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Describing the Medial Longitudinal Arch Using Footprint Indices and a Clinical Grading System
Robin M. Queen, Nathan A. Mall, W. Mack Hardaker and James A. Nunley
Foot Ankle Int 2007 28: 456
DOI: 10.3113/FAI.2007.0456

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FOOT & ANKLE INTERNATIONAL
Copyright © 2007 by the American Orthopaedic Foot & Ankle Society, Inc.
DOI: 10.3113/FAI.2007.0456
Describing the Medial Longitudinal Arch Using Footprint Indices and a Clinical
Grading System
Robin M. Queen, Ph.D.; Nathan A. Mall, M.D.; W. Mack Hardaker, B.S.; James A. Nunley, II, M.D.
ABSTRACT
Background: The current literature is not clear regarding the
best method of determining medial longitudinal arch (MLA)
height. Differences in MLA height can significantly alter lower
extremity biomechanics; therefore, an accurate and repro-
ducible assessment of arch height is essential for clinical eval-
uation and future research. The goal of this project was to
determine the reliability of common arch height measurement
techniques. Methods: Foot length, truncated foot length, navic-
ular height, dorsal height, and footprint indices were obtained
from healthy volunteers using a mirrored foot photograph
box (MFPB). Between-rater and between-day reliability was
determined using the interclass correlation coefficient, and the
Pearson correlation coefficient was used to determine if any of
the footprint parameters correlated with navicular height or
normalized navicular height. Results: The most reliable foot-
print measurement was the footprint index, followed by the
Staheli index, Chippaux-Smirak Index, arch index, truncated
arch index, and arch length index. The correlation of footprint
measurements to normalized navicular height ranged from
0.585 to 0.648. Conclusions: Historically, the height of the navic-
ular is considered to be the best approximation of MLA height.
The results of this study indicate that the footprint indices are
highly correlated with navicular height, indicating that both
navicular height measurements and footprint measurements
are valid measures of MLA height. Multiple methods exist for
measuring the height of the MLA; therefore, it is important to
develop a standard set of measurements to be used when foot
type is used as a variable in research studies or when making a
clinical diagnosis.
Key Words: Arch Height; Clinical Assessment; Foot Print
Index; Foot Type
Corresponding Author:
Robin M. Queen, Ph.D.
102 Finch Yeager Building
DUMC 3435
Durham, NC 27710
Email: robin.queen@duke.edu
For information on prices and availability of reprints, call 410-494-4994 X226
456
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Durham, N.C.
INTRODUCTION
Lower extremity injuries can be caused by many mech-
anisms, including trauma and degeneration. In many cases,
individuals are more susceptible to injury because of predis-
posing factors such as genetics, bony anatomy, or altered
lower extremity mechanics. These factors can lead to
abnormal stresses being placed on the skeletal system, which
can result in injuries. It is widely believed that the height of
the medial longitudinal arch of the foot is a predisposing
factor to injuries in the lower extremity.3,8,10,12,17,18 Indi-
viduals with both pes cavus and pes planus feet have been
identified as having a predisposition for the development
of stress fractures in the foot and lower leg.3,8,10,12,17,18
Previous literature has indicated that foot type can be both
protective against stress fractures as well as a predisposing
factor based on the location of the fracture.4,7,16 Some of the
discrepancy related to the role of arch height as a predis-
posing factor for injury could possibly be explained by the
wide variations in the methods that were used to measure the
height of the arch and or the determination of foot type as
pes planus, pes cavus, or normal in these research studies.
In addition, inconsistencies in measurement techniques for
determining foot type make it difficult to compare research
studies that examine different injuries and foot pathologies.
Previous research projects have used many different tech-
niques to define foot types as cavus, planus, or normal;
these techniques include radiographs, ultrasound, footprint
measurements, measurement of bony landmarks, and clin-
ical assessments.4,6,7,13,16 Arch height has been defined as
the highest point on the soft-tissue margin of the medial
longitudinal arch.6 Based on this definition of arch height,
poor correlation existed between footprint parameters and
arch height. However, if a bony landmark, such as the
height of the navicular, was used to define arch height, then
footprint measurements could demonstrate improved corre-
lations with arch height. While multiple studies have been
published examining different methods of characterizing foot
morphology, few compare one type of measurement, such as
Foot & Ankle International/Vol. 28, No. 4/April 2007 MEDIAL LONGITUDINAL ARCH 457

