Eur J Pediatr (2011) 170:611–617

DOI 10.1007/s00431-010-1330-4

ORIGINAL PAPER

Footprint analysis of flatfoot in preschool-aged children

Kun-Chung Chen & Chih-Jung Yeh & Jing-Fu Kuo &
Ching-Lin Hsieh & Shun-Fa Yang & Chun-Hou Wang

Received: 29 June 2010 / Accepted: 5 October 2010 / Published online: 23 October 2010
# Springer-Verlag 2010

Abstract Our aim in this study was to analyze the footprint
measurements of flatfoot in a population of preschool-aged
children. Three footprint measurements, the Clarke's angle
(CA), Chippaux-Smirak index (CSI), and Staheli arch index
(AI), were used for comparison with clinical diagnosis. A
total of 2,638 static footprints of children aged from 3 to
6 years were recorded. The clinical diagnosis as a gold
Ethical Board Review statement Each author certifies that his
institution approved the human protocol for this investigation that all
investigations were conducted in conformity with ethical principles of
research, and that informed consent for participation in the study was
obtained. (CSMUH No: CS09114).
K.-C. Chen : S.-F. Yang
Institute of Medicine, Chung Shan Medical University,
No.110, Sec. 1, Jianguo N. Rd.,
Taichung City 402, Taiwan
K.-C. Chen : J.-F. Kuo : C.-H. Wang
Physical Therapy Room,
Chung Shan Medical University Hospital,
No.110, Sec. 1, Jianguo N. Rd.,
Taichung City 402, Taiwan
C.-J. Yeh
School of Public Health, Chung Shan Medical University,
No.110, Sec. 1, Jianguo N. Rd.,
Taichung City 402, Taiwan
standard compared with the results of the CA, CSI, and AI
and displayed in a receiver operating characteristic (ROC)
curve. In order to illustrate the diagnostic accuracy in
clinical settings, their likelihood ratios were calculated
given their cutoff points, and their pretest/posttest proba-
bilities were plotted as the Fagan nomogram. The optimal
cutoff points for CA, CSI, and AI were 14.04°, 62.70%,
and 107.42%, respectively, and all of them showed high
sensitivity. The areas under curves were 0.91, 0.95, and
0.92, respectively. The positive predictive values were 0.84,
0.91, and 0.85, and the negative predictive values were
0.82, 0.85, and 0.85, respectively. The positive likelihood
ratio values for CA, CSI, and AI were 4.09, 7.52, and 4.61,
and the negative likelihood ratio values were 0.18, 0.14,
and 0.13, respectively. In conclusion, this study demon-
strated that footprint analysis methods are suitable for
diagnosing flatfoot in preschool-aged children, and that the
most appropriate cutoffs are as follows: CA≤14.04°, CSI>
62.70%, and AI>107.42%. The CSI had a predictive
probability of more than 90% and is recommended in
screening for flatfoot in preschool-aged children.
Keyword Flatfoot . Footprint . Preschool-aged children .
ROC curve

