Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 100700

AbstractMaterial and MethodsResultsDiscussionConclusionAcknowledgementReferencesDOI and Others
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : June | Volume : 16 | Issue : 6 | Page : AC01 - AC05 Full Version

Flat Foot in 14-16 Years Old Adolescents and its Association with Bmi and Sports Activity


Published: June 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53073.16459
R Jagadish Raj, Chamanahalli Appaji Ashwini, Shiv Manik Ajoy

1. Intern, Department of Medicine, MS Ramaiah Medical College, Bengaluru, Karnataka, India. 2. Associate Professor, Department of Anatomy, MS Ramaiah Medical College, Bengaluru, Karnataka, India. 3. Assistant Professor, Department of Orthopaedics, MS Ramaiah Medical College, Bengaluru, Karnataka, India.

Correspondence Address :
Dr. Chamanahalli Appaji Ashwini,
1465, 5th Main, 2nd Stage, 1st Block, Rajajinagar, Bengaluru-560010, Karnataka, India.
E-mail: ashwinicappaji@gmail.com

Abstract

Introduction: The main arches of foot are the medial longitudinal, the lateral longitudinal and the transverse arches. The term pes planus denotes an excessively flat foot. There is no precise degree of flatness that defines pes planus and it may be either physiological or pathological.

Aim: To identify flat foot in age group of 14-16 years by clinical examination, classify them into flexible and rigid and to study the association of Body Mass Index (BMI) and sports activity with flat foot.

Materials and Methods: The present cross-sectional study was conducted on 323 adolescents in the age group of 14-16 years chosen from five high schools in and around MS Ramaiah Medical College Campus, Bangalore, Karanataka, India. Both foot were clinically examined separately, with foot raised off the ground (non weight bearing) and standing on the same foot with the other foot raised (weight bearing position). Presence of arch in non weight bearing and absence in weight bearing was classified as flexible flat foot. Absence in both positions was classified rigid flat foot. The BMI was calculated and history of sports activity was recorded. Descriptive statistics were used to analyse the data.

Results: Out of the total participants, 106 (32.8%) participants had flat foot. Among them, 89.62% were flexible and 10.37% rigid flat foot. Bilateral Pes Planus was common when compared to unilateral, being more prevalent among the male students. Chi-square test gave a p-value of 0.521 for flexible and 0.176 for rigid flat foot in association with BMI.

Conclusion: Flat foot in the age group of 14-16 years is predominantly flexible. Higher prevalence of flexible and rigid flat foot was observed among males. No association between BMI or sports activity with Pes Planus was noted.

Keywords

Body mass index, Flexible, Pes planus, Rigid

There are three arches of the foot, namely; medial, lateral longitudinal and transverse arches. The medial longitudinal arch is characteristic of its elasticity. The plantar fascia, short and long plantar ligaments and spring ligaments are static stabilisers of the foot. It is supported by the plantar calcaeonavicular ligament and small joints of the foot, deltoid ligament which restore the normal position after the stretching in weight bearing movements. The tibialis posterior tendon supports the plantar calcaneonavicular ligament by preventing the undue tension of the ligament and thus, preventing extended stretching. Weakness of tibialis posterior tendon leads to collapse of the medial longitudinal arch (1). Hence, the tibialis posterior is an important muscle providing dynamic support to the foot and the ligaments play a major role in static support thus, maintaining the mechanical integrity of the medial longitudinal arch of foot. The arch is in addition supported by the small ligaments and muscles of the joints of the foot and tendons of tibilais anterior, and peroneus longus. The contribution to the stability of the arches is more significantly by the ligaments than the bones.

The lateral longitudinal arch is characteristic of its stability. Ligaments play a very important role in stabilising the lateral longitudinal arch, especially the lateral part of the plantar aponeurosis and the long and short plantar ligaments. The muscles which support the arch are the extensor tendons and the muscles related to the little toe. The peroneus brevis and tertius act as sling and peroneus longus acts by sustentacular mechanism.

In the transverse arch of the foot, ligaments bind the cuneiforms and metatarsal bases. The transverse arch of the foot is maintained by the plantar, dorsal and interosseus ligaments. The tendon of peroneus longus and tibialis posterior approximates the medial and lateral border of the foot. Both these factor provide stability to the arch, more so to the ligaments (1).

