot pain) 0.9% 0.53 (0.18, 1.54)
Esterman and Pilotto24 (HA, injury) 1.4% 1.12 (0.49, 2.52)
Esterman and Pilotto24 (HA, LE pain) 1.1% 1.04 (0.41, 2.64)
Gross et al33 (FF-SI) 6.6% 1.58 (1.34, 1.88)
Gross et al33 (HA-SI) 6.0% 0.80 (0.64, 0.99)
Huang et al41 (FF) 0.4% 8.08 (1.52, 42.83)
Kaufman et al46 (FF-AI-BF, AT) 0.7% 2.00 (0.58, 6.85)
Kaufman et al46 (FF-AI-BF, ITS) 1.1% 1.32 (0.51, 3.42)
Kaufman et al46 (FF-AI-BF, PF) 0.8% 0.53 (0.17, 1.65)
Kaufman et al46 (FF-AI-BF, SF) 0.9% 2.33 (0.79, 6.86)
Kaufman et al46 (FF-AI-IS, AT) 0.7% 1.21 (0.36, 4.10)
Kaufman et al46 (FF-AI-IS, ITS) 1.0% 1.86 (0.70, 4.94)
Kaufman et al46 (FF-AI-IS, PF) 0.9% 1.42 (0.47, 4.24)
Kaufman et al46 (FF-AI-IS, SF) 0.9% 2.63 (0.89, 7.77)
Kaufman et al46 (FF-NHI, AT) 0.8% 1.66 (0.53, 5.21)
Kaufman et al46 (FF-NHI, ITS) 1.3% 1.17 (0.51, 2.72)
Kaufman et al46 (FF-NHI, PF) 1.1% 0.79 (0.30, 2.06)
Kaufman et al46 (FF-NHI, SF) 1.7% 0.81 (0.39, 1.67)
Kaufman et al46 (HA-AI-BF, AT) 0.6% 1.26 (0.33, 4.84)
Abbreviations: AI, arch index; AT, Achilles tendinitis; BF, barefoot; F, female; FF, flatfoot; FPI, foot posture index; HA, high arch; IS, inshoe; ITS, iliotibial band syndrome; KP, knee pain; LBP, low back pain; LE, lower extremity; M, male; NF, neutral foot; NHI, navicular height index; PF, plantar fasciitis; Pr, prospective; RCSP, relaxed calcaneal stance position; Re, case-control; SF, stress fracture; SI, Staheli index; VI, valgus index.Heterogeneity: χ2 = 134.01, df = 65, I2 = 51%. Test for overall estimate. P<.001.
FIGURE 2. Forest plot of odds ratio between nonneutral foot type and lower extremity injuries. Favors HA or FF refers to the specific studies that showed an association between injuries and nonneutral foot type. Favors NF refers to the specific studies that showed an association between injuries and NF type. Figure continues on page 705.
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journal of orthopaedic & sports physical therapy | volume 43 | number 10 | october 2013 | 705
ticipants was less than 18 years,7,13,26,50 in 24 studies the mean age was 18 or great-er,1-3,5,10-12,22,33,34,38,41,46,52,53,56,63,72,79-81,97,101,104 and in 6 studies the age of the participants was not specified.24,47-49,65,88 In addition to low back pain,10,49 the following lower ex-tremity clinical injuries were considered:
stress fracture,38,46,48,52,88 knee pain,33,49,50 anterior cruciate ligament injury,2 foot pain,3,11,63,72 heel pain,41 plantar fasciitis,81 ankle sprain,65 Achilles tendinitis46 or rupture,53 iliotibial band syndrome,46 patellofemoral syndrome,46 blisters,47 medial tibial stress syndrome,5,7,104 foot
accident or rheumatoid arthritis,1 hip or knee79 or general34 osteoarthritis, and general lower extremity injury or pain.12,
13,22,24,26,56,80,97,101
Foot-Classification MethodsMethods of foot-type classification or as-
Study (Foot Type/Injury) Weight Odds Ratio (95% Confidence Interval)
Kaufman et al46 (HA-AI-BF, ITS) 1.0% 1.24 (0.47, 3.27)
2.0 5.00.50.2 1.0
Favors NF Favors HA or FF
Kaufman et al46 (HA-AI-BF, PF) 1.0% 0.78 (0.28, 2.17)
Kaufman et al46 (HA-AI-BF, SF) 0.8% 1.76 (0.57, 5.45)
Kaufman et al46 (HA-AI-IS, AT) 0.7% 1.25 (0.37, 4.23)
Kaufman et al46 (HA-AI-IS, ITS) 1.0% 1.50 (0.55, 4.11)
Kaufman et al46 (HA-AI-IS, PF) 0.8% 1.02 (0.32, 3.27)
Kaufman et al46 (HA-AI-IS, SF) 0.8% 1.89 (0.61, 5.85)
Kaufman et al46 (HA-NHI, AT) 0.8% 1.64 (0.52, 5.13)
Kaufman et al46 (HA-NHI, ITS) 1.4% 1.26 (0.55, 2.89)
Kaufman et al46 (HA-NHI, PF) 1.3% 1.32 (0.56, 3.12)
Kaufman et al46 (HA-NHI, SF) 1.6% 0.73 (0.35, 1.54)
Knapik et al47 (FF) 2.3% 1.84 (1.01, 3.35)
Knapik et al47 (HA) 1.7% 1.46 (0.71, 2.98)
Korpelain et al48 (FF) 0.2% 3.43 (0.26, 45.03)
Korpelain et al48 (HA) 0.3% 5.14 (0.81, 32.77)
Kosashvili et al48 (FF-KP) 7.6% 1.15 (1.06, 1.24)
Kosashvili et al48 (FF-LBP) 7.6% 1.10 (1.02, 1.18)
Lakstein et al50 (FF-flexible) 7.5% 1.11 (1.02, 1.21)
Lakstein et al50 (FF-rigid) 5.2% 1.76 (1.34, 2.31)
Leppilahti et al53 (FF-RCSP) 2.2% 0.77 (0.42, 1.40)
Leppilahti et al53 (FF-SI) 0.2% 0.26 (0.03, 2.37)
Leppilahti et al53 (HA-RCSP) 0.9% 4.29 (1.49, 12.32)
Leppilahti et al53 (HA-SI) 2.3% 1.36 (0.75, 2.49)
McManus et al56 (FF-first year) 1.0% 0.64 (0.24, 1.72)
McManus et al56 (FF-second year) 1.0% 1.08 (0.39, 3.02)
Michelson et al65 (FF) 2.1% 0.76 (0.40, 1.44)
Paiva de Castro et al72 (FF-AI-F) 1.9% 0.77 (0.39, 1.51)
Paiva de Castro et al72 (FF-AI-M) 1.3% 1.10 (0.46, 2.62)
Paiva de Castro et al72 (HA-AI-F) 1.8% 0.61 (0.31, 1.23)
Paiva de Castro et al72 (HA-AI-M) 1.4% 1.17 (0.52, 2.62)
Wang et al97 (FF) 1.1% 8.05 (3.18, 20.42)
Yates and White104 (FF) 1.2% 3.86 (1.60, 9.29)
Total 100.0% 1.23 (1.11, 1.37)
Abbreviations: AI, arch index; AT, Achilles tendinitis; BF, barefoot; F, female; FF, flatfoot; FPI, foot posture index; HA, high arch; IS, inshoe; ITS, iliotibial band syndrome; KP, knee pain; LBP, low back pain; LE, lower extremity; M, male; NF, neutral foot; NHI, navicular height index; PF, plantar fasciitis; Pr, prospective; RCSP, relaxed calcaneal stance position; Re, case-control; SF, stress fracture; SI, Staheli index; VI, valgus index.Heterogeneity: χ2 = 134.01, df = 65, I2 = 51%. Test for overall estimate. P<.001.
FIGURE 2. (CONTINUED) Forest plot of odds ratio between nonneutral foot type and lower extremity injuries. Favors HA or FF refers to the specific studies that showed an association between injuries and nonneutral foot type. Favors NF refers to the specific studies that showed an association between injuries and NF type.