footprint measurements, to other methods such as navicular

height or other linear measurements of the foot. The lack
of comparison between different measurement types causes
difficulty in comparing different research study designs. By
gaining an understanding of how different measurement tech-
niques are related, it should be easier to compare research
studies that use different techniques. In addition, this under-
standing will aid clinicians in comparing their clinical assess-
ments and measurements to those reported in the literature.
Therefore, the purposes of this study were (1) to inves-
tigate the inter-rater and between-day reliability of seven
commonly used footprint measurements (arch angle, foot-
print index, arch index, arch length index, truncated arch
index, Staheli index, and Chippaux-Smirak index)16 and
(2) to gain an understanding of how these footprint measure-
ments correlated with navicular height and normalized navic-
ular height (navicular height divided by foot length) as a Fig. 1: Setup for the mirrored foot photo box, demonstrating the positioning
of the mirrors to obtain a plantar view of the foot.
measurement of the height of the medial longitudinal arch in
a normal, healthy adult population.
Procedure
Footprint parameter data collection
MATERIALS AND METHODS The height, weight, and age of each participant was
recorded and 10% of the participant’s weight was determined
Participants and used throughout all of the data collection sessions. The
participant was then asked to place one foot on a scale until
Thirty healthy participants with no history of pain (15
the scale read 10% of his or her weight and the other foot
women and 15 men) were recruited from the university
was fully on the ground. Therefore, participants were tested
community. The mean age of the subjects was 24.8 ± 2.1
in a 90% weightbearing stance, which was used to simulate
years, and average weight was 161.60 ± 35.83 pounds.
the single-leg stance phase of gait. Participants were standing
Before participation in the study, each participant signed a
with a level pelvis throughout testing, which was monitored
consent from, which was approved by the university’s insti-
by one of the testers. While in the 90% weightbearing stance
tutional review board. Each participant was tested bilaterally
the navicular and head of the first metatarsal were palpated,
resulting in a total of 60 feet used for analysis. Participants
and the skin was marked with a washable marker, then
were included in the study if they had no history of lower
the procedure was repeated for the contralateral foot. The
extremity injuries within the past 6 months and no history
scale was then moved to the table directly adjacent to the
of foot or ankle surgery. They also were excluded from the
MFPB (Figure 1).11 The participant placed one foot on the
study if they had any foot abnormalities.
plexiglass base of the MFPB and the other foot on the
scale (Figure 2)11 then adjusted his or her weight until he
Equipment or she was in a 90% weightbearing stance, with level hips,
The footprint parameters that were measured during this at which time a digital photograph was taken from the medial
study were obtained from digital photographs that were taken direction and the procedure was repeated on the contralateral
using the mirrored foot photo box (MFPB). The MFPB was foot. Once the first examiner (NAM) completed measuring
constructed using a sturdy metal frame, with a standing both feet, the marks were removed and the second examiner
plate made of plexiglass (Figure 1). The plexiglass plate (WMH) repeated the entire process. Participants returned for
contained 1-inch square blocks that were used to calibrate a second day of testing approximately 1-week after the first
the pixel dimensions from the digital photograph. In addition test and the exact same procedure was completed.
to the plexiglass plate, the MFPB contained three mirrors.
The position of these mirrors was altered to enhance the Data Processing
view of the inferior, anterior, and posterior portions of Each of the photographs was saved on a personal
the foot (Figure 1). The camera and tripod positions were computer, where the SigmaScan Pro software was used to
predetermined and marked to standardize the multiple views measure several variables. From the medial view of the foot
of the foot. Once the digital images were recorded, they photo, foot length was measured as the distance from the
were transferred to a personal computer where they were most posterior aspect of the calcaneus to the end of the
analyzed using the SigmaScan Pro software (Systat Software longest toe, truncated foot length was measured from the
Inc, Richmond, CA). most posterior aspect of the calcaneus to the mark on the head

