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The validity and reliability of various footprint analysis in flatfoot diagnosis of competitive athletes

  • I Putu Juniartha ,
  • Damayanti Tinduh ,
  • Nuniek Nugraheni ,
  • I Putu Alit Pawana ,
  • Rosy Setiawati ,
  • Soenarnatalina Melaniani ,


Background: Foot morphology is an essential intrinsic factor in athlete performance. Therefore, abnormality of the foot morphology, such as flatfoot, can affect the foot biomechanics, reduce motor performance, and increase the risk of injury. Assessment of flatfoot in the competitive athlete is essential to decide on the appropriate management; however, the imaging evaluation method needs special equipment and experience. Footprint analysis using Clarke's angle (CA), Chippaux Smirak Index (CSI), and Staheli Index (SI) offers a cheaper, faster, more effective, and easier method for flatfoot diagnosis. This study aims to determine the validity and reliability of various footprint analysis with calcaneal inclination angle (CIA) from the radiographic image as the standard examination.

Method: This is an analytic observational study with a retrospective cohort design. The data of CIA, CA, CSI, and SI were collected from 70 athletes' medical records from 6 different sports that met inclusion criteria. The validity, reliability, diagnostic performance, and determination of the cut-off point were performed.

Results: The correlation test and intraclass correlation coefficient showed that CSI and SI were valid and reliable in diagnosing flatfoot, while CA was invalid but reliable in diagnosing flatfoot. Area under the curve of the ROC curve and the cut–off point of CA were 0.427 (p=0.403) and 39.32o; CSI was 0.446 (p=0.537) and 33.58; and SI was 0.418 (p=0.347) and 73.59, respectively. The sensitivity and specificity of CA were 26.78% and 100%; CSI was 10.71% and 100%; and SI was 78.57% and 78.57%, respectively.

Conclusion: Footprint analysis using CA is not valid but reliable in diagnosing flatfoot, while CSI and SI are valid and reliable in diagnosing flatfoot. The Staheli Index has the best diagnostic performance compared to others.