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sessment included visual observation,49,50 physical examination,3 Denis grade,1 arch index,24,46,63,65,72,81 arch height index,5,38,101 foot posture index,11-13,63,72,104 navicular height,26,79 navicular height index,22,46,63,88 Staheli index,33,41,48,53 center-of-pressure excursion index,5 valgus index,5,12 arch drop,38 navicular drop test,2,7,10,26,80 relaxed calcaneal stance position,7,26,38,53,79 rear-foot angle,7,81 longitudinal arch angle,38 lateral talar first metatarsal angle,34,52 lateral talocalcaneal angle,52 lateral cal-caneal pitch angle,52,88 and self-report.47,56
Foot-Type/Injury ClassificationOf the 34 studies, 17 used a foot-type classification approach based on distinct categories1,3,11,22,24,33,41,46-50,56,65,88,97,101 and 11
quantified foot type using measures based on a continuous scale2,7,10,13,26,38,52,63,79-81 when comparing the group of subjects who presented with low back or lower extremity injuries and the control group. Five studies used a combination of cate-gorical and continuous scales to describe foot type.5,12,53,72,104
One study quantified the severity of lower extremity injuries with the use of continuous scales (visual analog pain scale and Western Ontario and McMas-ter Universities Osteoarthritis Index) when comparing subjects with FF ver-sus NF foot types.34 Two studies did not have an NF comparative group and were therefore excluded from the meta-anal-ysis.88,101 The authors of 1 study did not
report standard deviations or standard errors,10 and the authors of 5 other stud-ies did not report data on the number of lower extremity injuries (outcome)1,12,56,72 or the number of participants (sample)3 with each foot type. Of the corresponding authors of these 6 studies with missing data, only 312,56,72 provided the required data when contacted; the remaining 3 studies1,3,10 were excluded from the meta-analysis.
Meta-analysisOf the initial 34 studies selected, 29 were included for meta-analysis. Of these studies, Paiva de Castro et al72 and Evans and Scutter26 reported results for male and female and left and right foot sepa-
Study (Measure) Weight Standardized Mean Difference (95% Confidence Interval)
Allen and Glasoe2 (NDT) 1.6% 0.67 (0.02, 1.37)
0.25 0.5–0.25–0.5 0.0
Favors Control
Favors Injury
Bartosik et al5 (AHI) 1.6% 0.49 (–0.21, 1.19)
Bartosik et al5 (CPEI) 1.6% 0.10 (–0.59, 0.79)
Bartosik et al5 (VI) 1.6% 0.36 (–0.34, 1.05)
Bennett et al7 (NDT) 1.9% 0.90 (0.31, 1.48)
Bennett et al7 (RCSP) 2.0% 0.14 (–0.42, 0.69)
Bennett et al7 (rearfoot angle) 2.0% 0.29 (–0.27, 0.85)
Burns et al12 (FPI-Pr) 2.6% 0.11 (–0.27, 0.49)
Burns et al12 (FPI-Re) 2.7% 0.04 (–0.32, 0.40)
Burns et al12 (VI-Pr) 2.6% 0.10 (–0.28, 0.48)
Burns et al12 (VI-Re) 2.7% 0.01 (–0.35, 0.37)
Cain et al13 (FPI) 2.2% 0.45 (–0.04, 0.94)
Evans et al26 (FPI-L) 3.0% 0.09 (–0.20, 0.39)
Evans et al26 (FPI-R) 3.0% 0.08 (–0.21, 0.38)
Evans et al26 (NDT-L) 3.0% 0.04 (–0.26, 0.33)
Evans et al26 (NDT-R) 3.0% 0.06 (–0.24, 0.35)
Evans et al26 (NH-L) 3.0% 0.32 (0.03, 0.62)
Evans et al26 (NH-R) 3.0% 0.25 (–0.05, 0.54)
Evans et al26 (RCSP-L) 3.0% 0.02 (–0.27, 0.32)
Evans et al26 (RCSP-R) 3.0% 0.05 (–0.25, 0.34)
Abbreviations: AD, arch drop; AHI, arch height index; AI, arch index; CPEI, center-of-pressure excursion index; F, female; FPI, foot posture index; L, left; LAA, longitudinal arch angle; LCPA, lateral calcaneal pitch angle; LTCA, lateral talocalcaneal angle; LTMA, lateral talar first metatarsal angle; M, male; NDT, navicular drop test; NF, neutral foot; NH, navicular height; NHI, navicular height index; OA, osteoarthritis; Pr, prospective; R, right; RCSP, relaxed calcaneal stance position; Re, case-control; VI, valgus index.Heterogeneity: χ2 = 148.31, df = 40, I2 = 73%. Test for overall effect: P<.00001.
FIGURE 3. Forest plot of standardized mean difference for foot-type assessment method reported as continuous measures between the group of subjects with lower extremity injuries and the control group. Favors injury refers to the specific studies that showed a tendency toward nonneutral foot type in the injury group. Favors control refers to the specific studies that showed a tendency toward neutral foot type in the control group. Figure continues on page 707.
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rately, Burns et al12 incorporated both case-control (retrospective) and prospec-tive study designs, and McManus et al56 reported the results of their 2-year pro-spective study separately for each year. Eleven studies either utilized more than 1 method to categorize foot type12,46,53 or assessed the foot using continuous scales,5,7,12,26,38,52,63,79,81 and 4 studies re-ported on more than 1 lower extremity injury using either a dichotomous out-come24,38,41 or a continuous scale.34
In the meta-analysis, to account for all genders, feet (right/left), study designs, low back and lower extremity injuries, and methods of foot-type classification/assessment reported in the included
studies, the outcome of each analysis was entered separately as a unique study. Accordingly, because Lakstein and col-leagues50 classified foot type as either FF flexible or FF rigid, the results of the anal-ysis for each foot-type classification were entered as a study of its own. In total, 66, 41, and 2 study entries were entered for the meta-analyses based on categorical foot-type classification, foot-type assess-ment using continuous measures, and lower extremity injuries reported as con-tinuous measures, respectively.
Main Analysis: Pooled Results From All StudiesThe weighted pooled estimates for the
results of studies that classified foot type based on distinct categories indi-cated a significant association (OR = 1.23; 95% CI: 1.11, 1.37; χ2 = 134.01; I2 = 51%; P<.001) between nonneutral foot type (HA and FF) and lower extremity injuries across all foot-type classifica-tion methods, with a medium level of heterogeneity39 (FIGURE 2). In studies that assessed foot type with continuous measures, the pooled SMD indicated the tendency of nonneutral foot types (SMD, 0.34; 95% CI: 0.22, 0.46; χ2 = 148.31; I2 = 73%; P<.00001) (FIGURE 3) to significantly favor the group of sub-jects presenting with lower extremity injuries. Pooled results of studies re-
Study (Measure) Weight Standardized Mean Difference (95% Confidence Interval)
Hetsroni et al38 (AD) 1.5% 0.35 (–0.42, 1.11)
0.25 0.5–0.25–0.5 0.0
Favors Control
Favors Injury
Hetsroni et al38 (AHI) 1.4% 0.49 (–0.28, 1.26)
Hetsroni et al38 (LAA) 1.4% 0.54 (–0.24, 1.31)
Hetsroni et al38 (RCSP) 1.5% 0.26 (–0.50, 1.02)
Lee et al52 (LCPA) 2.3% 1.92 (1.44, 2.39)
Lee et al52 (LTCA) 2.4% 1.36 (0.93, 1.80)
Lee et al52 (LTMA) 2.6% 0.10 (–0.29, 0.49)
Leppilahti et al53 (RCSP) 3.3% 0.67 (0.47, 0.86)
Menz and Morris63 (AI) 2.7% 0.00 (–0.36, 0.36)
Menz and Morris63 (FPI) 2.7% 0.01 (–0.35, 0.37)
Menz and Morris63 (NHI) 2.7% 0.33 (–0.03, 0.69)
Paiva de Castro et al72 (FPI-F) 3.1% 0.08 (–0.18, 0.34)
Paiva et al72 (FPI-M) 2.9% 0.13 (–0.20, 0.46)
Reilly et al79 (NH-hip OA) 2.7% 0.51 (0.15, 0.87)
Reilly et al79 (NH-knee OA) 2.7% 0.04 (–0.31, 0.40)
Reilly et al79 (RCSP-hip OA) 2.7% 0.87 (0.50, 1.25)
Reilly et al79 (RCSP-knee OA) 2.7% 0.89 (0.52, 1.27)
Reinking et al80 (NDT-R) 2.2% 0.44 (–0.07, 0.96)
Ribeiro et al81 (AI) 2.4% 0.69 (0.24, 1.14)
Ribeiro et al81 (rearfoot angle) 2.4% 0.07 (–0.37, 0.51)
Yates and White104 (FPI) 2.6% 0.62 (0.23, 1.02)
Total 100.0% 0.34 (0.22, 0.46)
Abbreviations: AD, arch drop; AHI, arch height index; AI, arch index; CPEI, center-of-pressure excursion index; F, female; FPI, foot posture index; L, left; LAA, longitudinal arch angle; LCPA, lateral calcaneal pitch angle; LTCA, lateral talocalcaneal angle; LTMA, lateral talar first metatarsal angle; M, male; NDT, navicular drop test; NF, neutral foot; NH, navicular height; NHI, navicular height index; OA, osteoarthritis; Pr, prospective; R, right; RCSP, relaxed calcaneal stance position; Re, case-control; VI, valgus index.Heterogeneity: χ2 = 148.31, df = 40, I2 = 73%. Test for overall effect: P<.00001.
