http://fai.sagepub.

com/
Foot & Ankle International
http://fai.sagepub.com/content/34/5/673
The online version of this article can be found at:

DOI: 10.1177/1071100712471662
2013 34: 673 originally published online 25 January 2013 Foot Ankle Int
Heather Barske, Ruth Chimenti, Josh Tome, Elizabeth Martin, Adolph S. Flemister and Jeff Houck
Lengthening Procedure
Clinical Outcomes and Static and Dynamic Assessment of Foot Posture After Lateral Column

Published by:
http://www.sagepublications.com
On behalf of:

American Orthopaedic Foot & Ankle Society

can be found at: Foot & Ankle International Additional services and information for

http://fai.sagepub.com/cgi/alerts Email Alerts:

http://fai.sagepub.com/subscriptions Subscriptions:
http://www.sagepub.com/journalsReprints.nav Reprints:

http://www.sagepub.com/journalsPermissions.nav Permissions:

What is This?

- Jan 25, 2013 OnlineFirst Version of Record

- Apr 30, 2013 Version of Record >>

by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
Foot & Ankle International
34(5) 673 683
The Author(s) 2013
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1071100712471662
fai.sagepub.com
Adult-acquired flatfoot deformity (AAFD) is a common clini-
cal problem presenting to the orthopedic surgeon. The causes
of adult-acquired flatfoot are multiple. The planovalgus defor-
mity occurs secondary to dysfunction of the posteromedial
soft tissues of the foot. Commonly, the posterior tibialis ten-
don becomes incompetent, leading to attenuation of the liga-
mentous support of the medial longitudinal arch. This results
in peritalar subluxation with varying degrees of increased
hindfoot valgus, flattening of the medial longitudinal arch,
forefoot abduction, and forefoot varus.
17,22,24
The repetitive microtrauma on the posteromedial hind-
foot with activity causes pain and leads patients to seek
medical attention. Treatment of AAFD is initially nonoper-
ative.
17,22,24
If this fails, operative treatment is based on
staging of the disease. Johnson and Strom
18
originally cat-
egorized AAFD into 3 stages based on the extent of the
deformity and the flexibility of the subtalar joint. Stage II
disease is characterized by a flexible pes planovalgus defor-
mity where the subtalar joint is flexible and the hindfoot
valgus is correctable actively or passively. Controversy sur-
rounds the surgical treatment of stage II disease. There is
agreement that stage II flatfoot should be corrected with
471662FAIXXX10.1177/1071100712471
662Foot & Ankle InternationalBarske et al
2013
1
University of Manitoba, Winnipeg, MB, Canada
2
University of Rochester, School of Nursing, Ithaca College, Department
of Physical Therapy, Rochester, NY, USA
3
Ithaca College Movement Analysis Laboratory, Rochester, NY, USA
4
University of Rochester Medical Center, Department of Orthopaedics,
Rochester, NY, USA
5
Physical Therapy, Ithaca College, Rochester, NY, USA
Corresponding Author:
Heather Barske, MD, FRCSC, University of Manitoba, Surgery, 75
Poseidon Bay, Winnipeg, MB, R3M 3E4 Canada
Email: [email protected]
Clinical Outcomes and Static and Dynamic
Assessment of Foot Posture After Lateral
Column Lengthening Procedure
Heather Barske, MD, FRCSC
1
, Ruth Chimenti, PT, DPT
2
, Josh Tome
3
,
Elizabeth Martin, MD
4
, Adolph S. Flemister, MD
4
, and Jeff Houck, PT, PhD
5

