GAIPOS-2294; No of Pages 8

Gait & Posture xxx (2006) xxx–xxx

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Age-related differences in foot structure and function

Genevieve Scott a, Hylton B. Menz b,*, Lesley Newcombe a
a
Department of Podiatry, School of Human Biosciences, La Trobe University, Bundoora, Victoria 3086, Australia
b
Musculoskeletal Research Centre, School of Physiotherapy, La Trobe University, Bundoora, Victoria 3086, Australia
Received 14 February 2006; received in revised form 14 July 2006; accepted 27 July 2006

Abstract

The aim of this study was to compare foot characteristics and plantar force and pressure patterns in young and older people. Fifty young
(mean age 20.9  2.6 years) and 50 older (mean age 80.2  5.7 years) people without foot problems underwent tests of foot posture, range of
motion, strength, sensation and deformity. Plantar force and pressure distribution during gait were evaluated using a floor-mounted resistive
sensor mat system. Older participants exhibited flatter/more pronated feet, reduced range of motion of the ankle and 1st metatarsophalangeal
joints, a higher prevalence of hallux valgus, toe deformities and toe plantarflexor weakness, and reduced plantar tactile sensitivity. Plantar
pressure analysis revealed decreased magnitude of forces and pressures under the heel ( 13% to 16%), metatarsophalangeal joints ( 11% to
16%) and hallux ( 19% to 25%), but greater relative contact time under the heel (+21%), midfoot (+14%) and metatarsophalangeal joints
(+5% to 8%) in older participants. Multiple regression analysis revealed that these age-related differences could be largely explained by
differences in step length and various foot characteristics, particularly foot posture and the severity of hallux valgus. These findings indicate
that ageing is associated with significant changes in foot characteristics which contribute to altered plantar loading patterns during gait.
# 2006 Elsevier B.V. All rights reserved.

Keywords: Ageing; Plantar pressure; Gait

1. Introduction
The foot provides the only direct source contact with the
supporting surface, and therefore plays an important role in
all weightbearing tasks. During gait, the foot contributes to
shock absorption, adapts to irregular surfaces and con-
tributes to generating momentum for forward propulsion [1].
Changes to foot structure therefore have the potential to alter
the load distribution function of the foot. In particular,
changes to the musculoskeletal and neurological character-
istics of the foot associated with advancing age, such as foot
deformity [2], reduced range of motion [3,4], reduced
strength [5] and diminished plantar tactile sensation [6]
could all potentially alter plantar loading patterns. However,
neither age-related changes in foot structure nor the
mechanisms responsible for altered foot function in older
people have been examined in detail.
* Corresponding author. Tel.: +61 3 94795801; fax: +61 3 94795768.
E-mail address: h.menz@latrobe.edu.au (H.B. Menz).
Only two studies have directly addressed how age may
influence the load distribution of the foot. Kernozek and
LaMott [7] analysed plantar pressure patterns during gait in
35 young (mean age 22  2.2 years) and 35 older (mean age
78  3.0 years) people using a capacitive platform system.
Similar force and pressure characteristics were found in the
heel and forefoot for both groups, however, older people
exhibited lower peak pressure under the midfoot and a lower
force-time integral under the midfoot and hallux. Using an
in-shoe pressure assessment of treadmill walking in nine
young (mean age 30  5.2 years) and six older (mean age
68.7  4.8 years) people, Hessert et al. [8] reported that
older people exhibited significantly less force and pressure
under the heel and the medial regions of the foot. Both
authors suggested that these changes may be indicative of a
less propulsive gait pattern in older people.
The major limitation with these studies, however, is that
no foot structure variables were considered. It has previously
been shown that foot posture [9], joint range of motion [10]
and severity of hallux valgus [11] influence loading patterns
under the foot. As these structural factors may also be

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doi:10.1016/j.gaitpost.2006.07.009