FIGURE 3. (CONTINUED) Forest plot of standardized mean difference for foot-type assessment method reported as continuous measures between the group of subjects with lower extremity injuries and the control group. Favors injury refers to the specific studies that showed a tendency toward nonneutral foot type in the injury group. Favors control refers to the specific studies that showed a tendency toward neutral foot type in the control group.
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porting lower extremity injuries using continuous scales (visual analog pain scale and Western Ontario and McMas-ter Universities Osteoarthritis Index)
indicated a near-significant effect of foot type, with high heterogeneity that favored FF as being associated with a more severe injury (SMD, 0.56; 95% CI:
–0.01, 1.13; χ2 = 4.62; I2 = 78%; P = .05) (FIGURE 4).
Subgroup Analysis: HA and FFFor studies using a classification ap-proach to categorize foot type, the as-sociation between nonneutral foot type and injuries remained significant for both FF (OR = 1.23; 95% CI: 1.08, 1.40; χ2 = 89.36; I2 = 59%; P<.01) and HA (OR = 1.31; 95% CI: 1.05, 1.62; χ2 = 43.78; I2 = 38%; P<.05) foot types when the data were pooled separately, but the extent of heterogeneity between studies for HA was lower (TABLE 3). For the stud-ies assessing foot type using continuous scales, separate subgroup analyses for HA (SMD, 0.35; 95% CI: 0.17, 0.53; χ2 = 101.24; I2 = 81%; P<.001) and FF (SMD, 0.34; 95% CI: 0.19, 0.49; χ2 = 46.74; I2 = 57%; P<.0001) tendencies also indi-cated significant effects for the group of subjects presenting with lower extremity injuries, but the levels of heterogeneity among studies for HA and FF analyses were high and medium, respectively (TA-
BLE 4). Regardless of the method of foot assessment, the level of association (OR = 1.23) and effect size (SMD, 0.34) link-ing FF to a greater incidence of lower ex-tremity injuries were highly comparable to those in the primary analyses (OR = 1.23; SMD, 0.34) (TABLES 3 and 4).
Subgroup Analysis: Methods of Foot Classification/AssessmentAmong foot assessment methods us-ing categories for classification of foot
TABLE 3Pooled Odds Ratio for the
Association Between Foot Type and Lower Extremity Injuries
Abbreviation: NA, not applicable.*Values in parentheses are 95% confidence interval.†Foot-type classification methods.
Subgroup Analysis Studies, n
Pooled Odds Ratio for
Lower Extremity Injuries* I2 Statistic
P Value of Overall Estimate
Foot type category
All 66 1.23 (1.11, 1.37) 51% <.001
High arch 28 1.31 (1.05, 1.62) 38% <.05
Flatfoot 38 1.23 (1.08, 1.40) 59% <.01
Subgroup analysis†
Arch index 27 1.06 (0.88, 1.29) 0% .53
Navicular height index 10 1.03 (0.77, 1.37) 17% .85
Staheli index 7 1.44 (0.86, 2.40) 82% .16
Foot posture index 6 2.58 (1.33, 5.02) 39% <.01
Valgus index 4 0.92 (0.27, 3.15) 0% .89
Visual/physical examination 4 1.17 (1.06, 1.28) 73% <.01
Self-report 4 1.33 (0.87, 2.02) 12% .18
Relaxed calcaneal stance position 2 1.71 (0.32, 9.31) 87% .62
Center-of-pressure excursion index 1 3.44 (0.79, 15.02) NA .10
Insufficient details 1 8.05 (3.18, 20.42) NA <.0001
Subgroup analysis: age group of population sample
<18 y 2 1.37 (0.88, 2.15) 90% .16
18 y 51 1.32 (1.10, 1.57) 53% <.01
Subgroup analysis: study design
Prospective 43 1.26 (1.04, 1.52) 33% <.05
Case-control (retrospective) 11 1.21 (1.08, 1.36) 58% <.01
Cross-sectional 12 1.18 (0.84, 1.66) 76% .33
Study (Foot Type/Measure) Weight Standardized Mean Difference (95% Confidence Interval)
Guler et al34 (FF-LTMA-VAS) 50.4% 0.27 (–0.10, 0.64)
1 2–1–2 0
Favors NF Favors FF
Guler et al34 (FF-LTMA-WOMAC) 49.6% 0.85 (0.47, 1.24)
Total 100.0% 0.56 (–0.01, 1.13)
Abbreviations: FF, flatfoot; LTMA, lateral talar first metatarsal angle; NF, neutral foot; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.Heterogeneity: χ2 = 4.62, df = 1, I2 = 78%. Test for overall effect: P = .05.
FIGURE 4. Forest plot of standardized mean difference for outcome of lower extremity injuries reported as continuous measures between NF and FF groups. Favors FF refers to the specific studies that showed a more severe injury in the FF group. Favors NF refers to the specific studies that showed a less severe injury in the NF group.
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type, the foot posture index showed sig-nificant association between nonneutral foot type and injuries, with a low level of heterogeneity among studies (OR = 2.58; 95% CI: 1.33, 5.02; χ2 = 8.21; I2 = 39%; P<.01). Although the methods using vi-sual observation/physical examination also showed a significant association be-tween nonneutral foot type and injuries, the heterogeneity was high (OR = 1.17; 95% CI: 1.06, 1.28; χ2 = 10.94; I2 = 73%; P<.01). The method of foot classification used by Wang et al97 also displayed sig-nificant association between nonneutral foot type and injuries, but insufficient de-tails on this method were provided in the article (OR = 8.05; 95% CI: 3.18, 20.42; P<.0001), and its estimate was much greater in magnitude than that of the main analysis (OR = 8.05 versus 1.23). Studies using visual observation/physical examination had results closest to that of the main analysis (OR = 1.17 versus 1.23).
Among the methods that used a con-tinuous scale to assess HA tendency, only the measures of navicular height (SMD, 0.34; 95% CI: 0.16, 0.52; χ2 = 1.23; I2 = 0%; P<.001), lateral calcaneal pitch angle (SMD, 1.92; 95% CI: 1.44, 2.39; P<.00001), and lateral talocalcaneal angle (SMD, 1.36; 95% CI: 0.93, 1.80; P<.00001) displayed significant effects in the group of subjects who presented with lower extremity injuries. There was no heterogeneity between studies that measured navicular height. The effect size for studies using navicular height (SMD, 0.34) was highly comparable to that of the main analysis (SMD, 0.34). Among the methods that used a con-tinuous scale to measure FF tendency, significance only occurred for the mea-surement of the relaxed calcaneal stance position (SMD, 0.49; 95% CI: 0.01, 0.97; χ2 = 18.53; I2 = 84%; P<.05) and navicular drop test (SMD, 0.45; 95% CI: 0.03, 0.87; χ2 = 8.44; I2 = 64%; P<.05), with high and medium heterogeneity observed, respectively. The effect size for studies using the navicular drop test (SMD, 0.45) was closest to that of the main analysis (SMD, 0.34).
Subgroup Analysis: Age Group of SubjectsThe association between nonneutral foot type and lower extremity injuries
was significant, with a medium level of heterogeneity for subjects 18 years and older (OR = 1.32; 95% CI: 1.10, 1.57; χ2 = 105.89; I2 = 53%; P<.01), with the OR
TABLE 4
Pooled SMDs for Foot-Type Assessment Methods Using a Continuous Scale
Between Subjects Presenting With Lower Extremity Injuries and a Control Group
Abbreviations: NA, not applicable; SMD, standard mean difference.*Values in parentheses are 95% confidence interval.†Foot-type assessment methods using a continuous scale.