Abstract
Background: Lateral column lengthening (LCL) has been shown to radiographically restore the medial longitudinal arch.
However, the impact of LCL on foot function during gait has not been reported using validated clinical outcomes and gait
analysis.
Methods: Thirteen patients with a stage II flatfoot who had undergone unilateral LCL surgery and 13 matched control
subjects completed self-reported pain and functional scales as well as a clinical examination. A custom force transducer was
used to establish the maximum passive range of motion of first metatarsal dorsiflexion at 40 N of force. Foot kinematic data
were collected during gait using 3-dimensional motion analysis techniques.
Results: Radiographic correction of the flatfoot was achieved in all cases. Despite this, most patients continued to report
pain and dysfunction postoperatively. Participants post LCL demonstrated similar passive and active movement of the
medial column when we compared the operated and the nonoperated sides. However, participants post LCL demonstrated
significantly greater first metatarsal passive range of motion and first metatarsal dorsiflexion during gait than did controls
(P < .01 for all pairwise comparisons).
Conclusion: Patients undergoing LCL for correction of stage II adult-acquired flatfoot deformity experience mixed
outcomes and similar foot kinematics as the uninvolved limb despite radiographic correction of deformity. These patients
maintain a low arch posture similar to their uninvolved limb. The consequence is that first metatarsal movement operates at
the end range of dorsiflexion and patients do not obtain full hindfoot inversion at push-off. Longitudinal data are necessary
to make a more valid comparison of the effects of surgical correction measured using radiographs and dynamic foot
posture during gait.
Level of Evidence: Level III, comparative series.
Keywords: atfoot, lateral column lengthening, kinematics, gait analysis
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
674 Foot & Ankle International 34(5)
joint-sparing procedures; however, the best combination of
soft tissue procedures and realignment osteotomies is not
defined by the current literature.
11
A lateral column lengthening (LCL) procedure com-
bined with soft tissue techniques spares the joints of the
foot while improving alignment. Evans
6
first described the
lateral column lengthening procedure in 1975. Sangeorzan
et al
26
applied the procedure to the stage II AAFD. Currently,
an LCL is often chosen to correct the stage II flatfoot
because it simultaneously corrects the hindfoot valgus and
forefoot abduction, raises the medial longitudinal arch, and
unloads the first metatarsocuneiform joint.
5,11,26
It does this
by adducting and plantar flexing the midfoot around the
talar head. An LCL has been shown to provide greater
realignment than a medializing calcaneal osteotomy.
2
It is a
popular choice for correction of the flexible flatfoot and has
resulted in good patient outcomes.
7,11,12
A survey of foot and
ankle surgeons in 2002 revealed that 41% of surgeons per-
formed lateral column lengthening as part of the bony pro-
cedure in the correction of a flatfoot.
11
Despite more than 2 decades of use of the lateral column
lengthening in AAFD, few data are available to inform
patients about their expected status if they elect these proce-
dures. A few studies have reported improvement in
American Orthopaedic Foot & Ankle Society (AOFAS)
scores, but no studies have been performed using validated
musculoskeletal outcome measures.
12,21,28
General health
scores such as the SF-12 and SF-36 have been used to assess
patients after LCL.
25,28
Alterations in alignment of the
medial longitudinal arch on weight-bearing radiographs
also have been assessed after LCL procedures. The lateral
talusfirst metatarsal angle or Mearys line has good inter-
and intraobserver correlation and is used to assess collapse
through the talonavicular, naviculocuneiform, and first tar-
sometatarsal joints.
32
Normal values are within 7 degrees of
neutral.
32
Studies have reported correction of these radio-
graphic angles following LCL.
2,10
Untested in previous studies is the influence of LCL pro-
cedures on medial longitudinal arch motion, defined by pas-
sive range of motion (ROM) and walking foot kinematics of
the first metatarsal. Although the LCL procedures are
designed to spare joint function, there has been little empha-
sis on evaluating joint function after LCL procedures.
Kinematic studies during gait show that persons with AAFD
demonstrate greater hindfoot eversion, greater first metatar-
sal dorsiflexion (suggesting lowering of the medial longitu-
dinal arch), and increased forefoot abduction compared
with healthy controls.
15,29
Weakness of the tibialis posterior muscle has been associ-
ated with these changes in foot kinematics.
23
Recent work has
also demonstrated greater first metatarsal dorsiflexion relative
to the calcaneus during bilateral heel raises in people with
AAFD.
13,15
Although the functional consequences of these
alterations in foot kinematics are unknown, improvement in
radiographic alignment associated with LCL procedures
may also influence passive ROM of the first metatarsal and
hindfoot eversion kinematics during walking. Damage to
ligaments that stabilize the midfoot in AAFD raises the pos-
sibility of greater passive ROM of the first metatarsal.
Theoretically, the LCL procedure may tighten the medial
foot ligaments, decreasing ROM and restricting foot kine-
matics during walking. To date there have been no studies
addressing the influence of lateral column lengthening on
passive ROM or forefoot kinematics during walking.
The purpose of this case-control study was to (1) clini-
cally assess participants post LCL (in terms of maximum
number of heel raises, foot posture, and radiographic
angles); (2) assess self-reported function between partici-
pants post LCL and controls (using the visual analogue
scale [VAS] for pain and Short Musculoskeletal Functional
Assessment [SMFA]); and (3) compare foot ROM mea-
sures collected passively and during walking in participants
post LCL and in controls. For the clinical assessment we
hypothesized that heel raise ability and arch height index of
the participants post LCL would be similar to those of con-
trols. We also compared radiographic angles collected before
and after surgery. We hypothesized that weight-bearing
radiographic findings would demonstrate decreased talus
first metatarsal angles after surgery compared with before
surgery. The SMFA was used to compare self-reported
function between participants post LCL and controls. We
hypothesized that the SMFA scores and VAS pain ratings
would approach data from controls. Last, we compared
3-dimensional motion analysis of the operated and nonop-
erated sides of the participants post LCL and controls. The
focus was on passive and active (ie, walking) movement of
the first metatarsal and active (ie, walking) movement of
the calcaneus. We hypothesized that the participants post
LCL would show similar movements when we compared
the operated and nonoperated sides. However, because
many patients with AAFD have a flatfoot posture bilater-
ally, we hypothesized that when the operated and nonoper-