Please cite this article as: Genevieve Scott et al., Age-related differences in foot structure and function, Gait & Posture (2006),
doi:10.1016/j.gaitpost.2006.07.009
GAIPOS-2294; No of Pages 8
2 G. Scott et al. / Gait & Posture xxx (2006) xxx–xxx
affected by age, a more detailed understanding of age-
related differences in foot function could be obtained by
measuring both structure and function in young and older
people. Therefore, the aims of this study were to: (i)
determine the effect of age on a range of structural foot
characteristics; (ii) determine the effect of age on force and
pressure distribution under the foot when walking; and (iii)
determine the extent to which differences in foot structure
can explain age-related differences in force and plantar
pressure distribution when walking.
2. Methods
2.1. Participants
The study sample comprised 100 participants. Fifty
healthy young participants (26 females, 24 males, mean age
20.9, S.D. 2.6) were recruited from the student population
of La Trobe University. Fifty older people (26 females, 24
males, mean age 80.2, S.D. 5.7) were selected from a
previously established database obtained as part of a larger
study of foot function in older people [12]. The exclusion
criteria for this study included current or previous foot pain,
previous foot surgery, osteoarthritis affecting the foot, major
medical conditions (including Parkinson’s disease, rheuma-
toid arthritis, diabetes, peripheral vascular disease), inability
to ambulate household distances without an assistive device,
or a score of <7 on the Short Portable Mental Status
Questionnaire [13].
The Faculty Human Ethics Committee of the Faculty of
Health Sciences at La Trobe University approved the study,
and informed consent was obtained from all participants.
2.2. Foot and ankle characteristics
Foot posture was assessed using three validated
techniques: the foot posture index, arch index and navicular
height [14]. The foot posture index (FPI) involved the rating
of six criteria: palpation of the talar head, observation of
supra/infra malleolar curvature, inversion/eversion of the
calcaneus, medial prominence of the talo-navicular joint,
congruence of the medial arch, and abduction/adduction of
the forefoot on the rearfoot. Each of these criterion were
scored on a five-point scale (range 2 to +2) and the
summed score provided a single index of the degree of the
pronated/supinated posture of the foot, with higher scores
representing a more pronated (flatter) foot [15,16]. To
calculate the arch index, static footprints were obtained
using carbon-paper imprint material with the participant
standing in a relaxed position. Using a computer graphics
tablet and graphics software, the arch index was calculated
as the ratio of area of the middle third of the footprint to the
entire footprint area ignoring the toes. The lower the arch,
the higher the arch index [17]. Navicular height was
measured in millimeters while the participant was fully
Please cite this article as: Genevieve Scott et al., Age-related differences in foot structure and function, Gait & Posture (2006),
doi:10.1016/j.gaitpost.2006.07.009
weightbearing, and was then corrected for differences in foot
size by dividing it by the length of the foot [18].
Two measures of foot and ankle range of motion were
performed. Ankle flexibility was measured in degrees using
a modified version of the weightbearing lunge test [18]. The
lateral malleolus and head of the fibula were first located and
marked with an ink pen. Participants then stood with their
right foot placed alongside a vertically aligned clear acrylic
plate inscribed with 28 protractor markings, and were
instructed to take a comfortable step forward with the left
leg. In this position, participants were instructed to bend
their knees to squat down as low as possible, without lifting
the right heel from the ground and while keeping the trunk
upright. The position of the fibular head was marked on the
clear acrylic plate, and the angle formed between the lateral
malleolus and the fibular head was measured. The test was
completed three times, and the highest score documented as
the test result. First metatarsophalangeal joint dorsiflexion
range of motion (1st MPJ ROM) was measured in a non-
weightbearing position with a goniometer while the hallux
was maximally extended. The value recorded was the
maximum angle at which the hallux could not be passively
moved into further extension [19].
Ankle dorsiflexion strength was measured isometrically
with participants seated, with the hip, knee and ankle placed
at 908, 1108 and 908, respectively. The foot was secured to a
metal footplate using a Velcro strap, and the participant was
requested to maximally dorsiflex their ankle by pulling
against the strap assembly for 2–3 s while the force output
was measured using an attached spring gauge. Three trials
were recorded and the highest score recorded (in kilograms)
was documented as the test result [20]. The strength of the
plantarflexor muscles of the toes was determined using the
paper grip test [21]. Participants were seated with their knee
and ankle at 908, and were instructed to use their toe muscles
to push down on a 1 mm thick piece of cardboard while the
examiner stabilized their ankle and attempted to slide the
cardboard away from the toes. The test was performed three
times for the lesser toes and the hallux in isolation, and was
documented as either pass (participant could hold the
cardboard for all three trials) or fail (participant failed to grip
the cardboard on at least one trial). The validity of this test is
described elsewhere [21].
Tactile sensitivity of the lateral malleolus and 1st MPJ
was evaluated using a Semmes Weinstein-type pressure
aesthesiometer. This instrument contains eight nylon
filaments of equal length that vary in diameter. The force
required to bend each filament is precalibrated and ranges
from 0.0045 to 447 g. The filaments were applied to the
lateral malleolus and the plantar aspect of the 1st MPJ and
tactile thresholds were determined using a two-alternative
forced choice protocol [18].