Subgroup Analysis Studies, n SMD* I2 StatisticP Value of
Overall Effect
Foot type category
All 41 0.34 (0.22, 0.46) 73% <.00001
High arch 20 0.35 (0.17, 0.53) 81% <.001
Flatfoot 21 0.34 (0.19, 0.49) 57% <.0001
Subgroup analysis†
Arch index: flatfoot 2 0.33 (–0.35, 1.01) 82% .34
Navicular height index: high arch 1 0.33 (–0.03, 0.69) NA .07
Navicular height: high arch 3 0.34 (0.16, 0.52) 0% <.001
Navicular height: flatfoot 1 0.04 (–0.31, 0.40) NA .81
Arch height index: flatfoot 2 0.49 (–0.03, 1.01) 0% .07
Arch drop: flatfoot 1 0.35 (–0.42, 1.11) NA .37
Foot posture index: high arch 6 0.12 (–0.02, 0.26) 0% .10
Foot posture index: flatfoot 3 0.23 (–0.11, 0.56) 66% .18
Relaxed calcaneal stance position: high arch 3 0.34 (–0.17, 0.84) 85% .19
Relaxed calcaneal stance position: flatfoot 4 0.49 (0.01, 0.97) 84% <.05
Navicular drop test: high arch 1 0.06 (–0.24, 0.35) NA .70
Navicular drop test: flatfoot 4 0.45 (0.03, 0.87) 64% <.05
Valgus index: high arch 2 0.05 (–0.21, 0.32) 0% .69
Valgus index: flatfoot 1 0.36 (–0.34, 1.05) NA .32
Rearfoot angle: flatfoot 2 0.16 (–0.19, 0.50) 0% .38
Center-of-pressure excursion index: flatfoot 1 0.10 (–0.59, 0.79) 0% .70
Longitudinal arch angle: high arch 1 0.54 (–0.24, 1.31) NA .17
Lateral calcaneal pitch angle: high arch 1 1.92 (1.44, 2.39) NA <.00001
Lateral talocalcaneal angle: high arch 1 1.36 (0.93, 1.80) NA <.00001
Lateral talar first metatarsal angle: high arch 1 0.10 (–0.29, 0.49) NA .62
Subgroup analysis: age group of population sample
<18 y: high arch 7 0.16 (0.04, 0.27) 0% <.01
<18 y: flatfoot 5 0.21 (–0.05, 0.47) 47% .11
18 y: high arch 13 0.46 (0.18, 0.73) 86% <.01
18 y: flatfoot 16 0.37 (0.19, 0.55) 58% <.0001
Subgroup analysis: study design
Prospective: high arch 3 0.19 (–0.05, 0.42) 0% .13
Prospective: flatfoot 5 0.49 (0.25, 0.73) 9% <.0001
Case-control (retrospective): high arch 13 0.40 (0.14, 0.67) 85% <.01
Case-control (retrospective): flatfoot 10 0.34 (0.09, 0.58) 72% <.01
Cross-sectional: high arch 4 0.30 (–0.03, 0.64) 79% .07
Cross-sectional: flatfoot 6 –0.02 (–0.28, 0.25) 0% .11
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being greater than that reported for the main analysis (1.32 versus 1.23).
Subgroup analysis of subjects young-er than 18 years of age in studies that used continuous measures for foot as-sessment exhibited significant effect only for HA tendency, with no heteroge-neity (SMD, 0.16; 95% CI: 0.04, 0.27; χ2 = 4.51; I2 = 0%; P<.01). The effect was smaller than that of the main analysis (SMD, 0.16 versus 0.34). Those aged 18 years and older showed significant ef-fects for both HA (SMD, 0.46; 95% CI: 0.18, 0.73; χ2 = 83.18; I2 = 86%; P<.01) and FF (SMD, 0.37; 95% CI: 0.19, 0.55; χ2 = 36.10; I2 = 58%; P<.0001) tenden-cies, with high and medium heterogene-ity, respectively. The effect was closest to that of the main analysis for FF tendency (SMD, 0.37 versus 0.34), in contrast to the effect for HA tendency (SMD, 0.46), which was larger.
Subgroup Analysis: Study DesignIn studies that classified foot type based on distinct categories, only prospective (OR = 1.26; 95% CI: 1.04, 1.52; χ2 = 62.56; I2 = 33%; P<.05) and case-control (OR = 1.21; 95% CI: 1.08, 1.36; χ2 = 23.63; I2 = 58%; P<.01) study designs displayed a significant association between nonneu-tral foot type and injuries, with low and medium heterogeneity, respectively. The association of case-control studies was closer to that of the main analysis but of a slightly lower magnitude (OR = 1.21 versus 1.23) when compared with pro-
spective studies (OR = 1.26 versus 1.23).The prospective study design using
continuous measures for foot assessment displayed a significant effect, with a low heterogeneity in the group of subjects pre-senting with lower extremity injuries for FF tendency only (SMD, 0.49; 95% CI: 0.25, 0.73; χ2 = 4.41; I2 = 9%; P<.0001). Significant effects were observed for both HA (SMD, 0.40; 95% CI: 0.14, 0.67; χ2 = 82.11; I2 = 85%; P<.01) and FF (SMD, 0.34; 95% CI: 0.09, 0.58; χ2 = 32.41; I2 = 72%; P<.01) tendencies, with high and near-high heterogeneity, respectively, in the group of subjects presenting with lower extremity injuries for case-control designs. No significant effects for either foot-type tendency were seen for cross-sectional studies. The effect of FF for prospective studies was much greater in magnitude than the main analysis (SMD, 0.49 versus 0.34), whereas that of case-control studies was highly comparable to the main analysis (SMD, 0.34). The effect of HA for case-control studies was great-er in magnitude than the main analysis (SMD, 0.40 versus 0.34).
Funnel PlotsThe funnel plot of foot-type assessment using categorical classification was “hol-low” at its lower center half (FIGURE 5A). This suggests that publication might be biased toward smaller studies that only showed significant associations between either HA and FF (OR>1) or NF (OR<1) with lower extremity injuries, and not
those reporting similar associations be-tween groups (OR = 1). Funnel plots of foot-type assessment and lower extrem-ity injuries reported as continuous mea-sures displayed symmetrical distribution graphically, which suggests that publica-tion bias is unlikely (FIGURES 5B and 5C).
DISCUSSION
To our knowledge, this is the first meta-analysis to report pooled data on the relationship between
foot type and lower extremity injuries. Our primary findings indicate that an HA or FF foot type, when compared to an NF foot type, is associated with lower extremity injuries (OR = 1.23). This sta-tistically significant but low OR estimate remained significant for both FF and HA foot types when data for each foot type were analyzed separately. Similarly, in studies that reported foot assessment as continuous measures, both HA and FF foot types exhibited significant effect siz-es in subjects who presented with lower extremity injuries.
The low but statistically significant level of association between foot type and lower extremity injuries found in our study is in contrast to the qualitative reviews of studies performed among the athletic population.8,20,70 These studies concluded that there is a lack of evidence to support the relationship between foot type and lower-limb injuries. Also in contrast to our review, Barnes and col-
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FIGURE 5. Funnel plot to assess publication bias for (A) all 66 study entries that reported categorical foot-type classification, (B) all 41 study entries that reported foot-type assessment as continuous measures between the group of subjects with lower extremity injuries and the control group, and (C) the 2 study entries that reported lower extremity injuries as continuous measures between nonneutral and flatfoot categories. Abbreviations: OR, odds ratio; SE, standard error; SMD, standardized mean difference.
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leagues4 concluded in their systematic review that foot type was not a definitive risk factor for tibial stress injuries. Carv-alho and colleagues,14 on the other hand, suggested that HA and FF foot types were associated with running-related injuries.
This review also attempted to pro-vide an evidence-based inquiry into the most acceptable and accurate method of assessing the foot type associated with lower extremity injuries. We believe that a foot-type assessment method that takes into account the associated presentation of lower extremity injuries is clinically meaningful. Barnes and colleagues4 sug-gested that quantitative measures of foot alignment were superior to a qualitative classification, based on better reliabil-ity. Our review seems to favor the use of the foot posture index and visual/physi-cal examination. However, it is possible that observer subjectivity and bias may undermine the accuracy of these quali-tative or, at most, semi-quantitative ap-praisal tools.23,92 The clinical method of choice for foot classification should be validated against the gold standard; how-ever, to our knowledge, there is currently no study that has validated a visual-as-sessment approach with radiographic measurements.
The foot posture index assessment tool aims to overcome the inconsisten-cies of qualitative visual methods. When using the foot posture index, investiga-tors visually assess the foot based on 6 or 8 criteria, each rated on a 5-point (–2 to +2) Likert scale. Although normative data sets have recently been collated for individuals aged 3 to 17 years, there is still no consensus on limits to define various foot types.77 Because the foot posture in-dex is based on visual observation, it has the same limitations as other qualitative methods. In addition, the elevated OR from the pooled estimates using the foot posture index must be interpreted with caution (foot posture index OR = 2.58 versus pooled OR = 1.23). Therefore, it may not be a suitable method for foot screening at this stage. Although the method suggested by Wang et al97 was
significant, its highly elevated estimate (OR = 8.05) compared to the main analy-sis (OR = 1.23) must also be interpreted with caution.
From our results, radiographic mea-surements appear best to detect whether HA foot type is associated with lower extremity injuries. Both the lateral calca-neal pitch angle and lateral talocalcaneal angle measurements provided the great-est effect sizes in the group of subjects presenting with lower extremity injuries when compared with the control group. Our findings support the common opin-ion of using radiographic measurements as the gold standard when assessing foot structure. However, as mentioned in the introduction, a method using ionizing ra-diation is not a viable routine clinical or screening option.
