0198-0211/87/0705-0285$02.
00/0
FOOT & ANKLE
Copyright © 1987 by the American Orthopaedic Foot and Ankle Society, Inc.
The Use of Footprint Contact Index II for Classification of Flat Feet in a
Nigerian Population
B. C. Oidia, M.B.B.S., E. T. Omu, B.Sc., and A. A. Obuoforibo, M.B.B.S., Ph.D.
ABSTRACT
The objective index as developed by Qaura, Deodhar, and
Jit, in 1980 was used to estimate the incidence of flat foot
(pes planus) in 990 school pupils (532 females and 458
males) between the ages of 5 and 14 years. The ratio of
contact area to the total area of the middle of the footprint
(contact index 1) (4/10), usually measured with a planim-
eter, is accepted as the true representative of the condi-
tion of arches. In this field study, contact index II (ratio of
contact width to the total width of the foot) which is simple,
reliable, and correlates with contact index I has been used
to assess flat foot. The mean for the contact index and
standard deviation have been calculated. Feet have been
considered as normal up to 1 SD around the mean value
of the index and values greater or lesser than this have
been considered abnormal. Furthermore, mean ± 1 SD to
2 SD has been considered as possible flat foot, whereas
mean ± 3 SD and above has been taken as definite flat
foot.
On the whole, bilateral flat foot is not common among
children of school age in Port Harcourt (0.60%). It is,
however, more common in females (0.75%) than males
(0.44%). Unilateral flat foot (2.22%) is found to be more
common than bilateral flat foot. Early introduction to the
use of shoes may predispose to flat foot. We were not in
a position to say if any of the subjects found with flat foot
would have a painful foot. Clinically speaking it could
become important when flat foot co-exists with painful
feet or even with pain extending up to the vertebral col-
umn.
Anthropology deals with measurable parameters,
and these parameters are known to vary from individual
to individual and from race to race. As a result of these
variations, it has even been erroneously used to classify
superiority of race.
Considerable standard work has already been done
and several methods of anthropological measurements
have been developed. Similarly, many guidelines or
predictable formulas have been established. These
From the Department of Anatomy, College of Health Sciences,
University of Port Harcourt, P.M.B. 5323, Port Harcourt, Nigeria.
Address reprint requests to Dr. Oidia.
285
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Port Harcourt, Nigeria
have helped in the clinical assessment of the nutritional
well-being of humans, in forensic medicine, and in the
estimation of body comoostnons.""
Flat foot (pes planus) is a congenital or acquired
deformity marked by depression of the arches? At-
tempts at studying the condition of arches have either
been through radiography2, 6 or the study of tootpnnts."
Most of the radiological methods used in these studies
assessing flat feet were unreliable. For example, Bon-
net and Baker in their work 2 found that 83% of clinically
normal feet showed radiological flat feet of various
degrees, of which 6% had fourth degree flat feet. On
the other hand, utilization of a clinical inspection of feet
or foot prints is prone to error due to limitations of
subjectivity. 5,14 As a result of the above difficulties,
mathematical determination of the arch of the foot from
footprints is currently favored.P'?
A study of footprints reveals that the anterior and
posterior portions show little or no changes in both the
normal and abnormal arch of foot. 9 By excluding the
anterior and posterior portion of the footprint and lim-
iting the measurements to the middle four-tenths of the
print, the sensitivity of the podographic indices for the
condition of arches has been successfully improved
Oaura."
In developing the study of physical anthropology at
the University of Port Harcourt, there is the need for
the establishment of baseline data. Our work seeks to
do just that and to provide data necessary for future
reference and comparison, as it is the first of its kind in
Nigeria. It compares favorably with most similar works
quoted in this text, and it supports the use of contact
index as a good method for the assessment of the
condition of the arch.
MATERIALS AND METHODS
Materials
For our study we selected 990 school pupils (532
females and 458 males) from the University of Port
Harcourt Demonstration Primary School (UDPS), a
school attended by people from almost all the ethnic
286 OIDIA ET AL. Foot & AnklefVol. 7, No. SIApr. 1987

groups in Nigeria, and from the Universal Primary Edu-

cation School (UPE), Choba. Cyclostyling ink, stamp
pads, and duplicating papers were used to obtain the
prints.
Method

Each subject was asked to wash the plantar surface

of each foot thoroughly; the foot was then dried. The
subject then stood firmly on a stamp pad on which
cyclostyling ink had been smeared. He or she then
stood on a clean duplicating sheet of paper on a hori-
zontal surface while one foot remained off the ground.
The outline of the foot was drawn with a vertically held
pencil with sharply exposed lead to approximately 2
cm (Figs. 1-3). The same procedure was repeated for
the other foot. They were then asked such questions
as: For how long have you been wearing shoes? Do
you wear shoes at home? Do you wear shoes to school
everyday? Do you feel comfortable without a shoe on?
The midpoints of the proximal end of the heel (J), the
midpoint of the distal end of the second toe (F), and
the big toe (K) were marked out. Straight lines were
then drawn to join FJ and KJ. The foot was divided into
an anterior 3/10, middle 4/10, and posterior 3/10 by lines
AS and EG (Figs. 1-3). On the medial aspect of the
footprint the innermost point of the head of first meta-
Fig. 2. Footprints of unilateral flat foot.
tarsal (A) and the innermost point of the heel were
joined by a straight line (ZQ), while on the lateral border

Fig. 1. Footprints of normal feet. Fig. 3. Footprints of bilateral flat feet.