C.-L. Hsieh Abbreviations

School of Occupational Therapy, College of Medicine, CA Clarke's angle
National Taiwan University, CSI Chippaux-Smirak index
4F, No 17, Xuzhou Rd,
AI Staheli arch index
Taipei 100, Taiwan
MLA medial longitudinal arch
C.-H. Wang (*) BMI body mass index
School of Physical Therapy, College of Medical Technology, ROC receiver operating characteristic
Chung Shan Medical University,
AUC area under the curve
No.110, Sec. 1, Jianguo N. Rd.,
Taichung City 402, Taiwan FPR false-positive rate
e-mail: chwang@csmu.edu.tw TPR true-positive rate
612
PV+ positive predictive value
PV− negative predictive value
LRs likelihood ratios
LR+ positive likelihood ratio
LR− negative likelihood ratio
CI confidence interval
Introduction
Flatfoot is characterized by the collapse of the foot's medial
longitudinal arch (MLA) [23]. The preschool age is a
crucial stage for MLA development [13, 33], and some
studies have suggested that early treatment can prevent
prominent navicular tuberosity or bunion development [19].
Parents of a flat-footed child of preschool age often worry
about the future consequences of the condition and seek
medical intervention. Therefore, early screening of flatfoot
has received close attention from parents and clinicians.
Several clinical diagnostic approaches have been adop-
ted to identify flatfoot, including clinical symptom−sign
methods [26, 28], radiology [7, 32], ultrasonography [16,
24], and footprint analysis [3, 6, 13–15, 17, 28, 31, 33].
Clinical diagnoses based on the assessment of symptoms
and signs tend to be subjective and require experienced
clinicians. The disadvantages of radiological and ultraso-
nographic methods are the requirement of medical person-
nel and the relatively high equipment costs. Footprint
analysis is a simple, quick, cost-effective, and readily
available method for evaluation of flatfoot and has been
recommended as a screening tool for flatfoot because of its
convenience and efficiency [3, 6, 13–15, 17, 28, 31, 33].
Various footprint-based analyses for foot arch assessment
have been developed in previous studies. For example,
Irwin's footprint index [17] determines the severity of flatfoot
by measuring the percentage of the arch's area in a footprint.
Staheli et al. [31] studied the midfoot- to hindfoot-width ratio
in a footprint as an indicator of foot arch development, which
is known as the Staheli arch index (AI). Clarke [6] explored
the angle formed by the tangential line of the foot's medial
edge and the line aligning the first metatarsal and the MLA's
first contact point, intersecting at the first metatarsal head;
this angle is called Clarke's angle (CA). In a study by Forriol
and Pascual [13], the ratio of the maximum width of the
metatarsals to the minimum width of the arch, known as the
Chippaux-Smirak index (CSI), was calculated to illustrate
arch development. The above-mentioned methods are
regarded as reliable by many investigators [3, 13, 18, 31]
and are recommended as screening tools for flatfoot [18].
However, the fact that these studies have rarely focused on
preschool-aged children indicates a lack of diagnostic criteria
for flatfoot in this particular age group.
Eur J Pediatr (2011) 170:611–617
With a focus on preschool-aged children, this study
aimed to evaluate the three most commonly used footprint
analysis methods for diagnosing flatfoot: the angle-based
CA, the width-ratio-based CSI, and the AI. By comparing
their performance with clinical diagnosis, we sought to
examine the suitability of these methods and to provide
clinicians with a standardized approach to diagnosing
flatfoot in preschool-aged children.
Materials and methods
A total of 1,319 children (691 boys and 628 girls), aged 3
to 6 years, from kindergartens in the central area of Taiwan
were included in this descriptive study. All children were
provided with details about the study procedure, and
informed consent was obtained from their parents or legal
guardians before they were enrolled in the study.
A static footprint was recorded on a Harris-Beath mat
[30] for each foot in a 100% weight-bearing position and
then converted to digital images with a scanner. Back-
ground information, including age, height (in centimeters),
and weight (to the nearest 0.1 kg) was collected. The body
mass index (BMI) was calculated for every child by
dividing the weight (kg) by the square of the height (m2).
Children with musculoskeletal or neurological diseases that
affected the structure and movement of the lower extrem-
ities were excluded from the study.
Because there are no universally accepted clinical
definitions of the height of the MLA for preschool-aged
children [31], we selected the results of clinical diagnosis to
be a gold standard. The children's feet were classified into
three grades of flatfoot according to clinical diagnosis [26]
on weight-bearing position: normal foot, the medial arch
looked normal, even if it was slightly impressed; moderate
flatfoot, the medial arch was not visible; and severe flatfoot,
the medial border of the foot was convex.
Assessments were conducted using the digital images,
and the CA, CSI, and AI were calculated using software.
As for footprint analysis, the CA is obtained by calculating
the angle of a first medial tangential line that connects the
medial edges of the first metatarsal head and the heel, and a
second line that connects the first metatarsal head and the
acme of the MLA concavity. The CSI is defined as the ratio
of line B, a parallel line to A at the narrowest point on the
foot arch, to line A, the maximum width at the metatarsals
(B/A×100%). The AI is the ratio of line B to line C, the
maximum width of the heel area (B/C×100%) (Fig. 1). The
Picture Archiving and Communication System, developed
by Chung Shan Medical University Hospital, was used to
conduct the analyses. Angles were shown to the nearest
0.01°, and lengths were shown in pixels. Because the
objectives of this study were to identify appropriate
Eur J Pediatr (2011) 170:611–617 613