Our analysis showed that navicular height can be an alternative continuous measure of foot type when assessing HA tendency. Although navicular height can be measured with high intrarater (intra-class correlation coefficient [ICC] = 0.90) and interrater (ICC = 0.74) agreement,85 the technique has not been validated against radiographic measures.
When assessing FF tendency on a continuous scale, both the navicular drop test and relaxed calcaneal stance position showed significant effect sizes in the group presenting with lower ex-tremity injuries. The intrarater reliability of the navicular drop test was previously reported, with ICCs between 0.61 and 0.79,68,73,86 whereas interrater reliabil-ity ranged from 0.46 to 0.83.25,73,86,87 The validity agreement of the navicular drop test with values calculated from radio-graphs through radio-opaque markers affixed at the surface anatomical land-marks had good Pearson correlation coef-ficients (between 0.61 and 0.89).37 As for relaxed calcaneal stance position, an ear-lier critical review of the literature con-cluded that this method was inherently unreliable and invalid.61 The ICCs for intrarater and interrater agreement for this measurement varied between 0.39 and 0.98,21,35,44,45,82,95,98 but skin measure-
ment of this angle correlated well (left, r = 0.74; right, r = 0.82) with radiographic measurement when radio-opaque mark-ers were applied.82
These anthropometric measures (na-vicular height, navicular drop test, and relaxed calcaneal stance position) may be good alternatives to radiographic mea-surements but are often time consuming, involving skin markings and laborious manual measurements. As a result, they may not be applicable for large-scale population screening. Furthermore, they are static measurements, which may not reflect the dynamic loads on the foot dur-ing locomotion.
Nonneutral foot type in subjects aged 18 years and older consistently presented with an association with lower extremity injuries, regardless of whether categori-cal or continuous measures were used. On the other hand, only the HA foot tendency showed significant effect in the group with lower extremity injuries for subjects aged younger than 18 years. It may be that children’s feet are still de-veloping, appearing flat and more adapt-able to mitigate any impending external factors that might cause injury. Although the estimate provided by categorical foot-type classification in subjects aged young-er than 18 years was insignificant (OR = 1.37, P = .16), its proximity to that of sub-jects aged 18 years and older (OR = 1.32) is worth mentioning, especially because there were only 2 study entries from Lakstein et al.50 In that study, a cohort of 92 279 military recruits with a mean age of 17.2 years were assessed. Based on the large sample size (increasing the weight of the analysis) and the mean age of the sample being close to the 18-year mark, it could be argued that the estimate should be interpreted as consistent with those aged 18 years or younger.
Evidently, prospective cohort studies were deemed more powerful than case-control (retrospective) and cross-sec-tional analyses.4,84 Although prospective studies that utilized continuous measures for HA foot-type assessment were not predictive of lower extremity injuries, all
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[ research report ]other prospective and case-control stud-ies in this meta-analysis displayed an as-sociation with lower extremity injuries.
There are several limitations of the present study. First, the search process on the electronic databases was conducted by a single reviewer, which could have biased the results. Second, the demo-graphics of the subjects were such that almost two thirds of them placed extrane-ous demands of physical activity on their feet, being military personnel and com-petitive/amateur athletes. Therefore, the results may not be applicable to seden-tary populations. In addition, only a few studies included subjects younger than 18 years of age, hence the specific methods reviewed might not be completely ap-plicable to this age group. Furthermore, because the range of lower extremity in-juries recorded in our review was so di-verse, it is not possible to pinpoint with confidence the kind of injuries associated with either HA or FF. Finally, studies re-viewed displayed publication bias toward smaller studies that reported significant results. Nevertheless, our systematic re-view of pooled estimates and effect sizes provided an evidence-based account of the relationship between nonneutral foot type and lower extremity injuries.
CONCLUSION
Both HA and FF foot types are significantly associated with lower extremity injuries, although the
strength of this relationship is low. If foot type was classified categorically, both foot posture index and visual/physical ex-amination methods showed the strongest associations, but these methods are semi-quantitative and qualitative techniques. For foot assessment using a continuous scale, radiographic measurements of the lateral calcaneal pitch angle and lateral talocalcaneal angle, followed by navicular height measurements, were effective in identifying HA foot type, and the relaxed calcaneal stance position and navicular drop test were effective in identifying the FF type. t
KEY POINTSFINDINGS: There is a significant associa-tion of HA and FF foot types with lower extremity injuries, but the strength of this relationship is low. The foot posture index and visual/physical examination foot-classification methods showed sig-nificant associations. Lateral calcaneal pitch angle, lateral talocalcaneal angle, and navicular height measurements displayed significant effect sizes in iden-tifying the HA foot type. The navicular drop test and relaxed calcaneal stance position displayed significant effect sizes for the FF foot type.IMPLICATIONS: When classifying foot type using categorical methods, the foot posture index and visual/physical examination showed significant associa-tions with lower extremity conditions. For foot assessment using continuous measures, radiographic measurements of the lateral calcaneal pitch angle and lateral talocalcaneal angle, followed by navicular height measurements, are effective in identifying HA foot type, and the navicular drop test and relaxed calcaneal stance position are effective in identifying the FF foot type.CAUTION: The studies reviewed predomi-nantly recruited adults older than 18 years of age and individuals who placed increased activity on their feet, such as athletes and military personnel. There-fore, the results must be interpreted with caution when applied to children or sed-entary adult populations.
ACKNOWLEDGEMENTS: The authors would like to thank all corresponding investigators who replied to our requests and provided us with the required data.
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journal of orthopaedic & sports physical therapy | volume 43 | number 10 | october 2013 | A1
TERMS ENTERED INTO THE ELECTRONIC SEARCH PROCESS(a) Classification [MeSH Subject Heading] OR Diagnosis [MeSH Subject Heading] OR Methods [MeSH Subject Heading] OR Pathology [MeSH Subject
Heading] OR Epidemiology [MeSH Subject Heading] OR Prevalence [MeSH Subject Heading] OR Development and Growth [MeSH Subject Heading] OR Anthropometry [MeSH Subject Heading] OR Structure [Keyword] OR Type [Keyword] or Arch [Keyword]
(b) Flatfoot [MeSH Terms] OR Foot, Flat [MeSH Terms] OR Flat Feet [MeSH Terms] OR Feet, Flat [MeSH Terms] OR Flatfeet [MeSH Terms] OR Pes Planus [MeSH Terms] OR Pes Cavus [MeSH Terms] OR Cavus Deformity [MeSH Terms] OR Cavus Deformities [MeSH Terms] OR Feet [MeSH Terms]
(c) Foot Injuries [MeSH Subject Heading] OR Pain [MeSH Subject Heading] OR Athletic Injuries [MeSH Subject Heading] OR Leg Injuries [MeSH Subject Heading] OR Knee Injuries [MeSH Subject Heading] OR Ankle Injuries [MeSH Subject Heading] OR Soft Tissue Injuries [MeSH Subject Heading] OR Tendon Injuries [MeSH Subject Heading] OR Fractures, Stress [MeSH Subject Heading] OR Complications [MeSH Subheading]
(d) a AND b AND c
APPENDIX A
EXTRACTION OF LOWER EXTREMITY INJURY DATA REPORTED IN THE STUDIES THAT SCORED 3 OR MORE POINTS ON THE SCALE FOR METHODOLOGICAL QUALITY ASSESSMENT*
StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Abdel-Fattah et al1
6 Case-control (retrospective)
