Document 6446528

THE
INFLUENCE
OF
PREVALENCE
A
SURVEY
UDAYA
From
We analysed
influence
static
of footwear
BHASKARA
Kasturba
of 2300
footprints
FLAT
2300
CHILDREN
RAO,
Medical
JOSEPH
Manipal,
between
children
FOOT
BENJAMIN
College,
THE
India
the ages of four and 13 years
to establish
the
who used footwear
was 8.6% compared
with 2.8% in those who did not
between the predominance
in shod and unshed children were noted in all
with generalised
ligament
laxity.
Flat foot was most common
in children
who wore closed-toe
shoes, less common in those who wore sandals or slippers, and least in the unshod.
Our findings suggest that shoe-wearing
in early childhood
is detrimental
to the development
of a normal
longitudinal
arch.
(p
0.001).
age groups,
In Europe
and
1979),
America
flat foot
at a children’s
but
treatment
in
India
this complaint
all wear shoes.
child
from
the
children
The
farming
who
If the incidence
reason
clinic
are
brought
few children
who
community
or from
complained
of flat
the
these
for
do attend
family
do
radius
of
of 10 km and
and
were
two
located
all the children
English-speakin an area
were
from
with
a
a common
background.
School attendance
in the region
is
good and all the children
at school on the day
of the screening
were included
in the study (Table
I).
Static
footprints
of both feet were obtained
from all 2300
generally
children
the rural
not
(vernacular)
All six schools
ethnic
foot.
children
Kannada-speaking
ing schools.
families
and
never
seen a
of flat foot is so low among
is it because
for
(Sharrard
seldom
are from affluent
urban
In our clinic
we have
labourer
population,
is a common
orthopaedic
for flat foot.
with
they
a manual
children
Significant
differences
most marked
in those
<
attendance
among
OF
ON
of flat foot.
on the prevalence
The incidence
OF
FOOTWEAR
wear
using
Harris
and
and Marshall
differential
Chacko
of shoes
1984;
Joseph
also influence
et al
1987).
the development
ofthe
mediallongitudinal
arch?
Our aims were to establish
the prevalence
offlat
foot
in a population
of schoolchildren
in rural
India
and to
determine
whether
this prevalence
varied
between
shod
and
unshod
of
Our survey
included
girls)
between
the
should
AND
in Orthopaedics
Orth,
Consultant
II
Surgery,
India.
be sent
©
No. 4, JULY
1992
Orthopaedic
used
footwear;
schools
did
not
Kasturba
and
Joint
1063
four
Surgeon
Medical
to Dr B. Joseph.
1992 British
Editorial
Society
of Bone
0301 -620X/92/4421
$2.00
J Bone Joint Surg [Br] 1992 ; 74-B :525-7.
74-B.
schools
in Kannada-speaking
high-
METHODS
2300 children
(1237 boys and
ages of four and 1 3 years
from
U. B. Rao, MB BS, Resident
B. Joseph,
MS Orth,
MCh
Head
ofOrthopaedic
Unit
Department
of Orthopaedic
Manipal
576 1 19, Karnataka,
VOL.
English-speaking
normal,
children.
MATERIAL
Correspondence
in the
50.7% of children
use footwear.
as
mat
Welton
children
and
classified
Rose,
(Joseph,
Jacob
were
footprint
by
arched
or flat (Fig.
1). Some form of footwear
was worn
by I 555 children
while
745 never
used
shoes.
All the
the wearing
footprints
pressure
as described
shoes?
The use of footwear
is known
to increase
the risk
of hallux
valgus
(Sim-Fook
and Hodgson
1958;
Shine
1965)
and
to decrease
the incidence
of hallux
varus
Does
The
the
Beath
(1947)
(1985).
Surgery
and
College,
Fig.
1
Method
ofgrading
footprints.
If the width
of the instep
(AB) at
its widest
part was less than
1 cm the foot was considered
as flat
(right).
If the width
of the footprint
at its narrowest
part (BC)
was less than
1 cm, the arch was considered
high (centre).
All
other
footprints
were considered
normal
(left).
525
526
U. B. RAO,
Table I.
The
number
of children
in each
B. JOSEPH
of the
six schools
and
Footwear
Children
Table
Total
strength
Number
Percent
Kannada/Parkala
543
501
92.3
Kannada/Kadiyali
542
536
98.9
Kannada/Manipal
252
216
85.7
Kannada/Saralabettu
210
197
English/Indrali
263
English/Manipal
630
The
prevalence
high-arched
foot
offlat
Closed-toe
shoes
None
1.6
14.2
21.3
62.9
3.5
35.4
19.1
42.0
4.2
21.7
21.3
52.8
93.8
2.0
22.4
34.5
41.1
254
96.6
32.8
34.0
33.2
0
596
94.6
37.7
13.0
49.3
0
Table
III. The distribution
different
forms
of footwear
foot in each group
is shown
foot
at different
Sandals
Slippers
UnshOd
Total
6
14.3
Normal
243
335
508
462
1548
7
9.1
17.6
High-arched
53
147
130
262
592
8
7.9
26.5
Flat
45 (13.2)
9
5.3
25.5
Total
10
3.8
28.3
foot
11
3.3
31.4
12
2.2
36.9
13
2.5
40.5
#{149}six
children
oftwo
child
elbows,
or morejoints
on a scale
measured
by
Index
(BMI)
was
the weight
(kg) by
with a BMI of
(Bray,
Jordan
for features
fingers,
710 children.
ligament
laxity
who
had
The
(±
2.05
( ±
2.0
bilaterally
and
or both feet
foot.