Fig. 1 Footprint analysis:

a Clarke's angle=α; b
Chippaux-Smirak index=
B/A×100%; c Staheli arch
index=B/C×100%

diagnostic methods and criteria for flatfoot in preschool-
aged children, the left foot and the right foot of each child
were treated independently. A total of 2,638 footprints of
children aged 3 to 6 years were obtained.
The background information for all participants along
with the CA, CSI, and AI results for both feet are described
using median and range. Classifications of flatfoot made by
clinical diagnosis were displayed in terms of number of
subjects and percentage among each age group. One-way
analysis of variance (ANOVA) was used to identify the
differences between the CA, CSI, and AI results within
each age group. A level of p< 0.05 was considered
statistically significant.
The results of the CA, CSI, and AI were compared with
clinical diagnosis and displayed in a receiver operating
characteristic (ROC) curve. For each method, the ROC area
under the curve (AUC) was computed, and its optimum
cutoff point was determined by the Youden index. The
ROC curve is a method often used to assess the accuracy of
diagnostic tests and is especially suitable for continuous
variables. While data from a diagnostic test are plotted as
an X−Y coordinate where the X axis represents the false-
positive rate (FPR, 1− specificity) and the Y axis represents
the true-positive rate (TPR, sensitivity), the ROC curve is
the linear connection of the dots [22]. In addition, the AUC,
varying between 0.5 and 1, is a commonly used index of
the test's performance: high accuracy (>0.9), moderate
accuracy (0.7−0.9), low accuracy (0.5−0.7), or a result of
chance (0.5) [11].
Another use of the ROC curve is to help researchers
identify an optimal cutoff point by balancing sensitivity and
specificity. In this study, the Youden index (J) is defined as
the maximum vertical distance between the ROC curve and
the diagonal or chance line and is calculated as J=max
[sensitivity+specificity−1] [2, 12]. Given cutoff points, the
positive predictive value (PV+) and negative predictive
value (PV−) of a diagnostic test can be calculated as
alternative indicators, where PV+ is defined as the
probability of the disease given a positive test result and
PV− is the probability of no disease given a negative test
result [20].
In order to illustrate the diagnostic accuracy of the CA,
CSI, and AI in clinical settings, their likelihood ratios (LRs)
were calculated given their cutoff points, and their posttest
probabilities were plotted on a Fagan nomogram [1]. The
LR serves as a useful index of the effectiveness of
diagnostic tests and can be further categorized as the
positive likelihood ratio (LR+) and the negative likelihood

Table 1 Subject characteristics

Total (n=1,319) Gender P value

Male (n=691) Female (n=628)

Age (months) 62 (36–82) 62 (36–82) 61 (36–82) 0.350

Height (cm) 110.0 (87.0–132.0) 110.0 (87.0–132.0) 109.0 (88.0–127.0) <0.001
Weight (kg) 19.0 (11.2–49.0) 19.0 (12.0–49.0) 18.0 (11.2–36.0) <0.001
BMI 15.8 (9.9–28.1) 15.9 (9.9–28.1) 15.7 (10.6–25.0) 0.322
CA (°) 15.5 (0–53.7) 14.6 (0–49.8) 16.6 (0–53.7) <0.001
CSI (%) 61.3 (13.8–117.7) 62.47 (26.7–111.9) 59.8 (13.8–117.7) <0.001
Values are given as median AI (%) 107.5 (26.1–184.0) 110.0 (44.9–169.7) 104.4 (26.1–184.0) <0.001
(range: minimum–maximum)
614 Eur J Pediatr (2011) 170:611–617

Table 2 Three kinds of footprint analysis distribution according to age group

Age Total (n=2,638)

3 years (n=440) 4 years (n=782) 5 years (n=1,044) 6 years (n=372)