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458 QUEEN ET AL.
Fig. 2: The mirrored foot photo box during data collection. It allows anterior, posterior, medial, and inferior views of the foot.
of the first metatarsal, and the navicular height was measured
from the floor to the mark that was placed on the navicular
during palpation. The between-rater and within-rater relia-
bility and validity to radiographic measurements for these
variables have previously been reported.11 From the plantar
view of the photo, the following footprint calculations were
obtained: arch angle, footprint index, arch index, arch length
index, truncated arch index, Staheli index, and Chippaux-
Smirak index (Figure 3). Each of these measurements has
been previously described in the literature.1,2,6,15
The arch angle is the angle between the medial borderline
of the footprint and the line connecting the most medial point
of the metatarsal region of the footprint and the point where
the slope of the inner segment of the longitudinal arch first
touches the metatarsal outline of the arch (Figure 4, A).6,15
The footprint index is the ratio of the noncontact area to
the contact area of the toeless footprint. For the footprint
Fig. 3: Plantar view of the foot from the mirrored foot photograph box.
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Foot & Ankle International/Vol. 28, No. 4/April 2007
index, the noncontact area was defined as the area between
the medial borderline of the footprint and medial footprint
outline, while the contact area was the area of the foot
without the toes (Figure 4, B).6,15 The arch index is the ratio
of the area of the middle third of the toeless footprint to the
entire area of the toeless footprint (Figure 4, C).1,2,6,15 The
arch length index is the ratio of the length of the medial
borderline between the most medial points of the metatarsal
and heel regions and the arch length, when arch length is
defined as the length of the outline of the medial longitudinal
arch between the metatarsals and the heel (Figure 4, D).6,15
The truncated arch index is the ratio of the arch area to the
truncated footprint area, when the truncated footprint area
is defined as the contact area of the footprint between the
metatarsals and the heel (Figure 4, E).6,15
The Staheli Index and Chippaux-Smirak Index were deter-
mined by drawing three lines: one at the minimal distance
of the midfoot region, one at the maximal distance of the
forefoot area, and one at the maximal distance of the rear-
foot region (Figure 4, F).15 The Staheli index is the ratio of
the minimal distance in the midfoot region to the maximal
distance in the rearfoot region.16 The Chippaux-Smirak index
is the minimal distance in the midfoot region divided by the
maximal distance in the forefoot area.15
Data and Statistical Analysis
The mean and standard deviation (SD) for both raters for
each of the footprint parameters as well as the navicular
height and normalized navicular height were determined.
Intertester reliability was determined using the intraclass
correlation coefficient (ICC) (2, k) model and intratester
reliability was evaluated using the ICC (2,1) model. Pearson
Foot & Ankle International/Vol. 28, No. 4/April 2007 MEDIAL LONGITUDINAL ARCH 459

A B C

D E F

Fig. 4: A, Arch angle. B, Footprint index. C, Arch index. D, Arch length index. E, Truncated arch index. F, Staheli index and Chippaux-Smirak index.

correlation coefficients were obtained for navicular height
and normalized navicular height relative to each of the seven
footprint indices. An alpha level of 0.05 was used for the one-
tailed test of significance. In addition, a regression analysis
was preformed to determine which of the footprint variables
best predicted navicular height and therefore the height of
the medial longitudinal arch. To control for multicolinearity
between the independent variables (footprint parameters),
regression diagnostics were completed and the variance
inflation factor (VIF) as well as the tolerance were examined.
If the VIF is greater than 10 and the tolerance value is less
than 0.1, the indication is that multicolinearity exists and one
or more of the variables are related to the others. Following
the initial regression analysis, variables that demonstrated