Flat foot (pes planus) is defined as a condition where the medial longitudinal arch of the foot is lost and hence, the whole sole of foot rests on the ground (2). There is no precise degree of flatness that defines pes planus. Development of arch normally starts at the age of 2-3 years and is completely formed by the age of 5-7 years (3). When the foot were evaluated with footprints of children aged less than 10 years using heel to arch width ratio and found that nearly 100% of 2 years were flat-footed but the same pattern was seen only in 4% of 10 year olds. It was believed that foot fat pad obscured the presence of arch. This was objected by a study showing radiographic evidence of actual flattening of the arch (4).

Clinically, flat foot can broadly be classified as flexible and rigid, depending on whether the arch is lost on weight bearing or, respectively. Flexile flat foot can be diagnosed clinically when the foot is flat on standing and reconstitutes with toe walking, hallux, dorsiflexion or foot hanging (5). Rigid flat foot and symptomatic flexible flat foot is an indication for treatment. Symptoms can be vague pain in medial side of ankle, swelling on medial side of foot, difficulty in walking on uneven surfaces, foot fatigue, painful limp and knee or hip pain due to unsteady gait putting stress on these joints.

Most of the literature demonstrates the incidence/prevalence of flat foot in children (9-13 years) and adults. Flat foot has been identified by plantar arch index, navicular drop test or foot posture index (6),(7),(8),(9).According to Mosca VS (10), actual prevalence of flat foot is not known as there is no established literature regarding criteria for defining a flat foot. The discussion is whether flexible flat foot is a variation in normal foot shape or a deformity.

Calcaneonavicular coalition and talocalcaneal coalition if present usually completes around 14-16 years of age and that is why this clinical study has probed into clinical identification of flat foot in this age group and early identification will facilitate immediate treatment and prevent progression of the condition and complications.

The Orthopaedicians diagnose flat foot by clinical examination. Here, the presence or absence of medial longitudinal arch of foot is observed for in weight bearing position. If the arch was present or slightly depressed but visible arch on standing, it is considered normal. Absence of the medial longitudinal arch or convexity of the medial aspect of foot in standing position is considered as flat foot (11),(12),(13). Since studies done in the age group of 14-16 years group were less, the present study was proposed with an aim of assessing the occurrence of flat foot by clinical examination to clinically identify flat foot in age group of 14-16 years.

Study Objectives

• To identify flexible and rigid flat foot in the age group of 14-16 years.
• To study the association of BMI and sports activity with flat foot. Also, to see the association of gender with flat foot.

Material and Methods

The present cross-sectional study was conducted in five high schools in and around MS Ramaiah Medical College campus, Bengaluru, Karnataka, India. The study was conducted in the year November 2018 to May 2019 after Ethics Committee clearance (5/10/2018) with Ethical Clearance Letter Number: MSRMC/EC/2018. Informed consent from the parents and assent from participants were obtained.

Inclusion criteria: Adolescents aged between 14-16 years were included.

Exclusion criteria: Adolescents with neuromuscular conditions and foot deformities other than flat foot were excluded from the study.

Sample size calculation: A study by Babu Y et al., revealed that the prevalence of flat foot disorder was 16% (7). In the present study expecting to get similar results with 95% confidence level and 25% relative precision, the study required a sample of minimum 323 subjects.

Study Procedure

Height, weight, gender and age of the participants was recorded. The BMI was calculated using the data of height and weight of the participants. History of sports activity in participants was documented by asking them questions such as what sports were they playing and number of hours spent in sports. All the participants were screened for flat foot by clinical examination (5),(12),(13). The participants were made to sit so that both the foot were off the ground (in non weight bearing position) and observed for the presence/absence of arch. Then, the participants were made to stand on one foot (in weight bearing position) and again observed for presence or absence of the arch. This was done for both foot. Presence of arch in sitting position and absence of arch on standing indicated flexible flat foot. Absence of arch in both positions indicated rigid flat foot. Photographs and videos were taken as evidence in the above-mentioned clinical examination.