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Foot & Ankle/Vol. 7, No. 5/Apr. 1987 FLAT FEET CLASSIFICATION 287
of the footprint the outermost point of the heel (N) and standard deviations and the incidence of flat foot were
the outermost point of the fifth metatarsal (M) were calculated.
joined by another line (MN). The line S'n' divides the
middle 4/10 to two equal halves and represents the total RESULTS
width of the footprint, while d'r' represents the contact
width. The results obtained in this exercise are outlined in
The contact index measurements were carried out Figs. 4 and 5 and Tables 1 to 5. Of the 990 footprints
using contact index II (ratio of the contact width d'r' to analyzed, 662 are those of pupils who have worn shoes
the total width of footprint S'n'). The figures obtained from childhood and who still put on shoes for school,
were analyzed statistically, and the mean values and while 328 footprints are of pupils who put on shoes

~.:1=r.:':.i:;-;~S~:"S:3.2':::E;.-r~~'!~~::'l~rF:~"'~~C,if~~T::-fc'F"'E'~r-:~l~,:~=."'~r::L~~i~~3';·~Z;C-L<:,;·..
-':j.g;';~~~T~-~"3£.-S::'£',:1'iSi"!;b~=:'it:~:?'".z1':'_~

S ~
(!(J ~~ "., ,., .' , ,., , ::'!':!.F'."{? , ,,............•.... , ' , , ,•.•~
:i IT I i

- - fi ,I I-_.~···I ". ~

20 ~ .."., """" .., ", ;/.., ,.,::/( :I~~~ ,~ "",; ", ,., "'1
10 ~.> "." , " •• , . . , . . , . . , / . . p<:~+:, ,., " ~~~S~;.">WI.:'''''''''''''''''''''''''''''''''''''''')
- ..~T·;_:).'l e~;:_:~=+_~/:i,.."\,.,. ~

r~:.,,~····_·~~"~'"·~·,"=,·i·~.,_·~··,«·~..~-I~.~"'-~~~~ ..~~:~:::i;~;··-l~~····~,~~~~,·~~~·~jo
;'" .'i - '"

Fig. 4. Graph showing age versus number of male pupils. _, without shoes; +, with shoes.

;;~ ~i ~;.-:;D~~r:'~~;'~~~'r;::;,..::_~J,~_~~~,,~~~,. . .~. .!5,;,~_«l\ili.€ntuG :-*~~"-=UR'i:Z~.;Er..:..~?~~~'";J":2~~:E';;!W'~~

t I
:=:17; ~~, '" ,..,.,." ,." " " , ,,, , " j

';~;i f~····,· , ,.. , , , /~~~:~~: ,., ,., , , ~

! I' I 5
~':,~-::i ~_
--,
, II
,"
,t .;.t;,
'I
JI

:;[,!c_···r·\;;/·\·····u....uul
;:~l,t:··:.L~.·.·:·:·::~::.. :\~:::.:.:.::::.:·:.::::.:::: . :-:1 ~
',"1I'"
i t .." . . .
'~'J- 1~ '~--I-_.,._._-5 __ '
,: :. i"J t'-··· , '..,..,.. ' / ....................•..., :t.:-; ···'..·.. 1
I
, I" '\ .
:t 0 L".,.."" ".., ,,.,.J/ ,,..,..,.,..".., ',., "')~?'~~~:~~,:"""'" ., , , , ··,···1
~~<t,'c;, ; -r:-':~" ,.,_._- ="'=;"' ' '-,_-=ll:1
_-=.~ ,.=. -=,:- = ' ~.,~. ,. == _...-"~_~-=:"'.""~<,="",..-'-.-e"'-.'.,,,.====,.,.~=,.<"""-=-'-.,,_,.-~
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•.
'5 . ,..
...
~o

,'! lr""··,',r=«J····""
!" 'f t; l"i i-:< ::. ,.:
Fig. 5. Graph showing age versus number of female pupils. _, without shoes; +, with shoes.