Army recruits: flatfoot, n = 104, 100% male, 19.1 0.4 y; control, n = 412, 100% male, 19.3 0.9 y
Saudi Arabia Denis grade Flatfoot nonsignificant association with: history of foot accident, OR = 0.79 (invalid CI); history of rheuma-toid arthritis, OR = 1.72 (0.35, 7.53)
Number of subjects with history of foot accident and rheuma-toid arthritis in each foot-type group was not reported
Allen and Glasoe2
3 Cross-sectional Adults (age matched): ACL injury, n = 18, 67% male, 29.9 9.5 y; control, n = 16, 29.9 8.6 y
United States Navicular drop test
Significant difference in navicular drop test between ACL injury and control group
Navicular drop test: ACL injury, 10.5 4.0 mm; control, 8.1 2.8 mm
Badlissi et al3
3 Cross-sectional Elderly adults: n = 784, 43% male, 74.5 y
United States Physical examination
High arch association with foot pain, adjusted OR = 4.0 (1.4, 11.3); flatfoot nonsignificant association with foot pain, adjusted OR = 1.6 (0.9, 2.9)
Total number of subjects in each foot-type group was not reported
Bartosik et al5
3 Cross-sectional Medial tibial stress syndrome, n = 14, 36% male, 22.7 3.8 y; control, n = 19, 53% male, 24.8 4.1 y
United States Valgus index, arch height index, center-of-pressure excursion index
Nonsignificant difference in valgus index, arch height index, and center-of-pressure excursion index between medial tibial stress syndrome and control group; flatfoot (center-of-pressure excursion index) nonsig-nificant association with medial tibial stress syndrome
Valgus index: medial tibial stress syndrome, 12.72 5.28†; control, 10.79 5.27†
Arch height index: medial tibial stress syndrome, 0.31 0.04†; control, 0.33 0.04†
Center-of-pressure excursion index: medial tibial stress syndrome, 18.17 6.17†; con-trol, 18.82 6.15†
Neutral foot, 4/15Flatfoot (center-of-pressure
excursion index), 10/18
APPENDIX B
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A2 | october 2013 | volume 43 | number 10 | journal of orthopaedic & sports physical therapy
[ research report ]
StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Bennett et al7
6 Prospective High school runners, n = 125 (250 limbs): medial tibial stress syn-drome, n = 15 (25 limbs), 13% male, 15.3 1.0 y; control, n = 21 (25 limbs) randomly selected from original cohort, 62% male, 15.7 1.5 y
United States Navicular drop test, relaxed calcaneal stance posi-tion, rearfoot angle
Flatfoot (navicular drop test) logisti-cally regressed with sex to predict medial tibial stress syndrome; risk prediction equation, –3.351 + 2.484 (men/women) + 0.328 (navicular drop test); relaxed calcaneal stance position and rearfoot angle, non-significant association with medial tibial stress syndrome
Navicular drop test: medial tibial stress syndrome, 6.8 3.7 mm; control, 3.6 3.3 mm
Relaxed calcaneal stance posi-tion: medial tibial stress syn-drome, 2.8° 3.3°; control, 2.2° 5.2°
Rearfoot angle: medial tibial stress syndrome, 17.2° 5.5°; control, 15.4° 6.7°
Brantingham et al10
3 Cross-sectional Chronic or recurrent low back pain, n = 100, 32% male, 31.2 y (range, 18-45 y); control, n = 104, 61% male, 28.8 y (range, 18-44 y)
South Africa Navicular drop test
Significant difference in navicular drop test between low back pain and control group
Navicular drop test (left): low back pain, 4.1 mm; control, 5.7 mm
Navicular drop test (right): low back pain, 3.9 mm; control, 5.6 mm
SD, SE, and CI not reported
Burns et al11 4 Case-control (retrospective)
Idiopathic high arch, n = 30, 30.6 13.5 y; neurogenic high arch, n = 10, 56.5 18.6 y; neutral foot, n = 30, 31.7 11.1 y
Australia Foot posture index
Significant difference in number of sub-jects with foot pain between high arch (60%) and neutral foot (23%)
Foot pain: high arch, 24/40; neu-tral foot, 7/30
Burns et al12 4 Case-control (ret-rospective) and prospective
Triathletes: n = 134, 69% male, 33.7 10.3 y
Australia Foot posture index, valgus index
Retrospective (preseason): high arch (foot posture index) nonsignificant association with injury, OR = 1.91 (0.65, 5.59); flatfoot (foot posture index) nonsignificant association with injury, OR = 0.64 (0.13, 3.01); high arch (valgus index) nonsignifi-cant association with injury, OR = 1.91 (0.12, 29.84); flatfoot (valgus index) nonsignificant association with injury, OR = 0.48 (0.06, 4.15); nonsignificant difference in foot posture index and valgus index be-tween injured and control group
Prospective (competition season): high arch (foot posture index) associ-ated with injury, OR = 4.30 (1.34, 13.83); flatfoot (foot posture index) nonsignificant association with injury, OR = 0.41 (0.05, 3.29); high arch (valgus index) nonsignificant association with injury, OR = 2.46 (0.16, 38.29); flatfoot (valgus index) nonsignificant association with injury, OR = 0.62 (0.07, 5.32); non-significant difference in foot posture index and valgus index between injured and control group
Retrospective injuryFoot posture index: high arch,
6/12; neutral foot, 37/111; flatfoot, 2/8
Valgus index: high arch, 1/2; neu-tral foot, 43/124; flatfoot, 1/5
Foot posture index: injured, 5.2 4.9; control, 5.0 4.3
Valgus index: injured, 10.1 7.2; control, 11.0 8.3
Prospective injuryFoot posture index: high arch,
7/11; neutral foot, 29/110; flatfoot, 1/7
Valgus index: high arch, 1/2; neu-tral foot, 35/121; flatfoot, 1/5
Foot posture index: injured, 4.7 4.8; control, 5.2 4.3
Valgus index: injured, 10.2 7.5; control, 11.0 8.2
APPENDIX B
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journal of orthopaedic & sports physical therapy | volume 43 | number 10 | october 2013 | A3
StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Cain et al13 4 Prospective Competitive futsal players: n = 76, 100% male, 14.5 1.7 y
Australia Foot posture index
High arch was linearly regressed with foot posture index scores to predict foot/ankle injury; risk prediction equation, –0.5 – 0.313 (foot posture index score)
Foot posture index: injured (n = 24), 2.8 11.3†; control (n = 52), 5.8 2.6†
Cowan et al22 5 Prospective Infantry trainees: n = 246, 20.3 y
United States Navicular height index
High arch associated with lower ex-tremity injury when compared with flatfoot, adjusted OR = 6.12 (2.17, 17.30); neutral foot associated with lower extremity injury when com-pared with flatfoot, adjusted OR = 2.96 (1.25, 7.04)
Lower extremity injury: high arch, 26/49; neutral foot, 58/148; flatfoot, 11/49
Esterman and Pilotto24
5 Prospective Air Force recruits: n = 205
Australia Arch index‡ Lower extremity pain: high arch non-significant association, RR = 1.03 (0.53, 1.99); flatfoot nonsignificant association, RR = 1.05 (0.49, 2.73)
Foot pain: high arch nonsignificant association, RR = 0.62 (0.27, 1.45); flatfoot nonsignificant association, RR = 0.56 (0.15, 2.05)
Injury: high arch nonsignificant as-sociation, RR = 1.09 (0.58, 2.05); flatfoot nonsignificant association, RR = 0.22 (0.03, 1.52)
Lower extremity pain: high arch, 8/27; neutral foot, 28/97; flatfoot, 4/12
Foot pain: high arch, 5/27; neu-tral foot, 29/97; flatfoot, 2/12
Injury: high arch, 10/44; neutral foot, 29/139; flatfoot, 1/22
Evans and Scutter26
6 Case-control (retrospective)
Preschoolers: growing pains, n = 76, 53% male, 5.3 1.0 y; control, n = 104, 52% male, 5.3 0.8 y
Australia Navicular height, navicular drop test, relaxed cal-caneal stance position
Navicular height (left) positively asso-ciated with growing pains, adjusted OR = 1.09 (0.95, 1.25); nonsignifi-cant difference in navicular height (right), navicular drop test (left and right), relaxed calcaneal stance po-sition (left and right), and foot pos-ture index (left and right) between growing pains and control group
Navicular height (left): pain, 33.93 3.23 mm; control, 32.60 4.63 mm
Navicular height (right): pain, 34.25 3.74 mm; control, 33.19 4.63 mm
Navicular drop test (left): pain, 6.65 2.78 mm; control, 6.53 3.36 mm
Navicular drop test (right): pain, 7.19 2.97 mm; control, 7.38 3.52 mm
Relaxed calcaneal stance posi-tion (left): pain, 4.21° 2.58°; control, 4.28° 3.11°
Relaxed calcaneal stance posi-tion (right): pain, 4.00° 2.72°; control, 3.87° 2.82°
Foot posture index (left): pain, 0.65 0.60; control, 0.71 0.66
Foot posture index (right): pain, 0.63 0.56; control, 0.68 0.62
Gross et al33 4 Cross-sectional Elderly adults: n = 1903, 44% male, 65.0 9.0 y
United States Staheli index Flatfoot associated with knee pain when compared with high arch, ad-justed OR = 1.39 (1.05, 1.84)