ated sides were compared with controls they would show
greater passive first metatarsal ROM and actively greater
first metatarsal dorsiflexion and greater hindfoot eversion,
indicating a greater flatfoot.
Material and Methods
Participants
All patients who had undergone an LCL procedure between
2006 and 2009 for stage II AAFD by 1 of 2 fellowship-
trained foot and ankle surgeons were invited to partici-
pate. Subjects were excluded if they were unable to
ambulate 50 feet without significant discomfort or diffi-
culty, had a comorbid condition (eg, insensate feet, metatar-
sus primus varus) in the same foot as AAFD surgery, had a
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
Barske et al 675
history of ipsilateral lower extremity pain or surgery not
due to AAFD, or had a postoperative infection or other seri-
ous operative complication. Thirty-four patients were eli-
gible for the study. Thirteen agreed to participate and
completed the testing session (Table 1). All patients under-
went an LCL combined with a flexor digitorum longus
transfer to the navicular. For the LCL, iliac crest autograft
was used in 11 of 13 patients; allograft iliac crest was used
in 2 patients. Six patients had a triple hemisection Achilles
tendon lengthening, and 6 had a gastrocnemius recession.
Four patients had a first tarsometatarsal fusion at the time
of their flatfoot reconstruction.
Control subjects were healthy individuals without foot
or ankle abnormality or discomfort who were recruited
from the general population. They were of similar age and
gender as subjects with AAFD. The exclusion criteria
described above were used. Control subjects completed the
same self-report questionnaires and laboratory testing ses-
sion with kinematic analysis as did subjects with AAFD.
However, controls were not included in the radiographic
analysis. Thirteen healthy volunteers participated. Control
participants were statistically similar for age (t = 0.17, P =
.87) and gender (
2
= 1.18, P = .28) but not for body mass
index (t = 2.52, P = .02) (Table 1). All subjects signed a
consent form and were informed of the study procedures
and risks consistent with an approved protocol by associ-
ated institutional review boards.
Clinical Assessment
All patients underwent a single laboratory testing session by
an independent examiner that included a clinical assessment
(maximum number of heel raises and arch height index),
self-report measures (VAS pain and SMFA), and a move-
ment analysis test. The number of heel raises each participant
was able to perform was determined for each side. During
testing each participant was required to achieve a height
similar to that achieved in the initial attempt. The number of
heel raises was stopped when the participants stopped,
started bending their knee, or lost heel height compared with
their initial attempt. The arch height index was used to deter-
mine the degree of pes planus deformity on the involved side
as described by Williams and McClay.
31
The arch height
index is a ratio of the height of the dorsum of the foot divided
by the length. The dorsum height is taken at 50% of the foot
length, divided by the foot length from the heel to the base of
the distal first metatarsal head.
31
Greater values indicate a
higher arch. Arch height index values can be compared with
uninjured samples reported in the literature.
Self-Reported Function
To assess function, patients completed the SMFA question-
naire and a VAS for pain. To assess pain level, we asked
each participant to rank his or her pain at its best, and worst,
in the last week on a 0 to 10 scale, where 10 was the worst
pain the participant could imagine. The SMFA is a 46-item
self-report questionnaire. The questionnaire assesses the
indices Function (25 items, including mobility [9 items])
and Bothersome (12 items).
20,27
The scale was originally
developed with 420 patients who had acute fracture or soft
tissue injury. Content, convergent, and construct validity
was demonstrated with clinical data, Short Form-36 results,
and life-change data with very few ceiling effects and no
floor effects reported.
20,27
The extensive normative data that
exist for the SMFA make the scale helpful to compare data
from the proposed study with population norms.
16
The
SMFA is also particularly suitable for the current investiga-
tion given the presence of a subcategory of questions that
pertains specifically to mobility.
Radiographic Assessment
Standing anteroposterior and lateral radiographic views of
the affected foot were reviewed preoperatively and at latest
follow-up. The long axis of the talus and first metatarsal
was used to measure the lateral and anteroposterior talus
first metatarsal angles. The weight-bearing lateral views
were also used to assess naviculocuneiform sag, which was
graded as present or absent. Although the presence or
absence of sag has not been evaluated for reliability, it is
included here because it is used clinically as an indicator of
arch correction.
First Metatarsal Range of Motion
Passive ROM of the first metatarsal was assessed using a
custom-designed force gauge motivated by previous
devices.
8,9
A force gauge (model SML-25 Interface,
Scottsdale, Arizona) was calibrated using known weights
(r
2
= 0.977) and integrated into a custom jig to move the
distal end of the first metatarsal (Figure 1). Pads con-
nected in series with the force gauge were designed to fit
around the first metatarsal head without disturbing the
markers used to track movement during the walking
analysis (Figure 1). To evaluate first metatarsal dorsiflex-
ion and first metatarsal plantar flexion ROM, the follow-
ing procedures were used. The participants were positioned
seated with the leg vertical and foot resting on a step. The
foot was placed with the second metatarsal on the edge of
the step, allowing the force gauge to be placed on the first
metatarsal head. The bottom pad was adjustable to accom-
modate the shape of the metatarsal head for each partici-
pant. Once the force gauge was adjusted for each
participant, two 40-N upward (dorsiflexion) and down-
ward (plantar flexion) loads were applied to each patient.
An oscilloscope was used to display the force readings in
real time. Using the oscilloscope feedback, the examiner
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
676 Foot & Ankle International 34(5)
Table 1. Demographics
LCL Subjects Age, y Sex BMI, kg/m
2
Side
Involved Procedures
Time Since
Surgery, mo
1 66 F 25.9 Right FDL, LCL, ICBG,
GR, first TMT
18
2 65 F 29.3 Left FDL, LCL, ICBG,
GR, first TMT
35
3 50 F 26.6 Left FDL, LCL, ICBG,
GR, first TMT
21
4 72 F 27.1 Left FDL, LCL, ICBG,
TAL, first TMT
56
5 60 F 27.8 Left FDL, LCL, ICBG,
TAL, Spring
11
6 60 F 38.3 Right FDL, LCL, ICBG,
TAL
28
7 62 F 29.3 Left FDL, LCL, GR,
Spring, Allog
19
8 51 M 32.3 Left FDL, LCL, ICBG,
GR
14
9 59 F 44.9 Right FDL, LCL, Allog,
MCL
27
10 71 F 30.0 Left FDL, LCL, ICBG,
GR
48
11 52 F 32.5 Right FDL, LCL, ICBG,
TAL
12
12 48 F 21.3 Left FDL, LCL, ICBG,
TAL
21
13 35 F 54.4 Right FDL, LCL, ICBG,
TAL
10
LCL group
a
(n = 13) 57.8 10.3 92% F 32.3 8.9 62% Left NA 24.6 14.2
Controls
a
(n = 13) 57.2 5.4 77% F 25.5 3.8 NA NA NA
Statistical value, P value t = 0.17, P = .87
b