Statistical Analysis

Descriptive statistics of flat foot disorder were analysed and summarised in terms of percentage. Chi-square test (or Fisher’s exact when the count in a cell was ≤5) was used to study the association of flat foot with sports activity, BMI and gender.

Results

Out of the 323 participants. 106 had clinical flat foot and 217 had normal foot. Out of 106, 69 were males and 37 were females. A total of 95 participants had flexible flat foot and 11 had rigid flat foot. The (Table/Fig 1), (Table/Fig 2), (Table/Fig 3) shows the detection of arches in the foot.It was found that 32.8% of participants demonstrated flat foot by clinical examination. Of these 89.63% were flexible and 10.37% were rigid flat foot (Table/Fig 4).

Laterality of Flat Foot

Among the flexible flat foot, bilaterality was seen in 83.16% and unilaterality in 16.84%. Among rigid flat foot, bilaterality and unilaterality was seen almost equally quantifying to 54.54% and 45.45% respectively (Table/Fig 5).

Gender Variation

(Table/Fig 6) demonstrates the gender distribution of flexible and rigid flat foot. Males had a higher incidence of flat foot (flexible and rigid).

Pearson Chi-square test did not reveal any significant association between gender and flexible flat foot (p-value=0.712). For rigid flat foot, since the count in a cell was less than 5, fisher exact test was applied. The fisher test did not show any association between gender and rigid flat foot (p-value=0.215). Hence, no association was observed between gender and flat foot.

Sports Activity and Flat Foot

Among the participants with flat foot, 52 (49.1%) were involved in sports activity. Remaining participants with flat foot that is 54 (50.9%) were not involved in any kind of sports activity. Among the participants with normal foot arches, 121 (55.8%) were involved in sports activity and 96 (44.2%) were not involved in sports activity. Pearson Chi-square test revealed a p-value of 0.257.There was no significant association of flat foot on sports activity.

BMI and Flat Foot

(Table/Fig 7) shows the BMI ranges among the participants having flat foot. High BMI is considered when the value is more than 30 which is called obesity. Only 3.44% and 11% of flexible and rigid flat foot had high BMI (Table/Fig 7). Pearson Chi-square test value was 0.520 for flexible and 0.176 for rigid flat foot. Thus, there was no association between the BMI and the presence of flat foot.

Discussion

Flat foot is a deformity, which is usually physiological and occasionally pathological. The flat foot is present in every newborn and it takes over 10 years for the arches to develop. With increasing age, the prevalence of flat foot decreases, due to the benign nature and spontaneous correction. The real prevalence of symptomatic flat foot is not very high among adolescents (11).

Prevalence of flat foot: The (Table/Fig 8) demonstrates the comparison of prevalence of pes planus among different age groups, based on the various methods of examination (7),(8),(11),(14),(15).

It is observed that the prevalence of flat foot varies anywhere from 0.69% to 48.7% (7),(8),(11),(14),(15). This variation can be attributed to the differing age groups and methodology employed in the detection of flat foot. Another study also mentions the varied results in incidence of flat foot and state the reason as different methodology used to assess flat foot. The authors also mention the criteria within a particular methodology also varies. Hence the difference in the prevalence of flat foot (16).

If the last two studies mentioned in the (Table/Fig 8) are compared, as the age group is almost the same, yet the prevalence of flat foot varies. This could be because of racial origin and difference in sample size.

Morley AJ evaluated the footprints of children aged less than 10 years using heel to arch width ratio and found that nearly 100% of 2-year-old children were flatfooted but the same pattern was seen only in 4% of 10-year olds (3).

It also can be confirmed that the physiological flat foot diminishes by 10-12 years and further lead to correction of flat foot and its actual prevalence leading to complications and disabilities could be actually very low.