CA (°) 12.9 (0–46.4) 15.2 (0–53.5) 16.2 (0–52.6) 17.4 (0.9–53.7) 15.5 (0–53.7)
CSI (%) 65.7 (24.8–117.7) 62.0 (20.5–89.2) 60.0 (22.0–86.1) 58.1 (13.8–91.3) 61.3 (13.8–117.7)
AI (%) 112.2 (48.9–184.0) 107.8 (31.1–155.5) 105.4 (36.1–165.7) 101 (26.1–169.7) 107.5 (26.1–184.0)
Flatfoot, n (%) 258 (58.64) 382 (48.85) 401 (38.41) 120 (32.26) 1,161 (44.01)

Values are given as median (range: minimum–maximum)

ratio (LR−) [1]. LR+ is defined as the probability of an
individual with disease having a positive test divided by the
probability of an individual without disease having a
positive test, and LR−is defined as the probability of an
individual with disease having a negative test divided by
the probability of an individual without disease having a
negative test [1].
The estimated probability of disease before the test result
is known is referred to as the pretest probability and is
usually estimated on the basis of the clinician's personal
experience, local prevalence data, and published reports.
The patient's probability or chance of having the disease
after the test result is known is referred to as the posttest
probability [1]. The Fagan nomogram is a graphic tool that,
in routine clinical practice, allows one to use the results of a
diagnostic test to estimate a patient's probability of having
disease [10].
were 0.82, 0.85, and 0.85, respectively. These findings
showed that the three tests have high diagnostic ability to
discern flatfoot in preschool-aged children (Table 3).
Given the ROC curve cutoff points, the LR+ values were
as follows: CA, 4.09; CSI, 7.52; and AI, 4.61. The LR−
values were as follows: CA, 0.18; CSI, 0.14; and AI, 0.13.
As the pretest probability was found to be 55.99%, the
above LR+ values yielded the following posttest probabil-
ities: CA, 83.89%; CSI, 90.54%; and AI, 85.43%. The
above LR− values yielded the following posttest probabil-
ities: CA, 18.34%; CSI, 15.15%; and AI, 14.52%. The three
tests demonstrated good diagnostic accuracy, and the
analysis results were displayed using the Fagan nomogram
(Fig. 3).
Discussion

The objectives of this study were to explore footprint

Results diagnostic methods and classifications for flatfoot in
preschool-aged children. The three tests studied—CA,
This study included 1,319 preschool-aged children (691 CSI, and AI—demonstrated good diagnostic abilities,
boys and 628 girls) with a median age of 62 (range: 36−82)
months, a median height of 110.0 (range: 87.0−132.0) cm,
and a median weight of 19.0 (range: 11.2–49.0) kg
(Table 1). Statistically significant differences were found
in the CA, CSI, and AI between genders (p<0.001),
whereas no gender difference was found in either age (p=
0.350) or BMI (p=0.322). Trends of the CA, CSI, and AI
by age group were also revealed. Differences in the test
results among all age groups reached statistical significance
(p<0.001) (Table 2).
From the ROC curves (Fig. 2), the cutoff points of these
tests for diagnosing flatfoot in preschool-aged children
were determined as follows: CA≤14.04°, CSI>62.70%,
and AI>107.42%, with sensitivities of 0.86, 0.88, and 0.89,
respectively. While good sensitivities were revealed, the
AUCs of the tests were as follows: CA, 0.91 (95% CI,
0.90–0.92); CSI, 0.95 (95% CI, 0.95–0.96); and AI, 0.92
(95% CI, 0.91–0.93). The PV+ values for the CA, CSI, and Fig. 2 The receiver operating characteristic (ROC) curve for three
AI were 0.84, 0.91, and 0.85, respectively; their PV− values kinds of footprint analysis
Eur J Pediatr (2011) 170:611–617 615