2
= 1.18, P = .28
c
t = 2.52, P = .02
b
NA NA NA
Abbreviations: Allog, iliac crest allograft; BMI, body mass index; F, female; FDL, flexor digitorum longus transfer to the navicular; first TMT, first
tarsometatarsal fusion; GR, gastrocnemius recession; ICBG, iliac crest bone graft; LCL, lateral column lengthening; M, male; MCL, medial collateral
ligament repair; NA, not applicable; Spring, spring ligament repair; TAL, triple hemisection tendo-Achilles lengthening.
a
Data presented as mean standard deviation unless otherwise indicated.
b
Independent samples t test.
c
Chi-square test for independence.
was able to hold the 40-N positions (dorsiflexion or plan-
tar flexion) for 1 to 2 seconds. During this 1- to 2-second
interval, 1 second of kinematic data were collected (see
description below). The sequence of applying the dorsi-
flexion and plantar flexion 40-N load was random, vary-
ing for each participant, in order to minimize sequence
effects. Prior to the start of data collection, 4 control par-
ticipants repeated this procedure on separate days to
determine reliability. The between-day correlation coeffi-
cients were 0.99 and 0.83 for dorsiflexion and plantar
flexion, respectively. The range of errors between days
was 0.1 to 1.0 degrees for dorsiflexion and 1.1 to 3.1
degrees for plantar flexion.
Foot Kinematic Measurements
Foot kinematics were collected to determine first metatarsal
movement in the sagittal plane (dorsiflexion) and hindfoot
movement in the frontal plane (eversion). The foot segments
measured were the tibia, calcaneus, first metatarsal, second
to fourth metatarsals, and hallux. Infrared emitting diodes
were mounted on thermoplastic molded platforms and
placed directly on the skin overlying the calcaneus (hindfoot
segment), first metatarsal (first metatarsal segment), second
to fourth metatarsals, and hallux (Figure 2). The hallux and
second to fourth metatarsal segment data were not used in
this analysis. Placement of the thermoplastic platforms was
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
Barske et al 677
based on previous studies that showed good repeatability and
validity of tracking the hindfoot and first metatarsal seg-
ments using skin-mounted sensors.
14,30
Foot segment move-
ment was tracked at 60 Hz using a 6-camera Optrotrak
Motion Analysis System (Northern Digital, Waterloo,
Canada). Data processing included smoothing the kinematic
signal using a fourth-order, zero phase lag, Butterworth filter
with a cut-off frequency of 6 Hz.
Segment angles were determined by first referencing
rigid body representation of each segment to digitized bony
landmarks consistent with previous studies.
15,23,29
The con-
ventions used result in a right-hand Cartesian reference sys-
tem for each segment (tibia, hindfoot, and first metatarsal).
Once reference frames were established, a Z-X-Y sequence
of rotations was used to calculate 2 angles: first metatarsal
dorsiflexion/plantar flexion with respect to the hindfoot, and
hindfoot inversion/eversion with respect to the tibia. The first
metatarsal plantar flexion/dorsiflexion angle was a rotation
around a medial-lateral axis (ie, motion in sagittal plane). The
hindfoot inversion/eversion angle was a rotation around an
anterior-posterior axis (ie, motion in frontal plane).
Participants were asked to walk down a 10-m walkway
at a speed of 1 m/s to capture foot kinematics. To ensure that
participants walked at the target speed, speed was moni-
tored with the use of a timing system (Brower, Salt Lake
City, Utah) and maintained during testing to within 5% of
the target speed of 1 m/s. This slow walking speed was used
to accommodate subjects with more severe problems. At a
10-N threshold, an embedded force plate (model 9286,
Kistler, Switzerland) was used to identify initial contact and
toe-off points during stance with force data collected at
1000 Hz. Each subject completed a minimum of 5 success-
ful trials consisting of full contact with the force plate.
Analysis
To assess the proposed hypotheses, a variety of statistical
analyses were used. For the clinical assessment variables,
2-sided independent samples t tests were used to compare
the means of the participants post LCL to controls for the
best/worst pain score. One-way analyses of variance
(ANOVAs) were used to assess differences between the
3 groups (LCL involved side, LCL uninvolved side, con-
trols) in the maximum number of single-limb heel raises
and the arch height index. If there were significant differ-
ences between the 3 groups with the 1-way ANOVA, then
pairwise comparisons were used to test for significant dif-
ferences among LCL involved side, LCL uninvolved side,
and controls. Repeated-measures t tests were used to com-
pare radiographic angles before and after surgery.
A mixed-effects 2-way ANOVA was used to examine for
differences in self-reported function between groups (LCL
and controls) by SMFA subscore. The fixed factor was
group with 2 levels (LCL and controls). The random factor
was SMFA subscore with 3 levels (Function, Mobility, and
Bothersome). The presence of interaction effects was deter-
mined prior to assessing main effects. A main effect, indi-
cating higher scores in the LCL group (ie, worse function)
across all SMFA subscores, would result in a rejection of
the initial hypotheses that the LCL group would report simi-
lar function as controls.
Prior to analysis of the first metatarsal data, preliminary
analyses were completed. Because some patients received a
first tarsometatarsal fusion, this subgroup was initially ana-
lyzed separately to assess the effect on first metatarsal
ROM. Descriptive data (Tables 1 and 2) and an indepen-
dent-samples t test demonstrated that there were no signifi-
cant differences in passive first metatarsal ROM between
Figure 1. Force gauge mounted on the first metatarsal head
to apply a 40-N superior(dorsiflexion) and downward (plantar
flexion) force.
Figure 2. Infrared emitting diodes on thermoplastic molded
platforms placed overlying the calcaneus, first metatarsal, second
through fourth metatarsals, and hallux.
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
678 Foot & Ankle International 34(5)
people with (n = 4) and without (n = 9) a first tarsometatar-
sal fusion (t = 0.06, P = .96). Because of the small sample,
this analysis does not rule out a subtle effect of the first
tarsometatarsal fusion on ROM, yet large effects were not
evident. Thus, for subsequent analyses, the LCL involved
group included both people with and without a first tarso-
metatarsal fusion. Because there were no significant differ-
ences between sides for the control group for all passive
ROM and walking kinematics (paired t tests, P > .05 for all
comparisons), the left side was arbitrarily chosen as the
involved side for the control group.
One-way ANOVAs were used to compare the average
passive ROM variables between the 3 groups (LCL
involved, LCL uninvolved, and controls). The average of
the maximum first metatarsal plantar flexion/dorsiflexion
from the two 40-N trials was used in the analysis. In addi-
tion, the difference between the maximum first metatarsal
dorsiflexion and first metatarsal plantar flexion was com-
puted to evaluate the total first metatarsal passive ROM. A
1-way ANOVA was used to compare first metatarsal plantar
flexion passive ROM between the LCL involved, LCL
uninvolved, and controls. The same 1-way ANOVA proce-
dures were used for first metatarsal dorsiflexion. For each
dependent variable, in the presence of a significant main
effect of a 1-way ANOVA, pairwise comparisons were per-
formed to detect differences among the 3 groups (LCL
involved, LCL uninvolved, and controls). A significant
main effect followed by significant pairwise comparisons
indicating greater first metatarsal dorsiflexion of the LCL
involved and LCL uninvolved groups compared with con-
trols was consistent with a hypothesis of increased forefoot
mobility.
One-way ANOVA models were also used to evaluate
foot kinematic data during walking. Initially, walking trials
were time normalized to 100% of stance, resulting in 101
points for each walking trial across stance. Subsequently, a
minimum of 3 trials were averaged for each kinematic vari-
able to gain a representative pattern for each subject. Key
points of gait were chosen to reflect patterns of first meta-
tarsal plantar flexion/dorsiflexion (initial contact, 12% of
stance, 78% of stance, toe-off) and hindfoot inversion/eversion
(initial contact, 25% of stance, 92% of stance, toe-off).
15