Foot deformity was evaluated by documenting the
presence of hallux valgus, lesser toe deformities, corns
and calluses. The presence and severity of hallux valgus was
determined using the Manchester scale [22]. This instrument
GAIPOS-2294; No of Pages 8
G. Scott et al. / Gait & Posture xxx (2006) xxx–xxx
consists of standardized photographs of feet with four
degrees of hallux valgus: none (score = 0), mild (score = 1),
moderate (score = 2) and severe (score = 3). The grading of
hallux valgus using this tool is highly correlated with
angular hallux valgus measurements obtained from foot
radiographs [23]. Presence of lesser digital deformity and
plantar calluses was determined according to previously
published criteria [24] and the location of these abnorm-
alities was documented.
The reliability of each of these foot and ankle tests has
been established in previous investigations. Intraclass
correlation coefficients for each of the tests were as follows:
foot posture index (0.61), arch index (0.99), navicular height
(0.64), ankle flexibility (0.87), 1st MPJ ROM (0.85),
Manchester scale (0.77), lesser toe deformities and lesions
(0.98), ankle dorsiflexion strength (0.88), paper grip test
(0.65), and tactile sensitivity (0.51–0.70) [18,25].
2.3. Temporospatial gait patterns
Barefoot walking speed, cadence and average step length
were recorded with a stopwatch over a distance of 6 m. Step
length was corrected for height prior to subsequent analysis.
2.4. Plantar pressure assessment
Plantar forces and pressures were recorded during level
barefoot walking using the MatScan1 system (Tekscan,
Boston, MA). This system consists of a 5 mm thick floor mat
(432 mm  368 mm) incorporating 2288 resistive sensors
(1.4 sensors/cm2) sampling at a rate of 40 Hz, with a range of
0.07–10.55 kg/cm2. The mat was calibrated for each
participant using their own bodyweight prior to each testing
session by recording a static unipedal stance trial. The two-
step gait initiation protocol [26–28] was used to obtain foot
pressure data, as it (i) requires fewer trials than the midgait
protocol; (ii) has similar re-test reliability to the midgait
protocol; and (iii) provides similar peak pressure values (with
the possible exception of an under-estimation of peak
pressures under the heel [28]). Each participant was positioned
two step lengths from the front edge of the pressure platform
and was instructed to walk in a normal manner, striking the
sensor area with the second step. Three to four additional steps
were taken after striking the sensor area. After the participant
completed several practice trials, their starting position was
marked to ensure proper placement of the right foot on the
sensor platform with the second step. A trial was repeated if it
appeared that the participant targeted the sensor surface or if
the investigator observed an atypical foot placement on the
platform. Three trials were recorded, which has been found to
be sufficient to ensure adequate reliability of pressure data
[26–28]. Pilot data from 30 healthy participants indicates that
the same-day coefficients of variation for three trials using this
system are as follows: maximum force (heel: 3%, midfoot:
11%, forefoot: 8–10%, toes: 6–13%) and peak pressure (heel:
4%, midfoot: 12%, forefoot: 3–7%, toes: 6–11%).
Please cite this article as: Genevieve Scott et al., Age-related differences in foot structure and function, Gait & Posture (2006),
doi:10.1016/j.gaitpost.2006.07.009
3
Fig. 1. The mask used to define the seven regions of the foot for regional
force and pressure analysis.
Following data collection, the Research Foot software
(Version 5.24) was used to construct individual ‘‘masks’’ to
determine forces and pressures under seven regions of the
foot: the heel, midfoot, 3rd–5th MPJs, 2nd MPJ, 1st MPJ,
hallux, and lesser toes (Fig. 1). Although the Systéme
International d’Unités for force and pressure are Newtons
and Pascals, respectively, most pressure recording systems
allow the user to express force as kilograms (kg), Newtons
(N) or pounds (P), and pressure as kilograms/cm2 (kg/cm2),
Newtons/cm2 (N/cm2), kilopascals (kPa) or pounds/inch2
(PSI), and the units are used interchangeably in the
literature. We chose to report force as kilograms and
pressure as kilograms/cm2 as these units are easily
conceptualised and to allow for direct comparison to our
previous study [12].
2.5. Statistical analysis
Only data from the right foot was analysed, in order to
satisfy the independence assumption of statistical analysis
[29] and because foot pressure patterns are highly symme-
trical [30]. Variables with right skewed distributions were
suitably transformed into a normal distribution, using either
log or square root transformations. To determine age-related
differences in foot structure and plantar pressure variables, a
series of independent samples t-tests were used. To determine
whether the differences in plantar pressure patterns between
young and older participants could be explained by
differences in foot structure, a series of multiple regression
analyses were undertaken. First, Pearson correlation coeffi-
cients were computed to examine the relationships between
each of the plantar loading variables and participant
characteristics (height, weight and body mass index),
temporospatial gait parameters, and foot and ankle char-
acteristics. Variables found to be significantly associated with
plantar loading parameters were then entered into a series of
multiple linear regression analyses to determine their relative
importance in explaining variance. Age-group was then added
to the model as a dummy variable (i.e. young = 0, older = 1) to
determine whether it could explain any further variance.
To avoid the inclusion of misleading or unhelpful
variables due to covariance among some independent
variables, only one variable from highly correlated variables
(e.g., the three foot posture measures and the temporospatial
gait parameters) was included as a possible predictor at the
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4 G. Scott et al. / Gait & Posture xxx (2006) xxx–xxx