Neutral foot category undefined in study; total feet, 3746
Knee pain: high arch, 134/745; neutral foot, 422/1954; flat-foot, 318/1047
APPENDIX B
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A4 | october 2013 | volume 43 | number 10 | journal of orthopaedic & sports physical therapy
[ research report ]
StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Guler et al34 4 Cross-sectional Women with osteoar-thritis: flatfoot, n = 59, 61.3 9.0 y; neutral foot, n = 56, 62.9 8.4 y
Turkey Lateral talar first metatarsal angle
Significant difference in WOMAC score but nonsignificant difference in VAS pain score between flatfoot and control group
VAS pain: flatfoot, 82.0 11.3; control, 78.8 12.1
WOMAC: flatfoot, 54.6 7.3; control, 48.2 7.6
Hetsroni et al38
3 Case-control (retrospective)
Professional soccer players: proximal fifth metatarsal stress fracture, n = 10 (10 feet), 21.0 3.0 y; control, n = 10 (20 feet), 24.0 2.6 y
Israel Arch drop, arch height index, longitudinal arch angle, relaxed cal-caneal stance position
Nonsignificant difference in arch height index and longitudinal arch angle between proximal fifth metatarsal stress fracture and control group
Arch drop: stress fracture, 7 4 mm; control, 6 2 mm
Arch height index: stress frac-ture, 0.35 0.02; control, 0.36 0.02
Longitudinal arch angle: stress fracture, 151° 4°; control, 148° 6°
Relaxed calcaneal stance posi-tion: stress fracture, 4° 3°; control, 5° 4°
Huang et al41 3 Cross-sectional Flatfoot (outpatients): n = 23, 61% male, 30.3 15.1 y; neutral foot (hos-pital staff): n = 23, 65% male, 31.0 12.3 y
Taiwan Staheli index Significant difference in number of subjects with plantar fascia thicken-ing and heel pain between flatfoot (10/23, 43.4%) and neutral foot (2/23, 8.7%)
…
APPENDIX B
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journal of orthopaedic & sports physical therapy | volume 43 | number 10 | october 2013 | A5
StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Kaufman et al46
4 Prospective Naval special warfare trainees, n = 449, 100% male, 22.5 2.5 y; assessed for arch index§-barefoot, n = 316; assessed for arch index§-inshoe, n = 315; assessed for navicular height index, n = 418
United States Arch index,§ na-vicular height index
Stress fracture: high arch (arch index§-barefoot) nonsignificant associa-tion, RR = 1.70 (0.59, 4.89); flatfoot (arch index§-barefoot) nonsignificant association, RR = 2.18 (0.80, 5.98); high arch (arch index§-inshoe) non-significant association, RR = 1.82 (0.63, 5.24); flatfoot (arch index§-inshoe) nonsignificant association, RR = 2.45 (0.89, 6.70); high arch (navicular height index) nonsignifi-cant association, RR = 1.71 (0.74, 3.95); flatfoot (navicular height index) nonsignificant association, RR = 1.86 (0.82, 4.25)
Achilles tendinitis: high arch (arch index§-barefoot) nonsignificant as-sociation, RR = 1.25 (0.35, 4.52); flatfoot (arch index§-barefoot) non-significant association, RR = 1.93 (0.60, 6.20); high arch (arch index§-inshoe) nonsignificant association, RR = 1.23 (0.39, 3.92); flatfoot (arch index§-inshoe) nonsignificant as-sociation, RR = 1.20 (0.38, 3.81); high arch (navicular height index) nonsignificant association, RR = 1.60 (0.54, 4.77); flatfoot (navicular height index) nonsignificant asso-ciation, RR = 1.62 (0.54, 4.84)
Iliotibial band syndrome: high arch (arch index§-barefoot) nonsignificant association, RR = 1.21 (0.50, 2.95); flatfoot (arch index§-barefoot) non-significant association, RR = 1.29 (0.54, 3.07); high arch (arch index§-inshoe) nonsignificant association, RR = 1.46 (0.58, 3.68); flatfoot (arch index§-inshoe) nonsignificant association, RR = 1.76 (0.72, 4.30); high arch (navicular height index) nonsignificant association, RR = 1.24 (0.58, 2.63); flatfoot (navicular height index) nonsignificant asso-ciation, RR = 1.16 (0.54, 2.49)
Patellofemoral syndrome: high arch (arch index§-barefoot) nonsignificant association, RR = 0.79 (0.31, 2.05); flatfoot (arch index§-barefoot) non-significant association, RR = 0.56 (0.19, 1.60); high arch (arch index§-inshoe) nonsignificant association, RR = 1.02 (0.34, 3.06); flatfoot (arch index§-inshoe) nonsignificant association, RR = 1.39 (0.50, 3.85); high arch (navicular height index) nonsignificant association, RR = 1.29 (0.59, 2.84); flatfoot (navicular height index) nonsignificant asso-ciation, RR = 0.80 (0.33, 1.97)
Stress fracture: high arch (arch index§-barefoot), 9/106; neutral foot (arch index§-barefoot), 5/100; flatfoot (arch index§-barefoot), 12/110; high arch (arch index§-inshoe), 9/105; neutral foot (arch index§-inshoe), 5/106; flatfoot (arch index§-inshoe), 12/104; high arch (navicular height index), 14/141; neutral foot (navicular height index), 8/138; flatfoot (navicular height index), 15/139
Achilles tendinitis: high arch (arch index§-barefoot), 5/104; neutral foot (arch index§-barefoot), 4/104; flatfoot (arch index§-barefoot), 8/108; high arch (arch index§-inshoe), 6/103; neutral foot (arch index§-inshoe), 5/106; flatfoot (arch index§-inshoe), 6/106; high arch (navicular height index), 8/140; neutral foot (navicular height index), 5/140; flatfoot (navicular height index), 8/138
Iliotibial band syndrome: high arch (arch index§-barefoot), 10/105; neutral foot (arch index§-barefoot), 8/102; flatfoot (arch index§-barefoot), 11/109; high arch (arch index§-inshoe), 10/105; neutral foot (arch index§-inshoe), 7/107; flatfoot (arch index§-inshoe), 12/104; high arch (navicular height index), 14/141; neutral foot (navicular height index), 11/137; flatfoot (navicular height index), 13/140
Patellofemoral syndrome: high arch (arch index§-barefoot), 7/104; neutral foot (arch index§-barefoot), 9/106; flatfoot (arch index§-barefoot), 5/106; high arch (arch index§-inshoe), 6/105; neutral foot (arch index§-inshoe), 6/107; flatfoot (arch index§-inshoe), 8/103; high arch (navicular height index), 13/140; neutral foot (navicular height index), 10/139; flatfoot (navicular height index), 8/139
APPENDIX B
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A6 | october 2013 | volume 43 | number 10 | journal of orthopaedic & sports physical therapy
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StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Knapik et al47
3 Prospective Cadets: n = 339 United States Self-report High arch nonsignificant association with blisters, adjusted OR = 1.3 (0.5, 3.4); flatfoot associated with blis-ters, adjusted OR = 2.0 (1.1, 3.7)
Blisters: high arch, 17/34; neutral foot, 103/253; flatfoot, 29/52
Korpelainen et al48
3 Case-control (retrospective)
Athletes (age and gender matched): LE stress fracture, n = 15; control (other injury), n = 15
Finland Staheli index Nonsignificant difference in number of subjects with high arch (right) between stress fracture (40%) and control (13%) group
Stress fracture: high arch, 6/8; neutral foot, 7/19; flatfoot, 2/3
Kosashvili et al49
3 Case-control (retrospective)
Military recruits: n = 97 279, 81% male
Israel Visual Significant difference in number of sub-jects with knee pain between neutral foot/flatfoot mild (4%) and flatfoot moderate/severe (7%); significant difference in number of subjects with low back pain between neutral foot/flatfoot mild (5%) and flatfoot moderate/severe (10%)
Knee pain: neutral foot, 3315/81 581; flatfoot (mild), 425/11 549; flatfoot (moderate), 246/3341; flatfoot (severe), 56/808
Low back pain: neutral foot, 4410/81 581; flatfoot (mild), 524/11 549; flatfoot (moder-ate), 325/3341; flatfoot (se-vere), 77/808
Lakstein et al50
3 Case-control (retrospective)
Military recruits: n = 97 279, 81% male, 17.2 y
Israel Visual Significant difference in prevalence of knee pain between flatfoot flexible (4.50%) and neutral foot (4.06%); flatfoot rigid (6.93%) and neutral foot (4.06%); flatfoot rigid (6.93%) and flatfoot flexible (4.50%)
Knee pain: neutral foot, 3312/81 582; flatfoot (flexible), 670/14 890; flatfoot (rigid), 56/808
Lee et al52 4 Case-control (retrospective)
Soccer players: fifth metatarsal stress fracture, n = 50, 100% male, 19.5 2.4 y; control, n = 50, 100% male, 25.3 3.7 y
Korea Lateral talar first metatarsal angle, lateral talocalcaneal angle, lat-eral calcaneal pitch angle
Significant difference in lateral talocal-caneal angle and lateral calcaneal pitch angle but nonsignificant differ-ence in lateral talar first metatarsal angle between fifth metatarsal stress fracture and control group