For each key point of gait, for each dependent variable a
1-way ANOVA was used to test for group main effect. If
significant, this was followed by pairwise comparisons to
determine which groups differed (LCL involved, LCL unin-
volved, and controls). As with the passive ROM variables,
we hypothesized that there would be a main effect of group
for all gait ROM variables. Furthermore, we hypothesized
that pairwise comparisons would demonstrate no differ-
ences between the involved and uninvolved side of the LCL
groups and that both LCL groups would have a greater
amount of passive ROM than the control group. All data
analyses were performed using SPSS 17.0 for Windows
(SPSS Inc, Chicago, Illinois). Statistical significance was
defined as a 2-tailed P value .05 for all analyses.
Results
Clinical Assessment
The number of single heel raises was significantly different
among groups; however, the arch height index was not dif-
ferent among groups. Controls demonstrated a significantly
higher number of single-limb heel raises than the LCL
involved (P < .01) and LCL uninvolved sides (P < .01).
However, there was no difference from the LCL involved
to the LCL uninvolved side (P = .2). A 1-way ANOVA
indicated that there were no significant differences in arch
height index between the LCL involved, LCL uninvolved,
and control groups (P = .11) (Table 3).
Self-Reported Function
There were significant differences in the VAS pain and
SMFA scores. The best VAS pain scores were not different
between the LCL and control groups (P = .15). However,
the LCL group reported greater pain on the VAS for worst
Table 2. Radiographic Measures
Decrease in TalusFirst
Metatarsal Angle, deg
LCL Subjects AP View Lateral View
1 27 16
2 10 38
3
4 8 21
5 25 33
6 25 28
7 29 7
8 14 17
9 18 18
10 5 11
11
12 13 8
13 11 17
LCL group involved
side
a
(n = 13)
17.5 16.6 15.4 10.4
LCL group uninvolved
side
a
(n = 12)
NA NA
Controls
a
(n = 13) NA NA
Statistical value, P value t = 6.64, P < .01
b
t = 6.64, P < .01
b
Abbreviations: AP, anteroposterior; LCL, lateral column lengthening;
NA, not applicable, , data not collected.
a
Data presented as mean standard deviation.
b
Repeated measures t test.
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
Barske et al 679
pain than did controls (P = .02). The LCL group reported
significantly greater scores on the SMFA compared with
healthy adults across the subscales. There was no interac-
tion between group and SMFA subscale (P = .12). However,
higher scores (Table 3) across subscales resulted in a main
effect for group (P < .01). Pairwise comparisons indicated
that all 3 scales were significantly higher compared with
controls (P < .01 for Function, Mobility, and Bothersome)
(Table 3).
Radiographic Assessment
Radiographic measures were significantly improved after
LCL (P < .01 for both angles compared pre- to postsur-
gery) (Table 2). Average correction of the lateral talusfirst
metatarsal angle was 15.4 10.4 degrees and average cor-
rection of the AP talusfirst metatarsal angle was 17.5
16.6 degrees (Table 2). The preoperative lateral talus
first metatarsal angle improved from 25.6 15.7 degrees
to 5.8 7.5 degrees. Six patients with naviculocuneiform
sag demonstrated improvement of the sag on postoperative
weight-bearing films.
First Metatarsal Range of Motion
There were significant differences between groups in
maximum first metatarsal passive dorsiflexion and total
first metatarsal passive ROM (Table 4). There were signifi-
cant differences across groups for first metatarsal dorsiflex-
ion ROM (P < .01) and maximum first metatarsal
dorsiflexion (P < .01). Both the involved and uninvolved
sides of the LCL group demonstrated significantly greater
maximum first metatarsal dorsiflexion ROM and total first
metatarsal passive ROM compared with controls (pairwise
comparisons for first metatarsal dorsiflexion ROM: LCL
involved vs control, P < .01, LCL uninvolved vs control, P =
.01; for first metatarsal total passive ROM: LCL involved
vs control, P < .01, LCL uninvolved vs control, P < .01).
There were no significant differences between the involved
and uninvolved sides for the LCL group (P .30). There
Table 3. Clinical Measures, Self-Reported Pain, and Function
SMFA
LCL Subjects Arch Height Index
Max No. Single-
Limb Heel Raises VAS Best VAS Worst Function Mobility Bothersome
1 0.15 12 0 0 5.9 0 6.3
2 0.27 0 0 8 16.2 25 8.3
3 0.35 0 0 6 25.0 30.6 37.5
4 0.31 0 0 0 18.4 16.7 10.4
5 0.27 0 0 4 4.4 2.8 10.4
6 0.24 20 0 0 16.2 25 12.5
7 0.32 5 0 1 16.9 22.2 18.8
8 0.31 6 0 1 22.8 30.6 25.0
9 0.3 0 3 8 25.0 41.7 14.6
10 0.27 0 0 13.2 16.7 22.9
11 0.33 3 2 5 30.2 33.3 43.8
12 0.36 7 0 1 2.9 8.3 0
13 0.30 0 8 10 44.1 72.2 41.7
LCL group involved
side
a
(n = 13)
0.29 0.05 4.1 6.1 1.1 2.4 3.7 3.7 18.6 11.3 25.0 18.7 19.4 14.0
LCL group uninvolved
side
a
(n = 12)
0.29 0.05 8.3 6.6 NA NA NA NA NA
Controls
a
(n = 13) 0.33 0.03 25.8 5.7 0.0 0.0 0.7 1.5 1.83 1.42 1.9 2.5 0.9 1.4
Statistical value, P value F = 2.34, P = .11
b
F = 83.73, P < .01
b
t = 1.57, P = .15
c
t = 2.63,
P = .02
c
Main effect for groups
d
: F = 23.69,
P < .01
Abbreviations: AP, anteroposterior; LCL, lateral column lengthening; NA, not applicable; SFMA, Short Form Musculoskeletal Assessment; VAS, visual
analogue scale; , data not collected.
a
Data presented as mean standard deviation.
b
One-way analysis of variance. Pairwise comparisons: LCL involved to uninvolved, P = .20; LCL involved to controls, P < .01; LCL uninvolved to