  1. Zhai JN, Qiu YS, Wang J. Effects of orthotic insoles on adults with flexible flatfoot under different walking conditions. J Phys Ther Sci. 2016 Nov;28(11):3078-3083. doi: 10.1589/jpts.28.3078. Epub 2016 Nov 29. PMID: 27942124; PMCID: PMC5140804.
  2. Moore, K.L., Dalley, A.F. and Anne M.R.A. Foot, in Chapter 5: Lower Limb, in Clinically Oriented Anatomy, 7th Edition. Philadelphia: Lippincott Williams & Wilkins, 2014: 609-612.
  3. Leardini A, Belvedere C, Nardini F, Sancisi N, Conconi M, Parenti-Castelli V. Kinematic models of lower limb joints for musculoskeletal modelling and optimization in gait analysis. J Biomech. 2017;62:77-86. doi:10.1016/j.jbiomech.2017.04.029.
  4. Aenumulapalli A, Kulkarni MM, Gandotra AR. Prevalence of Flexible Flat Foot in Adults: A Cross-sectional Study. J Clin Diagn Res. 2017;11(6):AC17-AC20. doi:10.7860/JCDR/2017/26566.10059.
  5. Tahmasebi R, Karimi MT, Satvati B, Fatoye F. Evaluation of Standing Stability in Individuals With Flatfeet. Foot & Ankle Specialist. 2014;8(3):168-174.
  6. Kumala MS, Tinduh D, Poerwandari D. Comparison of Lower Extremities Physical Performance on Male Young Adult Athletes with Normal Foot and Flatfoot. Surabaya Physical Medicine and Rehabilitation Journal. 2019;1(1):6.
  7. Ho M, Kong PW, Chong LJ, Lam WK. Foot orthoses alter lower limb biomechanics but not jump performance in basketball players with and without flat feet. J Foot Ankle Res. 2019;12:24. Published 2019 Apr 23. doi:10.1186/s13047-019-0334-1.
  8. Murphy DF, Connolly DA, Beynnon BD. Risk factors for lower extremity injury: a review of the literature. Br J Sports Med. 2003;37(1):13-29. doi:10.1136/bjsm.37.1.13.
  9. Michelson J, Durant D, McFarland E. The Injury Risk Associated with Pes Planus in Athletes. FAI. 2002;23(7). p629-633.
  10. Flores DV, Mejía Gómez C, Fernández Hernando M, Davis MA, Pathria MN. Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings. Radiographics. 2019;39(5):1437-1460. doi:10.1148/rg.2019190046.
  11. Zhang L, Yu D, Lei L, Gao Y, Dong J, Yu Z, Yuan Y. Validity of Two-Dimensional Static Footprint in Medial Longitudinal Arch Evaluation and the Characteristics of Athletes’ Footprints. 2020. p1-22.
  12. McPoil TG, Cornwall MW. Use of Plantar Contact Area to Predict Medial Longitudinal Arch Height During Walking. Journal of the American Podiatric Medical Association. 2006;96(6):489-494.
  13. Hahn T, Foldspang A, Vestergaard E, Ingemann-Hansen T. One-leg standing balance and sports activity. Scand J Med Sci Sports. 1999;9(1):15-18. doi:10.1111/j.1600-0838.1999.tb00201.x.
  14. Dingenen B, Janssens L, Claes S, Bellemans J, Staes FF. Lower extremity muscle activation onset times during the transition from double-leg stance to single-leg stance in anterior cruciate ligament reconstructed subjects. Clin Biomech (Bristol, Avon). 2016;35:116-123. doi:10.1016/j.clinbiomech.2016.04.014.
  15. Troester JC, Jasmin JG, Duffield R. Reliability of Single-Leg Balance and Landing Tests in Rugby Union; Prospect of Using Postural Control to Monitor Fatigue. J Sports Sci Med. 2018;17(2):174-180. PMCID: PMC595073.
  16. Werd MB, Knight EL, Langer PR. Athletic Footwear and Orthoses in Sports Medicine. Springer. 2017.
  17. Queen RM, Mall NA, Hardaker WM, Nunley JA 2nd. Describing the medial longitudinal arch using footprint indices and a clinical grading system. Foot Ankle Int. 2007;28(4):456-462. doi:10.3113/FAI.2007.0456.
  18. Kanatli U, Yetkin H, Cila E. Footprint and Radiographic Analysis of the Feet. Journal of Pediatric Orthopaedics. 2001;21(2):225-228.
  19. Adoración Villarroya M, Manuel Esquivel J, Tomás C, Buenafé A, Moreno L. Foot structure in overweight and obese children. Int J Pediatr Obes. 2008;3(1):39-45. doi:10.1080/17477160701520298.
  20. Koirala S, Khanal GP, Shah S, and Khanal L. Calculation of Staheli's Planter Arch Index, Chippaux- Smirak Index, Clarke's Angle Prevalence and Predictors of Flat Foot : a Cross-Sectional Study. Austin Journal of Anatomy. 2021;8(1).1–6.
  21. Toyooka S, Shimazaki N, Yasui Y, et al. Validity of a simple footprint assessment board for diagnosing the severity of flatfoot: a prospective cohort study. BMC Musculoskelet Disord. 2021;22(1):285. Published 2021 Mar 18. doi:10.1186/s12891-021-04154-3.
  22. Pita-Fernández S, González-Martín C, Seoane-Pillado T, López-Calviño B, Pértega-Díaz S, Gil-Guillén V. Validity of footprint analysis to determine flatfoot using clinical diagnosis as the gold standard in a random sample aged 40 years and older. J Epidemiol. 2015;25(2):148-154. doi:10.2188/jea.JE20140082.

How to Cite

Juniartha, I. P., Tinduh, D., Nugraheni, N., Pawana, I. P. A., Setiawati, R., & Melaniani, S. (2023). The validity and reliability of various footprint analysis in flatfoot diagnosis of competitive athletes. Bali Medical Journal, 12(1), 851–856.




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I Putu Juniartha
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Damayanti Tinduh
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Nuniek Nugraheni
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I Putu Alit Pawana
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Rosy Setiawati
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Soenarnatalina Melaniani
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