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460 QUEEN ET AL.
multicolinearity were systematically removed from the model
and the analysis was repeated until multicolinearity was no
longer present in the regression model.
RESULTS
The mean and standard deviation for the seven footprint
measurements and the two linear measurements are shown
in Table 1. All of the linear measurements (navicular height
and foot length) obtained from the MFPB demonstrated
good inter-rater and between-day reliability.11 Footprint
measurements obtained from the MFPB also demonstrated
excellent reliability. Inter-rater reliability ranged from 0.807
to 0.970, with the arch angle being the least reliable. The
most reliable footprint measurement was the footprint index
(0.970), followed by the Staheli index (0.963), Chippaux-
Smirak index (0.961), arch index (0.957), truncated arch
index (0.933), and arch length index (0.818) (Table 2).
Similar to the linear measurements, the inter-rater reliability
for the footprint measurements were higher than between-day
reliability. The between-day reliabilities ranged from 0.638
to 0.924; however, all of the variables except the arch length
index (0.755) and arch angle (0.638) were greater than 0.890
(Table 2).
Significant correlations existed between the linear mea-
surements (navicular height and normalized navicular height)
and the footprint measurements. The most significant corre-
lations between the linear measurements and the footprint
measurements involved the normalized navicular height. The
highest correlations existed between the normalized navicular
height (NH/FL) and the arch length index (ALI), followed by
NH/FL and Chippaux-Smirak index (CSI) (Table 3). Based
on the regression analysis and controlling for multicolin-
earity, the only footprint measurements that are unrelated
and can be used as predictors of navicular height are arch
angle, footprint index, and arch length index. However, these
three variables only explain 29% of the variance.
Table 1: Mean and standard deviation (SD) for both raters for the seven footprint parameters and
the linear measurements
Measurement Mean rater 1
Foot length (mm) 253.55
Navicular height (mm) 36.61
Arch angle (degree) 56.69
Footprint index 0.384
Arch index 0.212
Arch length index 0.741
Truncated arch index 0.608
Staheli index 0.422
Chippaux-Smirak index 0.271
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Foot & Ankle International/Vol. 28, No. 4/April 2007
DISCUSSION
The purposes of this study were to investigate the inter-
rater and between-day reliability of footprint measurements
and to gain an understanding of how footprint measure-
ments correlated with navicular height and normalized
navicular height (navicular height divided by foot length).
All of the footprint measurements demonstrated accept-
able inter-rater reliability, while the arch angle and the
arch length index were the only variables that did not
demonstrate acceptable between-day reliability. In contrast
to previous studies, we found that the inter-rater reliability
was greater than the between-day reliability for each of the
footprint measurements.5,9,18 One major difference between
the current study and previously reported studies was the
time between repeated measurements. Previous studies have
repeated the measurements either directly after the initial
measurement or within 2 days.10,14,18 In contrast, the current
study requested that participants return 1 week to 10 days
after their initial measurement. While it is doubtful that
the internal anatomy of the participant changed in this time
period, perhaps the pelvic alignment of the patient while he
or she was standing on the MFPB was different between the
two testing days, which could account for changes in the
footprint measurements. In addition, changes to the plantar
aspect of the foot such as callus growth could conceivably
alter the footprint measurements, potentially explaining the
difference in the between-day reliability. Both the inter-rater
and between-day reliability of the footprint measurements
that were assessed during this study were good and, therefore,
could be used in the future as one method for determining
footprint measurements and could be compared from one
investigation to another.
All of the correlations between navicular height and the
footprint measurements were statistically significant (p <
0.05). The same was true for the correlations between
the footprint measurements and the normalized navicular
height.11 The navicular height was most highly corre-
lated with the arch angle (r = 0.517) and had the lowest
SD rater 1 Mean rater 2 SD rater 2
19.23 252.41 18.61
6.54 36.61 6.98
11.65 48.08 9.81
0.137 0.376 0.137
0.071 0.206 0.069
0.083 0.760 0.078
0.245 0.521 0.208
0.247 0.410 0.237
0.153 0.273 0.155
Foot & Ankle International/Vol. 28, No. 4/April 2007 MEDIAL LONGITUDINAL ARCH 461