controls, P < .01.
c
Independent samples t test.
d
Result of 2-way mixed effect analysis of variance comparing across LCL and controls.
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
680 Foot & Ankle International 34(5)
were no significant differences between groups in maxi-
mum first metatarsal plantar flexion (P = .54).
Foot Kinematic Measurements
There were significant differences between groups in foot
kinematics during walking (Table 4). For the key points of
stance, first metatarsal dorsiflexion/plantar flexion was
significantly different between groups. The LCL group
had significantly greater first metatarsal dorsiflexion than
controls for all 4 selected points of walking (pairwise
comparisons: P < .01 for all 4 stance points). However, in
comparisons across the involved and uninvolved side of the
LCL group, there were no significant differences (pairwise
comparisons: initial contact, P = .73; 12% of stance, P =
.70; 78% of stance, P = .50; toe-off, P = .26). In contrast to
first metatarsal plantar flexion/dorsiflexion, the hindfoot
eversion/inversion showed significance only at 92% of the
stance phase of walking (Table 5). Controls demonstrated
significantly more inversion than both LCL groups at 92%
of stance (pairwise comparisons: LCL involved vs control,
P = .03; LCL uninvolved vs control, P = .03).
Discussion
The purpose of this case-control study was to assess par-
ticipants post LCL by clinical examination, self-reported
functional scores, radiographs, and foot ROM measures
collected passively and during gait. The findings of this
study suggest that patients undergoing the combination of
LCL and other soft tissue surgeries for correction of stage
II AAFD experience mixed outcomes and similar foot kine-
matics as the uninvolved limb despite radiographic correc-
tion of deformity. Consistent with our clinical assessment
hypotheses, the average VAS for best pain rating was
similar between participants post LCL and controls.
However, inconsistent with our clinical assessment hypoth-
eses were increased VAS worst pain rating and greater
difficulty in heel raise ability compared with controls.
Participants post LCL demonstrated good foot alignment
with a similar average arch height index as controls and
decreased talusfirst metatarsal angles after surgery com-
pared with before surgery.
Further insight into the global status of patients follow-
ing LCL surgery was obtained by the laboratory clinical
examination (Table 1). Most patients fared poorly on the
single heel raise test compared with control subjects. For
healthy sedentary Taiwanese women aged 41 to 60 years
and 61 to 80 years, a typical number of single-limb heel
raises was previously reported to be 9.3 3.6 and 2.7 1.5,
respectively.
17
The sedentary sample and strict ROM crite-
ria used in this study (ie, an electronic goniometer was
used) may have led to lower values. Our control group
vastly exceeded this estimation of typical heel raise ability,
with the lowest number of heel raises being 14. If we clas-
sify participants post LCL according to the values by Jan
et al,
17
then 5 participants (1, 6, 7, 8, and 12) were able to
achieve a typical number of heel raises (3); however, the
Table 4. Passive Range of Motion With 40 N of Pressure
LCL Subjects
Maximum Passive DF, deg
(plantar flexion/+dorsiflexion)
Maximum Passive PF, deg
(plantar flexion/+dorsiflexion) Total Passive ROM, deg
1 15.3 26.0 10.7
2 7.7 31.0 23.3
3 17.3 32.1 14.8
4 25.6 42.5 16.9
5 12.9 30.6 17.8
6 23.9 36.0 12.1
7 11.2 34.1 22.9
8 7.6 15.1 7.5
9 5.3 18.5 13.2
10 5.6 15.3 9.7
11 3.0 32.1 29.1
12 10.8 34.0 23.2
13 15.5 29.8 14.2
LCL group involved side
a
(n = 13) 12.4 7.0 29.0 8.2 16.6 6.4
LCL group uninvolved side
a
(n = 12) 15.1 7.5 31.6 7.5 16.5 5.5
Controls
a
(n = 13) 22.5 6.0 32.3 7.9 9.8 3.9
One-way ANOVA results F = 7.64, P < .01 F = 0.63, P = .54 F = 6.80, P < .01
Abbreviations: ANOVA, analysis of variance; DF, dorsiflexion; LCL, lateral column lengthening; PF, plantar flexion; ROM, range of motion.
a
Data presented as mean standard deviation.
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
Barske et al 681
participants results are grossly lower than those of the con-
trols used in this study (LCL group average 4.1 6.1 com-
pared with the control average 25.8 5.7).
Few studies report functional outcomes after LCL.
Hintermann et al
12
reported improvement in the AOFAS
score from 47 to 91 by 2 years postoperatively.
12
Mosier-
LaClaire et al
21
and Tellisi et al
28
reported similar improve-
ment with the AOFAS. Tellisi et al
28
reported a mean
postoperative SF-36 score of 79.2 for patients who had
undergone flatfoot reconstruction and correlated this to the
AOFAS. Although we cannot compare our data with the
data from these previous studies as different measures were
used, we report reasonable outcomes following LCL. Using
the VAS, 10 patients reported that, at best, their pain level
was 0 out of 10. Conversely, only 3 patients reported 0 out
of 10 pain at worst. The self-reported function hypothesis
that SMFA scores of participants post LCL would approach
the scores of controls was partially supported. The SMFA
subscales suggest mild functional difficulties and bother-
someness at an average follow-up of 24 months; however,
individual responses varied. Patients reported average
SMFA scores of 18.6, 25.0, and 19.4 for Function, Mobility,