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288 DIDIAETAL. Foot & AnklefVol. 7, No. SIApr. 1987

only on occasions and who do not wear shoes to who wore shoes more often than the other pupils.
school. (Table 1, Figs. 4 and 5). To avoid discrepancy Bilateral flat foot
therefore, the percentage incidence of a unilateral and Contact index II
bilateral flat foot was calculated from the whole popu- Percentage of occurrence with shoes 5/662 x 100/1= 0.76%
lation with regard to those putting on shoes; this was Percentage of occurrence in those not
not separated according to sex. Bilateral and unilateral wearing shoes 1/328 x 100/1= 0.31%
Overall percentage of occurrence of bi-
flat feet were found to be more common in those pupils lateral flat foot in the whole population
was found to be: 6/990 x 100/1 = 0.60%
TABLE 1 2 100
For males 458 x -1- = 0.44%
Ages and Number of Males and Females with and without
Shoes 4 100
For females 532 x -1- = 0.75%
Males Females
Ages Without With Without With Unilateral flat foot
Total Total 22 100
shoes shoes shoes shoes Overall percentage - x - = 2.22%
990 1
5 0 5 5 4 4 8
9 100
6 11 36 47 29 56 85 For male -x- = 1.97%
7 15 69 84 24 77 101 458 1
8 28 71 99 23 72 95 13 100
For females -x- = 2.22%
9 26 41 67 21 45 66 532 1
10 36 44 80 24 61 85 20 100
For those putting on shoes -x- = 3.02%
11 14 18 32 21 27 48 662 1
12 16 7 23 12 7 19 2 100
13 12 5 17 6 11 17
For those without shoes -x- = 0.61%
328 1
14 3 1 4 3 5 8
Total 161 297 458 167 365 532
On the whole, unilateral flat foot was found to be more
common than bilateral flat foot.
TABLE 2
Mean and Standard Deviation in Males and Females
Contact Index II DISCUSSION
Average mean
Left Right ± SO for both
The SUbject of flat foot has been widely studied, as
foot foot feet
already stated in this text. However, it is far from being
Male exhausted as no correlation has been drawn between
Mean 0.55 0.55 0.55 clinically determined and symptomatic flat foot. It is rare
SO 0.17 0.17 ±0.17
Female
to find a patient who walks into a clinic to complain of
Mean 0.53 0.53 0.53 pain as a result of flat foot; most of the treatment given
SO 0.18 0.17 ±0.175 to people with pes planus, therefore, has always been
to avoid further worsening of the arches. Introduction
TABLE 3 of shoes at an early age and the constant wearing of
Peak Mean Values for Normal Foot, Probable Flat Foot, and them could predispose one to a poorly developed arch,
Definite Flat Foot in Males and Females
as was evident in this study. The shoe prevents direct
Peak mean contact with the ground and reduces the stress that
Mean ± SO
value
normally would reach the muscles and plantar fascia,
Male whose increased activity and growth lead to the devel-
Normal Mean ± 1 SO 0.72 opment of good lateral and medial longitudinal arches.
Probable Mean ± 1-2 SO 0.89
Definite Mean ± 2-3 SO 1.06 Analysis from this work shows that there was no sig-
Female nificant difference in the mean values and standard
Normal Mean ± 1 SO 0.71 deviation between right and left foot in both sexes
Probable Mean ± 1-2 SO 0.89 (Table 2). This is in line with the findings of other
Definite Mean ± 2-3 SO 1.07 workers.
TABLE 4
Incidence of Bilateral Flat Foot
M F Total With shoe Without shoe Total
Normal feet 456 528 984 657 327 984
Flat feet 2 4 6 5 1 6
Total 458 532 990 662 328 990
% incidence 0.44% 0.75% 0.60% 0.76% 0.31% 0.60%

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Foot & Ankle/Vol. 7, No. 5/Apr. 1987 FLAT FEET CLASSIFICATION 289
TABLE 5
Incidence of Unilateral Flat Foot
M F Total With shoe Without shoe Total
Normal feet 449 519 968 642 326 968
Flat feet 9 13 22 20 2 22
Total 458 32 990 662 328 990
% incidence 1.97% 2.44% 2.22% 3.02% 0.61% 2.22%

Definite unilateral and bilateral flat feet were identi-
fied. Feet were generally classified as normal, probable
flat foot, and definite flat foot (Table 3). It was observed
that contact indice values were lower in females than
in males, a proof that the arches are better developed
in males. Other factors such as type of foot wear,
physical activities, and weightbearing habits may have
also played a role.
We stress that the incidence of bilateral flat feet is
low in this society. The occurrence of unilateral flat feet
is more common (Tables 4 and 5), but certain issues
remain unexplained. For example, what conditions
could exist to make one individual have a normal foot
on one side and a flat foot on the other side? Second,
the degree of flat foot does not suggest who is going
to have a painful foot in the future and have the need
for treatment. Moreover, since the definition of flat foot
in this article is based on standard deviation from the
mean, the actual definition of flat foot by this method
may vary from population to population. As long as
these questions and perhaps some others remain un-
answered, the condition of flat feet will continue to be
reevaluated.
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1. Aplay, A.G.: Systems of Orthopaedics and Fractures. 5th Ed.
London, Butterworth and Co., 1978, pp. 295-299.
2. Bonnet, W.L., Baker, D.R.: Diagnosis of pes planus by x-ray.
Radiology, 46:36-45,1940.
3. Clarke, H.H.: An objective method of measuring the height of
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107,1933.
4. Gartland, J.J.: Fundamentals of orthopaedics. 3rd Ed. Philadel-
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5. Ilfeld, F.W.: Pes planus-military significanceand treatment with
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