It is worthwhile to consider the social and environmental factors which play a role in the shape of the foot. The Indian population generally prefers to be barefooted and shoe wear is limited to occasions like school only. This may be one of the factors giving such varied incidence of pes planus compared to the other studies (7),(8),(11),(14),(15). Another specific cause can be the presence of medial ray instability in individuals. Medial ray instability involves hypermobility of the medial cuneiform and the first metatarsal. The exact evaluation of this is quite complicated and it has been hypothesised to contribute to hallux valgus. It is a known entity which gives rise to flat foot and is now being recognised as a cause for failures in reconstruction in pes planus (17),(18). Another factor to consider is recurrent talotarsal joint dislocation, currently being recognised as a cause for symptomatic pes planus in the adolescent population and this should be considered while evaluating adolescents (5). Its assessment is generally overlooked and could explain the increased incidence of pes planus in the study group, and would need further investigation in this regard. The incidence of a midfoot instability in the Indian population is a subject of discussion in most meetings, but it has still not been evaluated in great detail, for the simple reason that a device to test this objectively has not been designed yet.

Hence, further clinical examination and investigations are required to identify the symptomatic adolescents with pes planus.

Flexible flat foot vs rigid flat foot: Cilli F et al., study showed 100% of flexible flat foot when compared to the present study showing 93.1% of flat foot being flexible. This only demonstrates that flexible flat foot is more commonly present than rigid flat foot. Rigid flat foot is usually congenital and is caused due to bony or soft tissue defects such as tarsal coalition, accessory navicular bone, and congenital vertical talus to name a few (11),(19),(20).

The flexible flat foot is mainly due to laxity of the ligaments than the abnormal bone morphology. The flexible flat foot might progress by external factors such as bone fractures/dislocation/arthritis/tendon abnormalities/excessive weight bearing. Radiographic evidence is not much in patients with flexible flat foot which indicates towards muscle and ligaments as causative factors. Among the muscles, posterior tibial tendon dysfunction and short Achilles tendon are known causes for flexible flat foot (16),(21).

The patients with flexible flat foot are either asymptomatic or symptomatic. The symptomatic ones usually complain of pain on weight-bearing and disability in addition to deformity. Physical evaluation of the muscle action and evidence of laxity of the ligaments is required for deciding on the management. Follow-up would also be required.

Laterality of flat foot: The (Table/Fig 9) shows the comparison of studies on the laterality of the flat foot (7),(8),(14),(22). All studies including the present study demonstrates that bilateral flat foot is more common when compared to unilateral flat foot. Some of the studies have shown that bilateral flat foot could lead to more knee pain and disabilities in future affecting the quality of life than those having unilateral flat foot (23). This could be indicative of a genetic predisposition for occurrence of flat foot.

Gender variation: With respect to gender, most studies demonstrate higher prevalence in females than in males (Table/Fig 10) (14),(24),(25). The present study revealed a higher percentage of flat foot in males when compared to females. The present study (p=0.712, 0.215) and other studies did not show any association between gender and flat foot prevalence (8),(26). Some studies demonstrate higher prevalence of flat foot in males (27). Hence, there is no strong evidence to say either of the gender is significantly associated with flat foot. This could be due to small sample size or sample size not being gender matched.

Sports activity and flat foot: One of the studies tried to find out the association between flat foot and physical activities, BMI and kind of sports in university athletes (n=76, age-18-25). The authors concluded that there was no significant association between physical activity and flat foot among the university athletes (28).

Another study in the age group of 10-14 yrs (n=92) tried to assess the correlation of physical activity and flat foot. Pearson Chi-square test revealed a negative correlation between physical activity and arches of foot (29).

Another study tried to analyse the relationship between the physical activity and age on flat foot of children in elementary school children. Their study showed a significant correlation between age and arches of foot. The arch index reduced as the age increased. The study also demonstrated a strong correlation between flat foot and physical activity (p=0.040). As the child is involved in physical activity the fat pads breaks at a faster rate hence arches are well formed early. Whereas inactivity could lead to flat foot occurrence. Hence, good physical activity in children favours good arch formation (30). No association was found between physical activity and flat foot in the present study.

BMI and flat foot: The present study did not show any significant association between BMI and flat foot. Many studies also have derived a similar conclusion of no association between flat foot and BMI, height and weight (8),(9),(10),(16). One study comprising of adults who were traffic officials demonstrated an association between BMI and flat foot especially among the obese women.

Since, in the present study the sample size did not comprise of many individuals where BMI was >30, this could be one of the reasons for not showing a relation.