entry of each block. The selection of which variable to include Table 1

was based on the strength of the Pearson correlation Age-related differences in foot and ankle characteristics
coefficient, with only the most strongly associated variable Young Older
entered into the model. In addition, only those variables Foot posture
considered to have a plausible functional relationship to Foot posture index (FPI) 2.54 (2.35) 4.14 (3.86)*
Arch index 0.18 (0.73) 0.24 (0.05)**
loading patterns at each site were considered. For example,
Navicular height/foot length 0.19 (0.04) 0.11 (0.03)**
none of the forefoot characteristics (e.g., hallux valgus, lesser
toe deformities and toe plantarflexor strength) were con- Foot range of motion
Ankle flexibility (8) 45.14 (8.44) 35.68 (9.08)**
sidered to be potential predictors of loading of the heel. Beta 1st MPJ ROM (8) 81.42 (17.95) 56.40 (15.42)**
weights and signs for all variables entered into the regression
Foot deformity and lesions
model were also examined to ensure they made meaningful
Hallux valgus (%) 2 60**
contributions to plantar loading variables. Change in the None 98 40
amount of variance (r2) was assessed following the addition of Mild 2 30
age into the model. The standardized beta weights provided Moderate 0 24
give an indication of the relative importance of the various Severe 0 6
measures entered into the model in explaining variance in the Lesser toe deformities (%) 0 58**
plantar loading variables. The data were analysed using SPSS Corns (%) 0 6**
for Windows (SPSS, Inc., Chicago, IL). Calluses (%) 12 32**
Tactile sensitivity
Lateral malleolus 3.46 (0.67) 4.66 (0.62)**
1st MPJ 3.07 (0.90) 4.54 (0.54)**
3. Results
Strength
3.1. Sample characteristics Ankle dorsiflexion strength (kg) 16.86 (3.96) 10.87 (4.43)**

Passed paper grip test (%)