Lateral talar first metatarsal angle: stress fracture, –5.2° 3.2°; control, –4.9° 2.8°
Lateral talocalcaneal angle: stress fracture, 44.5° 8.4°; control, 35.1° 4.8°
Lateral calcaneal pitch angle: stress fracture, 27.4° 5.6°; control, 18.3° 3.6°
Leppilahti et al53
3 Cross-sectional Achilles tendon rup-ture (81% related to sport), n = 101, 85% male, 40 y (range, 19-71 y); control, n = 87, 20.0 0.8 y
Finland Relaxed calca-neal stance position, Sta-heli index
Significant difference in number of sub-jects with high arch (Staheli index) between Achilles tendon rupture (37%) and control group (29%); significant difference in number of subjects with flatfoot (relaxed calcaneal stance position) between Achilles tendon rupture (21%) and control group (5%); no statistical test performed on difference in relaxed calcaneal stance position between Achilles tendon rupture and control group
Achilles tendon rupture: high arch (relaxed calcaneal stance position), 21/26; neu-tral foot (relaxed calcaneal stance position), 47/95; flat-foot (relaxed calcaneal stance position), 33/77
Achilles tendon rupture: high arch (Staheli index), 37/65; neutral foot (Staheli index), 63/128; flatfoot (Staheli index), 1/5
Relaxed calcaneal stance posi-tion: Achilles tendon rupture, 7.0 3.0; control, 9.0 3.0
McManus et al56
3 Prospective Nonelite Australian footballers: n = 535, 100% male, 23 y (range, 16-50 y)
Australia Self-report Flatfoot associated with injury, IRR = 1.29 (1.07, 1.56)
Injury (first year): neutral foot, 317/519; flatfoot, 8/16
Injury (second year): neutral foot, 315/519; flatfoot, 10/16
APPENDIX B
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journal of orthopaedic & sports physical therapy | volume 43 | number 10 | october 2013 | A7
StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Menz and Morris63
3 Cross-sectional Disabling foot pain: n = 38, 16% male, 80.2 6.2 y; control: n = 134, 37% male, 80.0 6.5 y
Australia Arch index,‡ foot posture index, navicular height index
Nonsignificant difference in arch index,‡ foot posture index, and navicular height index between disabling foot pain and control group
Arch index‡: pain, 0.24 0.05; control, 0.24 0.06
Foot posture index: pain, 5.00 5.23; control, 5.04 4.59
Navicular height index: pain, 0.11 0.03; control, 0.10 0.03
Michelson et al65
4 Prospective Collegiate athletes: n = 196, 73% male
United States Arch index,‡ (me-dial midfoot ratio)
Nonsignificant difference between flatfoot subjects with incidence of ankle sprain (14.1%) and those without (17.9%)
Total ankles, 390Ankle sprain: neutral foot,
85/324; flatfoot, 14/66
Paiva de Castro et al72
3 Cross-sectional Elderly adults: n = 399, 172 male (69.4 6.7 y), 227 female (69.6 6.8 y)
Brazil Arch index‡, foot posture index
High arch (arch index‡) and flatfoot (arch index‡) nonsignificant associa-tion with foot pain; nonsignificant difference in foot posture index scores between subjects with foot pain (left) and those without
Foot pain (male): high arch (arch index‡), 23/73; neutral foot (arch index‡), 13/46; flatfoot (arch index‡), 16/53
Foot pain (female): high arch (arch index‡), 33/81; neutral foot (arch index‡), 28/53; flat-foot (arch index‡), 43/93
Foot posture index (male): pain (n = 52), 0.70 2.00; control (n = 120), 1.00 2.40
Foot posture index (female): pain (n = 115), 1.34 2.24; control (n = 112), 1.16 2.32
Reilly et al79 4 Case-control (retrospective)
Hip osteoarthritis: n = 60, 52% male, 66.6 9.1 y; knee osteoarthritis: n = 60, 42% male, 67.8 8.1 y; control: n = 60, 47% male, 64.9 12.2 y
UK Relaxed calcane-al stance posi-tion, navicular height
Significant difference in relaxed calca-neal stance position and navicular height between hip osteoarthritis, knee osteoarthritis, and control group (ANOVA with no post hoc test reported)
Relaxed calcaneal stance posi-tion: hip osteoarthritis, –2.67° 2.58°; knee osteoarthritis, –2.02° 2.04°; control, –0.25° 2.93°
Navicular height: hip osteoar-thritis, 5.18° 0.76°; knee osteoarthritis, 4.69° 0.83°; control, 4.73° 0.98°
Reinking80 3 Prospective Female collegiate athletes: n = 76, 19.3 1.0 y
United States Navicular drop test
Significant difference in navicular drop test (right) between athletes with exercise-related leg pain and those without, but nonsignificant associa-tion with exercise-related leg pain after logistic regression
Navicular drop test (right): exercise-related leg pain (n = 20), 7.9 3.5 mm; con-trol (n = 56), 6.4 3.3 mm
Ribeiro et al81
5 Case-control (retrospective)
Runners with plantar fasciitis: n = 30, 63% male, 46.0 7.0 y (male), 44.0 9.1 y (female); control runners: n = 60, 67% male, 36.0 5.0 y (male), 38.0 8.0 y (female)
Brazil Arch index,‡ rear-foot angle
Significant difference in arch index‡ but nonsignificant difference in rearfoot angle between runners with plantar fasciitis and those without
Arch index‡: plantar fasciitis, 0.22 0.05; control, 0.17 0.08
Rearfoot angle: plantar fasciitis, 7.2° 5.5°; control, 6.9° 3.2°
APPENDIX B
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A8 | october 2013 | volume 43 | number 10 | journal of orthopaedic & sports physical therapy
[ research report ]
StudyQuality Score Study Design Population
Country of Study
Method of Foot Assessment Results Remarks
Simkin et al88
3 Prospective Military recruits: n = 145 (290 feet), 100% male
Israel Lateral calcaneal pitch angle, navicular height index
Significant difference in number of feet with femoral stress fracture between high arch (lateral calca-neal pitch angle, 16%) and flatfoot (lateral calcaneal pitch angle, 3%); nonsignificant difference in number of feet with tibial stress fracture between high arch (lateral calca-neal pitch angle, 17%) and flatfoot (lateral calcaneal pitch angle, 10%); nonsignificant difference in number of feet with metatarsal stress frac-ture between high arch (lateral cal-caneal pitch angle, 2%) and flatfoot (lateral calcaneal pitch angle, 6%); significant difference in number of feet with metatarsal stress fracture between high arch (navicular height index, 16%) and flatfoot (navicular height index, 3%)
No neutral foot categoryFemoral stress fracture (5 feet
excluded due to unclear diag-nosis): high arch (lateral cal-caneal pitch angle), 32/207; flatfoot (lateral calcaneal pitch angle), 2/78
Tibial stress fracture (4 feet excluded due to unclear diag-nosis): high arch (lateral cal-caneal pitch angle), 39/225; flatfoot (lateral calcaneal pitch angle), 6/61
Metatarsal stress fracture (4 feet excluded due to unclear diagnosis): high arch (lateral calcaneal pitch angle), 4/207; flatfoot (lateral calcaneal pitch angle), 5/79; high arch (navicular height index), 2/169; flatfoot (navicular height index), 7/117
Wang et al97 4 Prospective Police recruits: n = 805, 100% male, 18.3 1.0 y
China Insufficient details
Flatfoot associated with overuse injuries, adjusted OR = 7.68 (2.67, 22.08)
Overuse injuries: neutral foot, 79/786; flatfoot, 9/19
Williams et al101
3 Cross-sectional Runners: high arch, n = 20, 50% male, 28.0 8.1 y; flat-foot, n = 20, 40% male, 27.7 7.5 y
United States Arch height index High arch showed more ankle, bony, and lateral injuries; flatfoot showed knee, soft tissue, and medial injuries
No neutral foot category
Yates and White104
5 Prospective Naval recruits: n = 112, 70% male, 21.1 4.3 y
Australia Foot posture index
Flatfoot (pronated) associated with medial tibial stress syndrome when compared with neutral foot or high arch, RR = 1.7
Significant difference in foot posture index between medial tibial stress syndrome recruits and those without
Medial tibial stress syndrome: high arch, 0/2; neutral foot, 9/46; flatfoot (pronated), 29/61; flatfoot (highly pro-nated), 2/3
Foot posture index: medial tibial stress syndrome, 7.45 3.17; control, 5.47 3.15
Abbreviations: ACL, anterior cruciate ligament; ANOVA, analysis of variance; CI, confidence interval; IRR, incidence rate ratio; LE, lower extremity; OR, odds ratio; RR, relative risk; SE, standard error; VAS, visual analog scale; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.*Continuous data are mean SD.†Computed SD from reported SE.‡Midfoot area defined as middle third of foot, excluding toes.§Midfoot area defined from point between calcaneus and cuboid to point between cuboid and base of metatarsals.
APPENDIX B
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