Table 3 Cutoff point and statis-

tical parameters for three kinds CA CSI AI
of footprint analysis
Cutoff point 14.04° 62.70% 107.42%
Sensitivity 0.861 0.876 0.892
Specificity 0.790 0.884 0.806
Youden index 0.65 0.76 0.70
AUC (95% CI) 0.907 (0.896–0.918) 0.953 (0.946–0.960) 0.920 (0.910–0.930)
PV+ 0.84 0.91 0.85
PV− 0.82 0.85 0.85
LR+ 4.09 7.52 4.61
LR− 0.18 0.14 0.13
Pretest probability 55.99% 55.99% 55.99%
Posttest probability (LR+) 83.89% 90.54% 85.43%
Posttest probability (LR−) 18.34% 15.15% 14.52%

showing that footprint analyses are suitable for assessing
flatfoot in children of this age group. Our analysis showed
that the overall performance of the CSI was superior to
those of the other tests. Therefore, the CSI is recommended
as the primary screening tool for preschool children.
According to the study of Forriol and Pascual [13] on
children and adolescents aged 3 to 17 years, the CA and
CSI are adopted as the classification criteria for flatfoot:
normal foot (CA>42° or CSI=0.1–29.9%), mild flatfoot
(CA=35–42° or CSI=30–39.9%), moderate flatfoot (CA=
30–34.9° or CSI=40–44.9%), and severe flatfoot (CA≤
29.9° or CSI≥45%). Furthermore, Echarri and Forriol [9]
studied children aged 3 to 12 years and developed an AI-
based classification system for flat-footedness: a high-arch
foot (AI=0–29%), normal foot (AI=30–59%), mild to
moderate flatfoot (AI=60–89%), and severe flatfoot (AI≥
90%). By the above-mentioned criteria, a large majority of
preschool-aged children's footprints in this study would be
regarded as indicating moderate to severe flatfoot: 96.3%
(2,541/2,638) by the CA standard, 93.5% (2,466/2,638) by
the CSI standard, and 76.7% (2,024/2,638) by the AI
standard. Therefore, these classification criteria are not
applicable for diagnosing flatfoot in children of this
particular age group. In this study, ROC curve analysis
found the following values to be appropriate benchmarks
for confirming flat-footedness in preschool-aged children:
CA ≤ 14.04°, CSI >62.70%, and AI> 107.42%. By the
criteria of our study, the footprints would be regarded as
indicating moderate to severe flatfoot: 42.7% (1,126/2,638)
by the CA standard, 44.88% (1,184/2,638) by the CSI
standard, and 1,321/2,638 (50.08%) by the AI standard; the
results are nearly the same as those of Pfeiffer et al. [26],
who reported that the prevalence of flatfoot in 3–6-year-old
children is 43.9%.
In the study of Staheli et al. [31], who analyzed the
footprints of subjects ranging in age from 1 to 80 years, by

Fig. 3 Fagan's nomograms for

three kinds of footprint analysis.
a b
a Positive likelihood ratio. b
Negative likelihood ratio