Table 2: Between-day and inter-rater reliability of the footprint measurements

Between-day reliability Inter-rater reliability

Arch angle+ 0.6377 0.8072
Footprint index∗,+ 0.9068 0.9701
Arch index∗,+ 0.9235 0.9565
Arch length index+ 0.7552 0.8177
Truncated arch index∗,+ 0.8909 0.9328
Staheli index∗+ 0.9142 0.9626
Chippaux-Smirak index∗,+ 0.9139 0.9609

∗ Indicates good intrarater reliability (ICC value of 0.800 or greater); + Indicates good interrater reliability
(ICC value of 0.800 or greater).

Table 3: Correlation between the anthropometric variables and footprint measurements

AA FPI AI ALI TAI SI CSI

NH 0.517 0.438 −0.423 −0.488 0.402 −0.469 −0.498
NH/FL 0.627 0.604 −0.609 −0.648 0.585 −0.619 −0.645

NH, navicular height; NH/FL, navicular height divided by foot length; AA, arch angle; FPI, footprint index; AI, arch index; ALI, arch length index; TAI,
truncated arch index; SI, Staheli index; CSI, Chippaux-Smirak index.

correlation with the arch index (r = −0.423) (Table 3). In a
previous study, the use of a MFPB to measure bony anatomy
of the foot was validated to a radiographic image, indicating
that the navicular height and normalized navicular height
used in this study are reflective of the bony anatomy of
the foot.11 Based on the results of this study, it does not
appear that footprint measurements are well correlated with
navicular height, which often is considered to be a good
measure of arch height and therefore foot morphology. In
addition, this study demonstrated that footprint parameters
cannot be used to predict navicular height and therefore
the height of the medial longitudinal arch. Shiang et al.15
reported similar correlations between navicular height and
the footprint measurements. They reported slightly better
correlations between arch height and footprint index (0.547),
truncated arch index (0.653), and arch index (−0.728) when
compared to the current study.15 In addition to examining the
correlation between navicular height and the different foot-
print measurements, the current study examined the correla-
tion between the footprint measurements and the normalized
navicular height. The normalized navicular height demon-
strated improved correlation with the footprint measurements
(range: r = 0.585 to r = 0.648). Based on this increase in
correlation, it appears that examining the normalized navic-
ular height might allow for more comparison between bony
anatomic landmarks and the footprint measurements that
often are reported in the literature.
In this study the footprint measurements correlated only
slightly with actual navicular height, which indicates that
perhaps the footprint of a subject is dependent on factors
other than arch height, such as rearfoot angle. Therefore,
when discussing foot morphology, whether for a clinical
diagnosis, assessment of injury risk factors, or for research
studies that use arch height as a variable, it appears that
a standardized scale of navicular height or normalized
navicular height would be the most appropriate method of
assessing foot morphology. A standardized method would
allow for improved collaboration between physicians and
researchers and would help further elucidate the effects
of arch height on risk factors for various injuries and
pathologic conditions of the foot, ankle, lower extremity, and
axial spine. In addition, a standardized method of assessing
arch height would allow easier comparison to previously
published literature. Future work in this area needs to be
pursued to determine the most reliable and potentially the
most effective method of measuring and reporting arch
height and foot morphology, either with a combination of
measurements or through a combination of measurements
and clinical assessment.
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