and Bothersome indexes respectively. These values repre-
sent patients indicating that they find mobility and function
a little difficult and are a little bothered by most activi-
ties. Although these values are significantly higher than
those of our control subjects indicating worse function, they
are within the range of normative data that have been
reported for the SMFA.
16
A primary goal of the LCL surgery is to alter foot align-
ment. Radiographic data suggest that all LCL subjects had a
decrease in the talusfirst metatarsal angle on both the ante-
rior-posterior and lateral radiographic views (Table 2).
Similar to our results, previous authors have reported 12 to
20 degrees of correction with an LCL.
2,4,12
All 6 patients
who had naviculocuneiform sag on their preoperative lat-
eral films demonstrated improvement or loss of the sag on
postoperative weight-bearing films. It is also interesting to
note that although no direct manipulation was performed on
the naviculocuneiform joint during the surgical procedure,
all patients who had naviculocuneiform sag on their preop-
erative films demonstrated improvement or full correction
of the midfoot sag postoperatively. This is consistent with
previous findings that an LCL adducts and plantar flexes the
midfoot relative to the hindfoot, raises the medial longitudi-
nal arch, and unloads the first metatarsocuneiform joint.
5,26
Our hypothesis that the participants post LCL would
show similar movements when we compared the operated
and nonoperated sides was supported by both passive mea-
sures of first metatarsal ROM and hindfoot eversion/inver-
sion. The hypothesis that the operated and nonoperated
sides would demonstrate greater passive first metatarsal
ROM and flatfoot posture than controls was supported. In
the LCL patients, the total first metatarsal ROM was larger
and shifted toward dorsiflexion during walking compared
with controls (Table 4). This shows that patients with flat-
feet operate at the end range of dorsiflexion of the first
metatarsal relative to the calcaneus. This may represent
hypermobility of the medial column that has occurred
because of the flattened arch. Previous studies have shown
that the functional ROM of patients with flatfeet occurs in a
dorsiflexed range relative to controls.
13,15
However, previous
studies did not assess first metatarsal dorsiflexion/plantar
flexion ROM. Unique to this study, measured passive ROM
of the first metatarsal with a 40-N force allowed the walk-
ing data to be referenced to the first metatarsal dorsiflexion/
plantar flexion ROM present. The foot walking kinematics
demonstrated that patients who had undergone LCL surgery
functioned toward the dorsiflexion limits of their available
ROM, with some exceeding their maximum passive dorsi-
flexion by a few degrees. The same was true of the walking
kinematics of their uninvolved side. These patients, how-
ever, did not reach their maximum plantar flexion during
walking. In contrast, the controls met or exceeded both the
Table 5. First Metatarsal and Calcaneal Motion During Gait
LCL Involved, deg LCL Uninvolved, deg Controls, deg One-Way ANOVA Results
First metatarsal motion
a
(plantar flexion/+dorsiflexion)
Initial contact 15.71 7.21 16.67 6.99 26.60 6.06 F = 10.23, P < .01
12% of stance 13.41 7.38 14.51 7.79 24.51 5.74 F = 9.82, P < .01
78% of stance 8.50 7.75 6.47 8.15 17.97 6.04 F = 8.89, P < .01
Toe-off 23.53 8.53 28.00 12.09 34.84 8.64 F = 4.37, P = .02
Calcaneal motion
a
(eversion/+inversion)
Initial contact 3.61 2.78 4.03 4.59 1.78 2.36 F = 1.63, P = .21
25% of stance 5.73 3.26 7.20 3.65 4.59 2.44 F = 2.16, P = .13
92% of stance 0.32 3.08 0.44 4.75 2.73 2.46 F = 3.325, P = .05
Toe-off 0.81 3.26 0.97 4.80 1.92 2.70 F = 0.34, P = .71
Abbreviations: ANOVA, analysis of variance; LCL, lateral column lengthening.
a
Data presented as mean standard deviation.
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
682 Foot & Ankle International 34(5)
maximum dorsiflexion and plantar flexion measurements
during walking. The differences between the LCL groups
and control subjects indicate that although the foot posi-
tion is improved, patients are only restored to their con-
tralateral equivalent, not to normal foot kinematics. The
participants may have exceeded the passive ROM mea-
surements due to increased forces applied across the mid-
foot during walking.
In contrast to first metatarsal dorsiflexion/plantar flex-
ion, there were fewer significant differences between
groups for calcaneal motion (hindfoot eversion/inversion)
during gait (Table 5). Hindfoot eversion/inversion was not
significantly different until late stance when the forefoot
was loaded during push-off. The failure of the hindfoot to
fully invert at 92% may influence first metatarsal kinemat-
ics. Hindfoot inversion is thought to contribute to arch rais-
ing and stability of the medial longitudinal arch,
1
both of
which may be associated with terminal plantar flexion of
the first metatarsal. Brodsky et al
3
also found no difference
in hindfoot motion between flatfoot reconstruction (flexor
digitorum longus transfer to the navicular, spring ligament
imbrication, and medializing calcaneal osteotomy) and
unaffected side or controls.
3
Previous case-control studies
of participants with posterior tibial tendon dysfunction prior
to surgery suggest significantly larger hindfoot eversion.
14,29