The
decreased
with
was
taken
The
years
very
1953).
studied,
1 55 1 were
in both feet, 595 had
and 154 (6.7%) had unilateral
prevalence
of flat
foot
increasing
age
(Table
695
as they
wore
considered
a high arch
to
in
or bilateral
progressively
II) ; it was
154
745
different
types
2294
of footwear
The
was
SD).
four were rigid and
laxity
was detected
ratio
of flat foot
in
14.4% compared
with
no ligament
mean
BMI
SD)
foot, only
Ligament
flat
foot in children
is shown
in Table
III.
laxity.
for children
and for those
This difference
with
had
in
children
with
3.3% in those
flat
foot
without
flat foot
is not statistically
was
14.72
it was 14.61
significant.
DISCUSSION
RESULTS
children
arches
flat
test.
ankles.
overall
Morley’s
The
flat (Jack
included
of ligamentous
knees
test
were
not
21 (2.8)
the year
comparable
which
513
Of those with
a negative
Jack’s
(m). Individuals
to be overweight
each
were
57 (8.2)
(p < 0.001).
The
frequency
of
wearing
various
types of footwear
of each child
was measured
of 100 g ; their height
was
thumbs,
31 (6.0)
341
to indicate
generalised
ligament
laxity.
Genu
valgum,
femoral
and tibial
torsional
abnormalities
and shortness
ofthe
calcaneal
tendon
were noted.
We performed
Jack’s
one
flat
wearing
of flat
14.9
Sims 1976).
We examined
Of the 2300
have normal
children
percentage
Closed-toe
shoes
the square
of the height
over 24 were considered
on all feet
types
among
children.
The
Footprint
a stadiometer.
The
Body
Mass
calculated
for each child
by dividing
Hypermobility
of footprint
and unshod
in parentheses
High-arched
feet (per cent)
The weight
an accuracy
of the
(percentage)
Slippers
during
laxity
sc reened
Flat foot
(per cent)
Age
(yr)
and
of children
habits
Sandals
ages
with
shoe-wearing
sereened
Language/
location
ofschool
II.
and
their
12.1%
among
children
attending
English-speaking
schools
and
3.5% in those at Kannada-speaking
schools
(p < 0.001).
There
was a significantly
higher
prevalence
in children
who wore
shoes
(8.6%)
than
among
the unshod
(2.8%)
prevalence
with
of
that
reported
of age, however,
low, while
in the
value.
distinctly
higher
flat
foot
in
by Morley
among
unshod
shod
children
incidence
this
study
was
At ten
(1957).
children
it was
it was as high as
in children
who
used
footwear
suggests
that shoe-wearing
predisposes
to flat
foot.
Before
accepting
a causal
relationship,
however,
some confounding
variables
should
be excluded.
Among
factors
known
to be associated
with flat foot are ligament
laxity
and
obesity
(Sharrard
1979).
It has also
been
established
that
there
is a tendency
for the arch
to
improve
spontaneously
with
age (Morley
1957) as was
also shown
in our study
(Table
II). A higher
proportion
of younger
children
or children
with ligamentous
laxity
among
for the
those who wore shoes,
however,
did not account
high incidence
of flat foot in them since the trend
THE
JOURNAL
OF BONE
AND
JOINT
SURGERY
THE
INFLUENCE
Table
IV.
in various
Percentage
age groups
of normal,
Number
unshod
Shod
Unshod
Shod
UnshOd
Shod
UnshOd
p-value
97
70.1
72.1
12.6
18.6
17.3
9.2
NS
61.0
17.0
34.5
10.1
4.5
0.001
9to
506
242
70.2
65.2
23.3
34.3
6.5
0.4
0.001
353
229
66.0
55.0
30.3
43.7
3.7
1.3
0.001
10
II
Percentage
ligament
of normal,
laxity
<
high-arched
Number
shod
6
8
10
I1
<6
8
of the groups
between
the
This
analysed,
prevalence
suggests
Number
unshod
127
182
132
65
50
65
52
37
104
47
1 12
190
192
283
374
288
and
was independent
laxity
(Table
in the study.
flat
any
factor
It seems
that closed-toe
of the arch of the foot
This
may
be because
children.