Limitation(s)

The study was restricted to adolescents as early detection could lead to early intervention and prevention of complications. The flat foot identification is controversial as detection is being done by various methods. Hence, there is a need to validate the methods against a gold standard method. Race differences, gender matching and detection of flat foot in obese individuals are required for concluding on their association with flat foot.

Conclusion

Flat foot occurrence is moderately prevalent as flexible flat foot in Indian adolescents whereas the rigid flat foot prevalence is low. They may be asymptomatic, but become symptomatic later. Bilateral flat foot being more common than unilateral, indicates a genetic predisposition. The flat foot need not get corrected. The present study did not reveal any association between gender and flat foot, despite being more prevalent among the male. No association was found between BMI, sports activity and flat foot.

Acknowledgement

The authors sincerely thank the institution for supporting and facilitating the research. The authors thank the schools which gave permission to conduct the study. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript.

References

1.
Anthony V D’Antoni. Ankle and foot: In: Susan Standring, editor. Gray’s Anatomy The Anatomical Basis of Clinical Practice. 41st ed. Philadelphia: Elsevier; 2016. p1418-1450.
2.
Michaudet C, Edenfield KM, Nicolette GW, Carek PJ. Foot and ankle conditions: Pes planus. FP Essent. 2018;465:18-23.
3.
Morley AJ. Knock-knee in children. Br Med J. 1957;2:976-79. [crossref] [PubMed]
4.
Gould N, Moreland M, Alvarez R, Trevino S, Fenwick J. Development of the child’s arch. Foot Ankle. 1989;9:241-45. [crossref] [PubMed]
5.
Evan Siegall. Flexible Pes Planovalgus (Flexible Flatfoot). Lineage Medical Inc.; 2021. Updated on 11.2.2021. Cited on 20.12.2021. Availale from: https://www.orthobullets.com/pediatrics/4069/flexible-pes-planovalgus-flexible-flatfoot.
6.
Daniel DK, Chandrasekaran C, Mano A. A study on prevalence of flat feet among school children in kanchipuram population. Int J Anat Res. 2015;3(3):1240-44. [crossref]
7.
Babu Y, Mohanraj KG, Pranati T. Assessment of Plantar Arch Index and Prevalence of Flat Feet among South Indian Adolescent Population. J Pharm Sci Res. 2017;9(4):490-92. [crossref]
8.
Bhoir T, Anap DB, Diwate A. Prevalence of flat foot among 18-25 years old physiotherapy students: Cross sectional study. IJBAMR. 2014;3(4):272-78.
9.
Nurzynska D, Di Meglio F, Castaldo C, Latino F, Romano V, Miraglia R, et al. Flatfoot in children: Anatomy of decision making. Italian Journal of Anatomy and Embryology. 2012;117(2):98-106.
10.
Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop. 2010;4:107-21. [crossref] [PubMed]
11.
Cilli F, Pehlivan O, Keklikçi K, Mahiroğullari M, Kuşkucu M. Prevalence of flatfoot in Turkish male adolescents. Joint diseases and related surgery. 2009;20(2):90-92.
12.
What is the Difference Between Flexible Flatfoot and Rigid Flatfoot? Springfield Podiatry Associates; 2021. (Cited on 20.12.2021). Available from: https://www.springfield-podiatry.com/component/k2/item/117-what-is-the-difference-between-flexible-flatfoot-and-rigid-flatfoot.html.
13.
Damien Jonas Wilson. Flexible vs Rigid Flat foot. News Medical Life Sciences. Azo network; 2021. (Cited on 20.12.2021). Available from: https://www.springfield-podiatry.com/component/k2/item/117-what-is-the-difference-betwe en-flexible-flatfoot-and-rigid-flatfoot.html.
14.