The older participants were shorter (162.1  8.9 versus Hallux 100 66**
172.1  9.3 cm, t98 = 5.47, p < 0.001) and had a higher Lesser toes 100 68**
body mass index (25.9  3.8 versus 23.1  2.8 kg/m2, *
Significant difference at p < 0.05.
t98 = 4.26, p < 0.001), however there was no difference **
Significant difference at p < 0.01.
in bodyweight between the groups (68.5  13.1 versus
68.8  12.7 kg, t98 = 0.13, p = 0.895). exhibited significantly lower maximum forces at the heel,
3rd–5th MPJs and hallux, lower peak pressure at the heel,
3.2. Age-related differences in foot and ankle 3rd–5th MPJs, 2nd MPJ and hallux, and longer relative
characteristics contact time at the heel, midfoot, 3rd–5th MPJs, 2nd MPJ
and 1st MPJ.
Descriptive statistics for each of the foot and ankle tests
according to age are shown in Table 1. Compared to the 3.5. Multiple regression analyses
young participants, older participants exhibited flatter/more
pronated feet, less range of motion at the ankle and 1st MPJ, Results of the multiple regression analyses are shown in
a higher prevalence of hallux valgus, lesser toe deformities, Figs. 2–4. Maximum force at the heel was associated with
corns and calluses, reduced tactile sensitivity at the lateral step length, 3rd–5th MPJ force was associated with step
malleolus and 1st MPJ, reduced ankle dorsiflexion strength, length and the foot posture index, and hallux force was
and were more likely to fail the paper grip tests. associated with hallux valgus. Peak pressure at the heel was
associated with step length and age, 3rd–5th MPJs pressure
3.3. Age-related differences in temporospatial gait was associated with step length and the foot posture index,
parameters 2nd MPJ pressure was associated with step length, and
hallux pressure was associated with hallux valgus, the paper
Descriptive statistics for walking speed, step length and grip test of the hallux, and ankle flexibility. Contact time at
cadence are shown in Table 2. Compared to the young the heel was associated with step length, tactile sensitivity
participants, older participants exhibited a slower walking
speed and shorter step length, however there was no Table 2
difference in cadence between the two groups. Age-related differences in temporospatial gait parameters
Young Older
3.4. Age-related differences in plantar pressure patterns Walking speed (m/s) 1.19 (0.14) 0.94 (0.18)**
Step length (cm) 66.36 (8.10) 52.19 (8.17)**
Descriptive statistics for maximum force, peak pressure Cadence (steps/min) 108.89 (14.34) 107.65 (10.35)
**
and contact time are shown in Tables 3–5. Older participants Significant difference ( p < 0.01).

Please cite this article as: Genevieve Scott et al., Age-related differences in foot structure and function, Gait & Posture (2006),
doi:10.1016/j.gaitpost.2006.07.009
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G. Scott et al. / Gait & Posture xxx (2006) xxx–xxx 5

Table 3
Age-related differences in maximum force (kg)
Young Older
Total 58.81 (12.08) 61.08 (14.31)
Heel 38.24 (7.89) 33.45 (8.80)**
Midfoota 9.91 (6.25) 9.49 (6.69)
3rd–5th MPJsa 15.19 (5.87) 12.84 (5.03)*
2nd MPJ 15.55 (3.27) 14.59 (4.34)
1st MPJb 14.67 (4.82) 16.09 (5.25)
Hallux 7.78 2.17) 5.82 (2.60)**
Lesser toes 4.11 (1.93) 4.24 (2.23)
a
Square root transformed.
b
Log transformed.
*
Significant difference ( p < 0.05).
**
Significant difference ( p < 0.01).
Fig. 2. Predictors of maximum force. Only significant independent pre-
dictors are shown. Values in brackets represent standardized b weights with
Table 4 associated significance level (*p < 0.05, **p < 0.01). Values in mask
Age-related differences in peak pressure (kg/cm2) regions represent multiple r2 values.
Young Older
Total 2.53 (0.30) 2.35 (0.40)
Heel 2.34 (0.38) 1.97 (0.49)**
Midfoota 0.71 (0.38) 0.51 (0.63)
3rd–5th MPJs 1.70 (0.41) 1.42 (0.46)**
2nd MPJ 2.37 (0.33) 2.11 (0.53)**
1st MPJ 1.67 (0.41) 1.68 (0.48)
Hallux 1.54 (0.35) 1.25 (0.39)**
Lesser toes 0.73 (0.27) 0.72 (0.30)
a
Log transformed.
**
Significant difference ( p < 0.01).

and age, midfoot contact time was associated with the arch
index and age, 3rd–5th MPJ contact time was associated
with navicular height, 2nd MPJ contact time was associated
with step length, ankle flexibility and age, and 1st MPJ Fig. 3. Predictors of peak pressure. Only significant independent predictors
contact time was associated with step length and age. These are shown. Values in brackets represent standardized b weights with
associated significance level (*p < 0.05, **p < 0.01). Values in mask
predictor variables accounted for 14–28% of the variance in regions represent multiple r2 values.
maximum force, 16–26% of the variance in peak pressure,
and 25–46% of the variance in contact time.