CA CSI AI CA CSI AI
616
children's age, a higher prevalence of flat-footedness in
preschool-aged children was discovered. Forriol and Pasc-
ual [13] also studied the footprints of children aged 3 to
17 years and reported that younger age was associated with
a lower-rising MLA. Pfeiffer et al. [26] reported that the
prevalence of flatfoot decreases significantly with age in
preschool children. In our study, a decreasing trend in the
prevalence of flatfoot was found from younger to older age,
a finding that is consistent with previous literature [5, 9, 13,
26, 31]. However, because school-aged children and
adolescents were not included in this study, information
on foot development at later stages was not available.
Although most studies suggest a higher prevalence of
flatfoot in males than in females [4, 5, 26], some have
found no gender difference [21]. Our study discovered
statistically significant differences in CA, CSI, and AI
between genders (p<0.001), with a greater prevalence of
flatfoot in boys. This phenomenon may be related to the
slower growth of the MLA and thicker plantar fat pads in
boys [25].
Although dispute persists over whether footprints are
predictive of foot arch development, and some researchers
even dismiss the idea that a footprint can truly represent the
height of the foot arch [15, 29], Kanatli et al. [18] reported
a positive correlation of arch index between lateral talo–
horizontal and lateral talo–first metatarsal angles on radio-
graphs and concluded that footprint analysis can be as
effective as radiologic measurements. Villarroya et al. [32]
also found a significant correlation between footprint-based
CA and CSI methods and radiography-based talus–first
metatarsal and calcaneal inclination angles. According to a
study by Queen et al. [27], the inter-rater reliabilities of the
CSI and AI were both 0.96, and the between-day
reliabilities of the CSI and AI were both 0.91. Because
footprint collection requires less time than other methods
and can be performed even on a noncooperative child with
some assistance, it has been recognized as a simple,
effective tool for massive screening for flatfoot in
preschool-aged children.
A major advantage of likelihood ratios is that they can
be used to help the clinician adapt the sensitivity and
specificity of tests to individual patients. They provide a
summary of how many times more (or less) likely patients
with the symptom are to have that particular result than
patients without the symptom, and they can also be used to
calculate the probability of symptom for individual patients
[8]. In our study, the CSI with an LR+ value of 7.52
indicates that a flat-footed child is 7.52 times more likely to
have a positive test result than a non-flat-footed person, and
an LR− value of 0.14 indicates that a flat-footed person is
0.14 times less likely to have a negative test result than a
non-flat-footed person. When displayed in the Fagan
nomogram, the LR+ yielded an increase in probability
Eur J Pediatr (2011) 170:611–617
from 55.99% (pretest) to 90.54% (posttest), while the LR−
yielded a decrease in probability from 55.99% (pretest) to
15.15% (posttest). This finding demonstrates that CSI
analysis is highly accurate in diagnosing flatfoot in
preschool-aged children. To our best knowledge, no studies
have explored the performance of tools for diagnosing
flatfoot in preschool-aged children, and our study has
shown that the CSI is a practical, convenient instrument
in clinical settings for screening of flat-footed preschool-
aged children.
As our study did not include school-aged children or
adolescents, the question of whether our findings could
inform the diagnosis and classification of flatfoot in these
age groups has yet to be answered. In addition, because of a
lack of long-term follow-up, this study revealed little about
the foot development process. These limitations should be
addressed in future studies.
This study demonstrated that footprint analysis methods
are suitable for diagnosing flatfoot in preschool-aged
children. All three of the diagnostic tests studied showed
high sensitivity and discerning power. The CSI had an
especially outstanding performance, with a predictive
probability of more than 90%; thus, it is recommended as
the screening tool of choice for flatfoot in preschool-aged
children. Our findings suggest that appropriate criteria for
diagnosing flatfoot in preschool-aged children are as
follows: CA≤14.04°, CSI>62.70%, and AI>107.42%.
Acknowledgments The authors thank all participants in this study
and the physical therapists, Shiao-Wen Liu, Shiou-Han Yang, and
Pei-Shan Tsai, who kindly provided assistance with data collection.
This study was supported by research grants from the National
Science Council, Taiwan (NSC99-2314-B-040-004-MY3).
Financial disclosure statement No party having a direct interest in
the results of the research supporting this article has or will confer a
