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      The relationship between paediatric foot posture and body mass index: do heavier children really have flatter feet?

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          Several studies have found positive correlation between flatfeet and increased body mass in children. One study, utilizing a differing method of foot posture assessment, found the inverse. The purpose of this study was to further explore the relationship between children’s foot posture and body mass, utilizing the foot posture index in a large study population, as opposed to the footprint based measures of most previous studies.


          Data for both foot posture index (FPI) and body mass index (BMI) for healthy children were acquired from five previous studies. The amalgamated dataset comprised observations for both BMI and FPI-6 in 728 children aged from three to 15 years. Three FPI-6 scores levels defined the range of flatfeet detected: FPI-6 ≥ +6; FPI-6 ≥ +8; FPI-6 ≥ +10. BMI cut-points were used to define overweight for each age group.


          In the study population of 728 children, flatfeet (FPI ≥ +6) were found in 290 (40 %) cases and non-flatfeet in 438 (60 %) cases. FPI ≥ +8 yielded flatfeet in 142 (20 %) cases and FPI ≥ +10 yielded flatfeet in 41 (5 %) cases. Whilst 272 (37 %) children were overweight, only 74 (10.1 %) of the overweight children had flatfeet (FPI ≥ +6), which diminished to 36 (4.9 %) at FPI ≥ +8, and 9 (1.2 %) at FPI ≥ +10.

          Significant and moderate correlation was found between BMI and age ( r = 0.384, p < 0.01). Very weak, but significant, correlation was found between BMI and FPI ( r = −0.077, p < 0.05). Significant mean differences between gender and BMI were found ( t-test = 2.56, p < 0.05). There was strong correlation between FPI scores on left and right sides ( r = 0.899, p < 0.01).


          This study found no association between increased body mass and flatfeet in children, a finding in contrast to that repeatedly concluded by many previous studies. Whilst properties of the FPI and BMI are limiting, these findings question the concern about children’s increased body mass as a specific influence on (flatter) foot posture, and also the validity of footprint versus anatomically based foot posture measures.

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          Most cited references 19

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          Establishing a standard definition for child overweight and obesity worldwide: international survey.

          To develop an internationally acceptable definition of child overweight and obesity, specifying the measurement, the reference population, and the age and sex specific cut off points. International survey of six large nationally representative cross sectional growth studies. Brazil, Great Britain, Hong Kong, the Netherlands, Singapore, and the United States. 97 876 males and 94 851 females from birth to 25 years of age. Body mass index (weight/height(2)). For each of the surveys, centile curves were drawn that at age 18 years passed through the widely used cut off points of 25 and 30 kg/m(2) for adult overweight and obesity. The resulting curves were averaged to provide age and sex specific cut off points from 2-18 years. The proposed cut off points, which are less arbitrary and more internationally based than current alternatives, should help to provide internationally comparable prevalence rates of overweight and obesity in children.
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            Development and validation of a novel rating system for scoring standing foot posture: the Foot Posture Index.

            The limitations of clinical methods for appraising foot posture are well documented. A new measure, the Foot Posture Index is proposed, and its development and validation described. A four-phase development process was used: (i) to derive a series of candidate measures, (ii) to define an appropriate scoring system, (iii) to evaluate the validity of components and modify the instrument as appropriate, and (iv) to investigate the predictive validity of the finalised instrument relative to static and dynamic kinematic models. Methods included initial concurrent validation using Rose's Valgus Index, determination of inter-item reliability, factor analysis, and benchmarking against three dimensional kinematic models derived from electromagnetic motion tracking of the lower limb. Thirty-six candidate components were reduced to six in the final instrument. The draft version of the instrument predicted 59% of the variance in concurrent Valgus Index scores and demonstrated good inter item reliability (Cronbach's alpha = 0.83). The relevant variables from the motion tracking lower limb model predicted 58-80% of the variance in the six components retained in the final instrument. The finalised instrument predicted 64% of the variance in static standing posture, and 41% of the variance in midstance posture during normal walking. The Foot Posture Index has been subjected to thorough evaluation in the course of its development and a final version is proposed comprising six component measures that performed satisfactorily during the validation process. The Foot Posture Index assessment is quick and simple to perform and allows a multiple segment, multiple plane evaluation that offers some advantages over existing clinical measures of foot posture.
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              Prevalence of flat foot in preschool-aged children.

              Our aim with this study was to establish the prevalence of flat foot in a population of 3- to 6-year-old children to evaluate cofactors such as age, weight, and gender and to estimate the number of unnecessary treatments performed. A total of 835 children (411 girls and 424 boys) were included in this study. The clinical diagnosis of flat foot was based on a valgus position of the heel and a poor formation of the arch. Feet of the children were scanned (while they were in a standing position) by using a laser surface scanner, and rearfoot angle was measured. Rearfoot angle was defined as the angle of the upper Achilles tendon and the distal extension of the rearfoot. Prevalence of flexible flat foot in the group of 3- to 6-year-old children was 44%. Prevalence of pathological flat foot was 90% of the treatments were unnecessary.

                Author and article information

                J Foot Ankle Res
                J Foot Ankle Res
                Journal of Foot and Ankle Research
                BioMed Central (London )
                27 August 2015
                27 August 2015
                : 8
                [ ]Department of Podiatry, Lower Extremity and Gait Studies (LEGS) Research Program, La Trobe University, Bundoora, Melbourne, Australia
                [ ]School of Public Health and Human Biosciences, La Trobe University, Bundoora, Melbourne, Australia
                © Evans and Karimi. 2015

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.

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                weight, paediatric, bmi, body mass index, foot posture, children, flatfeet


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