4. Discussion

The aims of this study were to determine the effect of age

on a range of structural foot characteristics, to determine the

Table 5
Age-related differences in contact timea
Young Older
Heel 55.35 (6.81) 67.19 (8.17)**
Midfoot 64.42 (9.38) 73.34 (7.54)**
3rd–5th MPJs 84.56 (3.73) 88.99 (4.59)**
2nd MPJ 85.47 (3.57) 91.43 (4.42)**
1st MPJ 82.61 (4.48) 89.28 (5.17)**
Hallux 70.05 (11.01) 73.04 (15.23)
Fig. 4. Predictors of contact time, expressed as a percentage of total contact
Lesser toes 69.84 (10.94) 74.14 (12.22)
time. Only significant independent predictors are shown. Values in brackets
a
Expressed as a percentage of total contact time. represent standardized b weights with associated significance level
**
Significant difference ( p < 0.01). (*p < 0.05, **p < 0.01). Values in mask regions represent multiple r2 values.

Please cite this article as: Genevieve Scott et al., Age-related differences in foot structure and function, Gait & Posture (2006),
doi:10.1016/j.gaitpost.2006.07.009
GAIPOS-2294; No of Pages 8
6 G. Scott et al. / Gait & Posture xxx (2006) xxx–xxx
effect of age on force and pressure distribution under the foot
when walking, and to determine whether differences in foot
structure can explain age-related differences in plantar force
and pressure distribution. The results demonstrate that older
people have flatter/more pronated feet, reduced range of
motion of the ankle and 1st MPJ, a higher prevalence of
hallux valgus, toe deformities and toe plantarflexor
weakness, and reduced tactile sensitivity. Significant
differences in pressure distribution were also noted, with
older people exhibiting reduced magnitude of forces and
pressures under the heel, lateral forefoot and hallux, but
greater relative contact time under the heel, midfoot and
MPJs.
The age-related differences in foot posture, range of
motion, sensation and strength reported here are generally
consistent with previous studies. Using a footprint measure-
ment technique similar to the arch index, Staheli et al. [31]
reported a trend towards flatter feet above the age of
approximately 30 years. The reduced range of ankle joint
motion in older people is consistent with several previous
studies [3,4], however the observation of a reduced range of
motion in the 1st MPJ is a novel finding. Although age-
related changes in ankle dorsiflexion strength have been
widely reported [32], only one study has examined age-
related differences in toe plantarflexion strength. Using a
force platform, Endo et al. [5] found that older people
generated 29% less force under their toes compared to
younger people. Finally, several authors have confirmed that
ageing is associated with reduced tactile sensitivity [33,34],
with the most pronounced changes evident in the lower limb
[6]. These findings indicate that ageing is associated with
significant changes to the musculoskeletal and sensory
characteristics of the foot.
A number of significant differences in force and pressure
distribution were also observed between young and older
participants. Specifically, older participants demonstrated
reduced magnitude of forces and pressures under the heel,
lateral forefoot and hallux, and spent a relatively longer
period of stance phase loading the heel, midfoot and
forefoot. These findings are similar to those of Kernozek and
LaMott [7], who reported decreased forces and pressures
under the hallux in older people, and Hessert et al. [8], who
reported lower pressures in the heel and medial region of the
foot in older people. However, the results of the current
study suggest that these changes can be largely explained by
step length and foot structure differences between the
groups.
The multiple regression models provide useful insights
into the factors responsible for these age-related differences.
Heel and lateral forefoot forces and pressures were found to
be significantly lower in older people, and regression
analysis identified step length as a significant predictor of
maximum force and peak pressures in these regions. The
relationship between step parameters and plantar loading
have previously been reported by Drerup et al. [35], who
found that reducing stride length lead to reduced peak
Please cite this article as: Genevieve Scott et al., Age-related differences in foot structure and function, Gait & Posture (2006),
doi:10.1016/j.gaitpost.2006.07.009
pressures in all regions of the foot except the small toes, and
Zhu et al. [36], who reported that adopting a ‘‘shuffling’’ gait
pattern reduced peak pressures by 42%. This reduction has
been attributed to the adoption of a less propulsive push-off
phase of gait.
Maximum force and peak pressure under the lateral part
of the foot were also strongly correlated with the foot posture
variables, particularly the foot posture index. The direction
of these associations signifies that the flatter (more pronated)
the foot, the less lateral loading, which supports the earlier
results of Song et al. [37], who found that people with pes
planus feet demonstrated a greater medial displacement of