Ukoha UU, Egwu OA, Okafor IJ, Ogugua PC, Igwenagu NV. Pes planus: Incidence among an adult population in Anambra State, Southeast Nigeria. International Journal of Biomedical and Advanced Research. 2012;3(3):166-68. [crossref]
15.
Milenkovic S, Zivkovic M, Bubanj S. Incidence of flat foot in high school students. Physical Education and Sport. 2011;9(3):275-81.
16.
Aenumulapalli A, Kulkarni MM, Gandotra AR. Prevalence of Flexible Flat Foot in Adults: A Cross-sectional Study. JCDR. 2017;11(6):AC17-20. [crossref] [PubMed]
17.
Morton DJ. Hypermobility of the first metatarsal bone; the interlinking factor between metatarsalgia and longitudinal arch strains. J Bone Joint Surg. 1928:10187-96.
18.
Roukis TS, Landsman AS. Hypermobility of the first ray: A critical review of the literature. J Foot Ankle Surg. 2003;42(6):377-90.
19.
Graham ME- Physcian’s guide to Recurrent Talotarsal Joint Displacement. Available from: http://gramedica.com/flipBooks/physicians-guide-rttjd/physicians- guide-rttjd/assets/common/downloads/HyProCurePhysiciansGuide-FINAL_VERSION_9-16_Digital.pdf. (Accessed on 24.9.2020). [crossref] [PubMed]
20.
Raj MA, Tafti D, Kiel J. Pes Planus. [Updated 2021 Aug 3]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430802 (Accessed on 08.10.2021).
21.
Ricco I, Gimigliano R, Porpora G, Iolascon G. Rehabilitative treatment in Flexible flat foot: A perspective cohort study. Musculoskeletal Surgery. 2009;93(3):101-07. [crossref] [PubMed]
22.
Didia BC, Omu ET, Obuoforibo AA. The use of footprints contact index II for the classification of flat foot in a Nigerian population. Foot Ankle. 1987;7(5):285-89. [crossref] [PubMed]
23.
Iijima H, Ohi H, Isho T. Association of bilateral flat feet with knee pain and disability in patients with knee osteoarthritis: A cross-sectional study. JOR. 2017;23565:2490-98. [crossref] [PubMed]
24.
Eluwa MA, Omini RB, Kpela T, Ekanem TB, Akpantah AO. The incidence of Pes Planus amongst Akwa Ibom State students in the University of Calabar. The Internet Journal of Forensic Science. 2009;3(2). [crossref]
25.
Okezue OC, Akpamgbo OA, Ezeukwu OA, John JN, John DO. Adult Flat Foot and its Associated Factors: A Survey among Road Traffic Officials. Nov Tech Arthritis Bone Res. 2019;3(4):65-69.
26.
Pita-Fernandez S, Gonzalez-Martin C, Alonso-Tajes F, Seoane-Pillado T, Pertega-Diaz S, Perez-Garcia S, et al. Flat Foot in a Random Population and its Impact on Quality of Life and Functionality. J Clin Diag Res. 2017;11(4):LC22-27.
27.
Kalra Y, Murthuza A, Geentanjali B, Mokhasi V, Rajini T. Study of footprints to determine the incidence of pes planus in South Indian using Staheli’s plantar arch index. International Journal of Current Research. 2016;8(9):38928-32.
28.
Tiaotrakul A, Jaruchart T, Jangthong P, Matitopanam J, Joychue P, Khomawut A. Prevalence and Correlation between Flat Foot and Related Factors in University Athletes. Journal of Sports Sciences and Health. 2021;22(1):86-102.
29.
Truszczyńska-Baszak A, Drzal-Grabiec J, Rachwal M, Chalubińska D, Janowska E. Correlation of physical activity and fitness with arches of the foot in children. Biomedical Human Kinetics. 2017;9(1):19-26. [crossref]
30.
Jasrin CJ, Mayasari W, Rakhmilla LE. Relationship between Physical Activity and Age on Flatfoot in Children. Althea Medical Journal. 2016;3(3):396-400. [crossref]

DOI and Others

DOI: 10.7860/JCDR/2022/53073.16459

Date of Submission: Nov 17, 2021
Date of Peer Review: Dec 06, 2021
Date of Acceptance: Mar 17, 2022
Date of Publishing: Jun 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Dec 06, 2021
• Manual Googling: Jan 21, 2022
• iThenticate Software: Mar 12, 2022 (9%)

ETYMOLOGY: Author Origin

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com