The hypothesis that nearly equivalent side-to-side hindfoot
kinematics represent improvement is supported by one pro-
spective study. Marks et al
19
found that after an LCL,
patients demonstrated increased hindfoot inversion during
stance. Although more data on foot kinematics are desir-
able, the current studies provide preliminary evidence that
walking kinematics are preserved post LCL surgery when
combined with other procedures. The importance of restor-
ing foot kinematics to the uninvolved side or controls on
clinical outcomes remains theoretical.
The strengths of this study include the use of validated
outcome measures and in-depth foot biomechanical analy-
sis determined by an independent evaluator. This is the first
study to report validated musculoskeletal outcome mea-
sures post LCL. There are several limitations to this study.
The sample size is low; however, this is comparable to other
studies that included motion analysis of patients with
AAFD.
3,13,15,19
Although the LCL group was similar in age
and gender, the control group had a lower mean body mass
index than the LCL group. The groups also varied consider-
ably with regard to additional soft tissue and bony proce-
dures that were combined with the LCL technique (Table 1).
Remarkably, there was no obvious difference between
patients who had undergone a first tarsometatarsal fusion
and those who had not. This likely reflects the limitations of
our foot modeling approach. Relative movement between
the talonavicular, naviculocuneiform, and first tarsometa-
tarsal joint is not measurable with the model we used in
this study. Rather the first metatarsal dorsiflexion/plantar
flexion kinematics used in this study are a composite of all
these joints. The alterations in ROM attributable to the first
tarsometatarsal fusion are likely occurring in these joints
that we did not model. Another limitation is that preopera-
tive motion analysis and functional scoring were not per-
formed. It is difficult to interpret the SMFA and VAS scores
without preoperative data.
Conclusion
Some patients may continue to have pain and disability
with daily activities following surgical correction of their
flatfoot with an LCL. These patients maintain a low arch
posture similar to their contralateral foot and therefore
operate at the end range of dorsiflexion for the first meta-
tarsal and do not obtain full hindfoot inversion at push-off.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
1. Blackwood CB, Yuen TJ, Sangeorzan BJ. The midtarsal joint
locking mechanism. Foot Ankle Int. 2005;26(12):1074-1080.
2. Bolt P, Coy S, Toolan B. A comparison of lateral column
lengthening and medial translational osteotomy of the cal-
caneus for the reconstruction of adult acquired flatfoot. Foot
Ankle Int. 2007;28(11):1115-1123.
3. Brodsky J, Charlick D, Coleman S, Pollo F, Royer C. Hind-
foot motion following reconstruction for posterior tibial ten-
don dysfunction. Foot Ankle Int. 2009;30(7):613-618.
4. Chi TD, Toolan BC, Sangeorzan BJ, Hansen ST. The lateral
column lengthening and medial column stabilization proce-
dures. Clin Orthop Rel Res. 1999;365:81-89.
5. DuMontier T, Falicov A, Mosca V, Sangeorzan B. Calcaneal
lengthening: investigation of deformity correction in a cadaver
flatfoot model. Foot Ankle Int. 2005;26(2):166-170.
6. Evans D. Calcaneo-valgus deformity. J Bone Joint Surg.
1975;57(B):270-278.
7. Flemister AS, Baumhauer JF, Digiovanni BF. Flexor digito-
rum longus to posterior tibialis transfer with lateral column
lengthening for stage II posterior tibial tendon dysfunction.
Tech Foot Ankle Surg. 2007;6(1):1-8.
8. Glasoe WM, Grebing BR, Beck S, et al. A comparison of
device measures of dorsal first ray mobility. Foot Ankle Int.
2005;26:957-961.
9. Glasoe WM, Yack HJ, Saltzman CL. The reliability and
validity of a first ray measurement device. Foot Ankle Int.
2000;21:240-246.
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from
Barske et al 683
10. Haeseker G, Mureau MA, Faber FW. Lateral column length-
ening for acquired adult flatfoot deformity caused by posterior
tibial tendon dysfunction stage II: a retrospective compari-
son of calcaneus osteotomy with calcaneocuboid distraction
arthrodesis. J Foot Ankle Surg. 2010;49(4):380-384.
11. Hiller L, Pinney SJ. Surgical treatment of acquired flatfoot
deformity: what is the state of practice among academic foot
and ankle surgeons in 2002? Foot Ankle Int. 2003;24:701-705.
12. Hintermann B, Valderrabano V, Kundert HP. Lengthening of
the lateral column and reconstruction of the medial soft tissue
for treatment of acquired flatfoot deformity associated with
insufficiency of the posterior tibial tendon. Foot Ankle Int.
1999;20:622-629.
13. Houck J, Neville C, Tome J, Flemister A. Foot kinematics dur-
ing a bilateral heel rise test in participants with stage II pos-
terior tibial tendon dysfunction. J Orthop Sports Phys Ther.
2009;39(8):593-603.
14. Houck JR, Tome JM, Nawoczenski DA. Subtalar neutral posi-
tion as an offset for a kinematic model of the foot during walk-
ing. Gait Posture. 2008;28:29-37.
15. Houck JR, Neville CG, Tome J, et al. Ankle and foot kinemat-
ics associated with stage II PTTD during stance. Foot Ankle
Int. 2009;30:530-539.
16. Hunsaker F, Cioffi D, Amadio P, Wright J, Caughlin B. Amer-
ican Academy of Orthopedic Surgeons outcomes instru-
ments: normative values from the general population. J Bone
Joint Surg. 2002;84:208-215.
17. Jan MH, Chai HM, Lin YF, et al. Effects of age and sex on
the results of an ankle plantar-flexor manual muscle test. Phys
Ther. 2005;85(10):1078-1084.
18. Johnson KA, Strom DE. Tibialis posterior tendon dysfunction.
Clin Orthop. 1989;239:196-206.
19. Marks R, Long J, Ness M, Khazzam M, Harris G. Surgical
reconstruction of posterior tibial tendon dysfunction: prospec-
tive comparison of flexor digitorum longus substitution com-
bined with lateral column lengthening or medial displacement
calcaneal osteotomy. Gait Posture. 2009;29:17-22.
20. Martin DP, Engelberg R, Agel J, Swiontkowski MF. Com-
parison of the Musculoskeletal Function Assessment ques-
tionnaire with the Short Form-36, the Western Ontario and
McMaster Universities Osteoarthritis Index, and the Sickness
Impact Profile health-status measures. J Bone Joint Surg Am.
1997;79(9):1323-1335.
21. Mosier-LaClair S, Pomeroy G, Manoli A. Intermediate
follow-up on the double osteotomy and tendon transfer pro-
cedure for stage II posterior tibial tendon insufficiency. Foot
Ankle Int. 2001;22(4):283-291.
22. Myerson M. Adult acquired flatfoot deformity: treatment of
dysfunction of the posterior tibial tendon. J Bone Joint Surg
Am. 1996;78-A:780-792.
23. Neville C, Flemister AS, Houck JR. Deep posterior compart-
ment strength and foot kinematics in subjects with stage II poste-
rior tibial tendon dysfunction. Foot Ankle Int. 2010;31:320-328.
24. Pedowitz WJ, Kovatis P. Flatfoot in the adult. J Am Acad
Orthop Surg. 1995;3:293-302.
25. Philbin TM, Pokabla C, Berlet GC. Lateral column length-
ening using allograft interposition and cervical plate fixation.
Foot Ankle Spec. 2008;1(5):288-298.
26. Sangeorzan BJ, Mosca V, Hansen ST. Effect of calcaneal
lengthening on relationships among the hindfoot, midfoot,
and forefoot. Foot Ankle. 1993;14:136-141.
27. Swiontkowski MF, Engelberg R, Martin DP, Agel J. Short
musculoskeletal function assessment questionnaire: valid-
ity, reliability, and responsiveness. J Bone Joint Surg Am.
1999;81(9):1245-1260.
28. Tellisi N, Lobo M, OMalley M, Kennedy J, Elliott A, Deland J.
Functional outcome after surgical reconstruction of posterior
tibial tendon insufficiency in patients under 50 years. Foot
Ankle Int. 2008;29:1179-1183.
29. Tome J, Nawoczenski DA, Flemister A, Houck J. Comparison
of foot kinematics between subjects with posterior tibialis ten-
don dysfunction and healthy controls. J Orthop Sports Phys
Ther. 2006;36:635-644.
30. Umberger BR, Nawoczenski DA, Baumhauer JF. Reliabil-
ity and validity of first metatarsophalangeal joint orientation
measured with an electromagnetic tracking device. Clin Bio-
mech. 1999;14:74-76.
31. Williams DS, McClay IS. Measurements used to characterize
the foot and the medial longitudinal arch: reliability and valid-
ity. Phys Ther. 2000;80(9):864-871.
32. Younger AS, Sawatzky B, Dryden P. Radiographic assessment
of adult flatfoot. Foot Ankle Int. 2005;26:820-825.
by charles lombardi on May 11, 2013 fai.sagepub.com Downloaded from