benefit on us or on any organization with which we are associated.
Conflict of interest statement All authors state that they do not
keep any commercial, financial, or personal relationships that may
lead to a conflict of interest that could inappropriately influence (bias)
their work.
References
1. Akobeng AK (2007) Understanding diagnostic tests 2: likelihood
ratios, pre- and post-test probabilities and their use in clinical
practice. Acta Paediatr 96(4):487–491
2. Akobeng AK (2007) Understanding diagnostic tests 3: receiver
operating characteristic curves. Acta Paediatr 96(5):644–647
3. Cavanagh PR, Rodgers MM (1987) The arch index: a useful
measure from footprints. J Biomech 20(5):547–551
4. Chang JH, Wang SH, Kuo CL et al (2010) Prevalence of flexible
flatfoot in Taiwanese school-aged children in relation to obesity,
gender, and age. Eur J Pediatr 169(4):447–452
Eur J Pediatr (2011) 170:611–617
5. Chen JP, Chung MJ, Wang MJ (2009) Flatfoot prevalence and
foot dimensions of 5- to 13-year-old children in Taiwan. Foot
Ankle Int 30(4):326–332
6. Clarke HH (1933) An objective method of measuring the height
of the longitudinal arch in foot examinations. Res Q 4:99–107
7. Cobey JC, Sella E (1981) Standardizing methods of measurement
of foot shape by including the effects of subtalar rotation. Foot
Ankle 2(1):30–36
8. Deeks JJ, Altman DG (2004) Diagnostic tests 4: likelihood ratios.
BMJ 329:168–169
9. Echarri JJ, Forriol F (2003) The development in footprint
morphology in 1851 Congolese children from urban and rural
areas, and the relationship between this and wearing shoes. J
Pediatr Orthop B 12(2):141–146
10. Fagan TJ (1975) Letter: Nomogram for Bayes theorem. N Engl J
Med 293(5):257
11. Fischer JE, Bachmann LM, Jaeschke R (2003) A readers' guide to
the interpretation of diagnostic test properties: clinical example of
sepsis. Intensive Care Med 29(7):1043–1051
12. Fluss R, Faraggi D, Reiser B (2005) Estimation of the Youden
Index and its associated cutoff point. Biom J 47(4):458–472
13. Forriol F, Pascual J (1990) Footprint analysis between three and
seventeen years of age. Foot Ankle 11(2):101–104
14. Garcia-Rodriguez A, Martin-Jimenez F, Carnero-Varo M et al
(1999) Flexible flat feet in children: a real problem? Pediatrics 103
(6):e84
15. Hawes MR, Nachbauer W, Sovak D et al (1992) Footprint
parameters as a measure of arch height. Foot Ankle 13(1):22–26
16. Henning EM, Cavanagh PR (1985) Ultrasonic quantification of the
arch of the weight-bearing foot. In Biomechanics IX-B 211–216
17. Irwin LW (1937) A study of the tendency of school children to
develop flat-footedness. Res Q 8:46–53
18. Kanatli U, Yetkin H, Cila E (2001) Footprint and radiographic
analysis of the feet. J Pediatr Orthop 21(2):225–228
19. King DM, Toolan BC (2004) Associated deformities and
hypermobility in hallux valgus: an investigation with weightbear-
ing radiographs. Foot Ankle Int 25(4):251–255
617
20. Langlotz CP (2003) Fundamental measures of diagnostic perfor-
mance: usefulness for clinical decision makingand research.
Radiology 228(1):3–9
21. Lin CJ, Lai KA, Kuan TS et al (2001) Correlating factors and
clinical significance of flexible flatfoot in preschool children. J
Pediatr Orthop 21(3):378–382
22. Lusted LB (1971) Signal detectability and medical decision-
making. Science 171(977):1217–1219
23. Magee DJ, Zachazewski JE, Quillen WS (2008) Pathology and
intervention in musculoskeletal rehabilitation. Elsevier
24. Mickle KJ, Steele JR, Munro BJ (2006) The feet of overweight
and obese young children: are they flat or fat? Obesity (Silver
Spring) 14(11):1949–1953
25. Mickle KJ, Steele JR, Munro BJ (2008) Is the foot structure of
preschool children moderated by gender? J Pediatr Orthop 28
(5):593–596
26. Pfeiffer M, Kotz R, Ledl T et al (2006) Prevalence of flat foot in
preschool-aged children. Pediatrics 118(2):634–639
27. Queen RM, Mall NA, Hardaker WM et al (2007) Describing the
medial longitudinal arch using footprint indices and a clinical
grading system. Foot Ankle Int 28(4):456–462
28. Rose GK, Welton EA, Marshall T (1985) The diagnosis of flat
foot in the child. J Bone Joint Surg Br 67(1):71–78
29. Saltzman CL, Nawoczenski DA, Talbot KD (1995) Measurement
of the medial longitudinal arch. Arch Phys Med Rehabil 76(1):45–
49
30. Shores M (1980) Footprint analysis in gait documentation. An
instructional sheet format. Phys Ther 60(9):1163–1167
31. Staheli LT, Chew DE, Corbett M (1987) The longitudinal arch. A
survey of eight hundred and eighty-two feet in normal children
and adults. J Bone Joint Surg Am 69(3):426–428
32. Villarroya MA, Esquivel JM, Tomas C et al (2009) Assessment of
the medial longitudinal arch in children and adolescents with
obesity: footprints and radiographic study. Eur J Pediatr 168
(5):559–567
33. Volpon JB (1994) Footprint analysis during the growth period. J
Pediatr Orthop 14(1):83–85