the centre of foot pressure. Although extrapolating plantar
loading patterns to the kinematic function of the foot is
difficult, it is likely that older people, who demonstrate
flatter feet, tend to undergo greater ankle-subtalar joint
eversion during gait which may manifest as reduced lateral
loading. Indeed, Redmond et al. [16] have recently shown
that the foot posture index can explain 41% of the variance in
the degree of eversion of the ankle joint complex during the
midstance phase of gait.
Maximum force and peak pressure under the hallux
region of the foot were found to be correlated with the degree
of hallux valgus. The more pronounced the hallux valgus
deformity, the less loading under the hallux, which is
consistent with the results of Mueller et al. [38] and Menz
and Morris [12]. This may be due to hallux valgus altering
the propulsive function of the first MPJ, resulting in a lateral
redistribution of loading [39]. Peak pressure under the hallux
was also positively associated with the paper grip test,
indicating that toe strength plays a role in stabilising the foot
during propulsion [12], and with ankle flexibility, which may
also be related to a more active propulsion in people with
adequate motion in the ankle joint.
Contact time, expressed as a percentage of total contact
time, was greater in the older group for all sites except the
hallux and lesser toes, indicating that most regions of the
foot were in contact with the ground for a relatively longer
proportion of stance phase compared to younger partici-
pants. This may also indicate the adoption of a less
propulsive gait pattern in older people. The regression
results support this suggestion, as step length was an
independent predictor of contact time at the heel and across
all MPJs (i.e. the shorter the step length, the longer the
relative contact time). In addition to step length, heel contact
time was associated with tactile sensitivity, which may
indicate a more cautious weight acceptance in the presence
of peripheral sensory loss. Foot posture variables (arch index
and navicular height) were also related to contact time at the
midfoot and 3rd–5th MPJs, respectively, indicating that the
flatter the foot, the greater the relative duration of loading of
the midfoot and the shorter the duration of loading of the
lateral forefoot.
Overall, these findings indicate that although there are
significant differences in plantar loading patterns related to
age, these differences can be partly explained by the reduced
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G. Scott et al. / Gait & Posture xxx (2006) xxx–xxx
step length and altered foot characteristics evident in older
people. Nevertheless, it is clear that some aspects of ageing
not represented in our test battery are responsible for a
substantial amount of unexplained variance for some regions
of the foot. For example, age-related changes in soft tissue
characteristics may have provided further insight into force
and pressure patterns, particularly under the heel. In this study,
the foot and ankle assessments were limited to those that could
be used easily in a clinical setting, which limits the degree of
variance that could be accounted for. An additional limitation
is that we intentionally selected participants without foot
symptoms. It is possible that older people with foot pain
demonstrate more pronounced foot deformity and therefore
stronger associations with plantar loading variables. Indeed,
our previous analysis of pressure patterns in 172 older people
(some of whom reported foot pain) revealed higher multiple r2
values for forefoot regions than those reported here [12].
Further research is now required to determine whether
specific foot problems in older people demonstrate char-
acteristic changes in plantar loading patterns.
5. Conclusion
This study was undertaken to compare foot structure and
function in young and older people. The results indicate that
older people exhibit flatter feet, reduced range of motion,
tactile sensation and strength, and a higher prevalence of
foot deformity. Examination of pressure patterns revealed
significant reductions in the magnitude of forces and
pressures under the heel, lateral forefoot and hallux, but
greater relative duration of contact under the heel, midfoot
and MPJs in older participants. Multiple regression analysis
revealed that these age-related differences could be largely
explained by differences in step length and selected foot
characteristics. These findings confirm that there are
significant changes in the structure and function of the foot
with advancing age. Future studies should focus on the
contribution of both structural and functional changes to the
development of common foot problems in older people.
Acknowledgement
Dr. Menz is currently NHMRC Australian Clinical
Research Fellow (id: 234424).
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Please cite this article as: Genevieve Scott et al., Age-related differences in foot structure and function, Gait & Posture (2006),
doi:10.1016/j.gaitpost.2006.07.009