These
observations
Our
in early
normal
ibility
VOL.
that
begun
cross-sectional
study
childhood
is detrimental
74-B,
No. 4, JULY
1992
without
Unshod
Shod
Unshod
p-value
65.4
76.0
14.2
12.0
20.5
12.0
67.0
56.9
13.2
33.8
19.8
9.2
64.4
58.5
78.8
54.1
21.2
29.2
21.2
43.2
14.4
12.3
0
2.7
NS
0.001
0.05
NS
76.0
68.1
10.6
25.5
13.5
6.4
76.7
72.2
67.7
63.4
61.6
55.2
19.4
24.1
30.6
34.8
37.9
43.8
3.9
3.7
1.7
evident
if there
is associated
most
V).
ligament
laxity.
be encouraged
sandals
are less
We
to play
harmful
The authors
thank
Dr R. S. Phaneendra
Rao and Dr T. N. Sugathan
of
the Department
of Community
Medicine,
Kasturba
Medical
College,
for their assistance,
Mr T. S. Krishna
Rao and Mrs Y. Shreemathi
for
the statistical
analysis,
and Dr S. Solomon
of SLRTC,
Karigiri,
for
providing
the Harris
and Beath
mat.
No benefits
the
0.05
0.01
0.001
0.05
1.8
0.5
1.0
suggest
that
children
should
unshod
and that
slippers
and
than closed-toe
shoes.
from
this
in any form
a commercial
party
have
related
been
received
directly
or will be received
or indirectly
to the
subject
of
article.
muscle
contrary
to the
earlier.
suggests
that shoe-wearing
to the development
of a
or a high medial
longitudinal
for flat foot among
children
and
Shod
the arch is before
six years.
This hypothesis
is supported
by the observations
of Rose et al (1985)
who noted
that
‘treatment’
for flat foot instituted
after the age of four is
than
with
Unshod
statement
of Kelsey
(1982)
that there
is no evidence
that
the type offootwear
influences
the occurrence
offlat
foot.
The high concentration
of flat foot among
six-yearold children
who wore shoes as compared
with those who
did not, implies
that the critical
age for development
of
less effective
children
shoes
inhibit
more
than
do
intrinsic
are
unshod
Shod
who wear slippers
and sandals
as they are more
removed
than
shoes.
Such
interludes
of unshod
may account
for the lower prevalance
of flat foot
in these
and
Unilateral/
bilateral
flat foot
detri-
who used footwear.
foot also varied
with
shod
Unilateral/
bilateral
high arch
development
of a normal
arch leads
to a
of high-arched
feet and a high
one of
in children
of flat
among
feet
we noted
an inverse
of flat foot and of
that
feet
Normal
activity
is necessary
to keep
slippers
from
falling
off.
Rural
Indian
children
who normally
use footwear,
tend
to play
barefoot,
and
this
is more
common
among
children
easily
activity
children
Unilateral/
bilateral
fla t foot
was seen in all age groups
(Table
IV)and
of the presence
or absence
of ligament
In addition,
there were no obese
children
or sandals.
unshod
Unilateral/
bilateral
hi gh arch
9 to 10
>11
slippers
and
72.9
7 to
type of footwear.
the development
shod
527
177
ligaments
as was seen
preponderance
among
FOOT
465
>
foot,
The
feet
FLAT
7 to 8
9to
flat
flat
OF
231
7 to
mental
to the
low proportion
and
PREVALENCE
<6
Lax ligaments
feet.
high-arched
THE
Norm al feet
Age
(yr)
high-arched
ON
Number
shod
Table
V.
generalised
In each
relationship
FOOTWEAR
Age
(yr)
>
Normal
OF
arch.
The
who wear
susceptshoes
is
REFERENCES
GA, Jordan
Bray
algorithm.
HA,
in Canadian
Canada,
1947.
Jack
EA.
Evaluation
of the
obese
patient.
1. An
1976; 235:1487-91.
JAMA
RI, Beath T. Army
Harris
EA.
Sims
foot survey
soldiers.
Ottawa:
Naviculo-cuneiform
fusion
: an investigation
National
of foot ailments
Research
in the
Council
treatment
of
flat
of
J
foot.
Bone Joint Surg [Br] 1953 ; 35-B :75-82.
Joseph
B, Chacko
congenital
and
study.
FootAnkle
Joseph
B, Jacob
T, Chacko
V. Hallux
1984; 23:392-7.
FootSurg
KelseyJL.
Morley AJM.
GK,
Press,
1982;
a study
-
EA,
in children.
Marshall
Surg [Br]
Sharrard
WJW.
Paediatric
Oxford,
etc : Blackwell
lB.
Incidence
community.
Sim-Fook
shoe
[Am]
of
L, Hodgson
AR.
and
shoe-wearing
1958; 40-A:l058-62.
New
Br MedJ
1957;
York
J
cases.
: Oxford
2:976-9.
T. The diagnosis
1985; 67-B :71-8.
offlat
orthopaedics
and
Scientific
Publications,
fractures.
1979.
hallux
BrMedJ
of thirty
of
178-82.
Knock-knee
Welton
J BoneJoint
Shine
varus
Epidemiologyofmusculoskeletaldisorders.
University
Rose
V, Abraham
T, Jacob
M.
Pathomechanics
acquired
hallux
varus : a clinical
and anatomical
1987; 8:137-43.
1965;
valgus
in
a
partially
foot
in the child.
Second
ed.
shoe-wearing
1:1648-50.
A comparison
Chinese
of foot forms among the nonJ Bone Joint Surg
population.