Change of Segmental Motion Following Total Ankle Arthroplasty Using a 3-Dimensional Multi-segment Foot Model.

Background: Total ankle arthroplasty (TAA) enhances patients' subjective outcomes with respect to pain and function. The aim of this study was to analyze the biomechanical changes of the affected limb following TAA using gait analysis with a 3-dimensional multi-segment foot model (3D MFM). Methods: We reviewed medical records, simple radiographs, and gait analyses using a 3D MFM of patients who underwent TAA for severe varus ankle arthritis. Preoperative and postoperative gait data of 24 patients were compared. Postoperative gait analyses were done at least 1 year after surgery. Results: TAA significantly increased stride length (p = 0.024). The total range of motion of all planes in the hindfoot and forefoot showed no significant changes between preoperative and postoperative states. Hindfoot was significantly plantarflexed and pronated after TAA, while forefoot was significantly supinated in all phases. After appropriate calculations, the genuine coronal motion of the hindfoot showed no changes after TAA in all phases. Conclusions: TAA did not result in biomechanical improvements of segmental motions in the forefoot and hindfoot, except for changes to the bony structures. Therefore, it is important to point out to patients that TAA will not result in significant improvement of ankle function and range of motion. Clinicians can consider this information during preoperative counseling.

Discrepancies in plantar pressure distribution between affected and unaffected sides in patients with plantar fasciitis.

PURPOSE: A fundamental understanding of plantar pressure distribution is important for prescribing an appropriate orthosis and applying nonoperative methods, such as stretching exercises, for the treatment of plantar fasciitis. Despite existing research on plantar pressure distribution, discrepancies between affected and unaffected sides in unilateral plantar fasciitis patients warrant further investigation. This study aimed to evaluate the plantar pressure distribution in patients with unilateral plantar fasciitis by comparing it with that on the contralateral unaffected side. METHODS: We retrospectively reviewed records from 20 consecutive patients diagnosed with unilateral plantar fasciitis, using the unaffected side as the control. The emed® pedobarographic system was used to measure the plantar pressure distribution during gait. The analysis was performed using a 4-mask configuration (toes, forefoot, midfoot, and hindfoot). RESULTS: Both sides showed no significant differences in radiographic parameters. The affected side showed a significantly higher contact area, maximum force, and force-time integrals in the midfoot. However, the unaffected side demonstrated significantly higher maximum force and force-time integrals in the hindfoot. There was no difference in the distribution of the peak pressure and pressure-time integrals between the two sides in all mask regions. The increased contact area and maximum force in the midfoot on the side with plantar fasciitis may result from heel pain-induced weight transfer from the hindfoot. CONCLUSION: The findings of this study provide a basic understanding of plantar pressure distribution in the treatment of plantar fasciitis and highlight the importance of considering inter-side differences when designing treatment interventions or orthotic devices.

Clinical Efficacy of Application-Linked Stretching Ball as Digital Therapeutics in Plantar Fasciitis.

Background/Objectives: This study aimed to evaluate the efficacy of application-linked stretching ball instruments that record the rolling time and force of patients compared with a traditional simple stretching ball. Methods: Fourteen participants with plantar fasciitis were divided into a simple massage ball group (group A, n = 8) and an application-linked massage ball group (group B, n = 6). The application-linked massage ball sends information regarding the massages, such as the frequency and force of the massage on the foot, to the application on the patient's smartphone. All clinical outcomes were evaluated at the beginning of the study and 1-, 2-, and 3-month follow-up. The primary outcome measure was the Manchester-Oxford Foot Questionnaire (MOXFQ) score. Results: At the beginning of the study, the initial MOXFQ score was not significantly different between the two groups (p = 0.948). At each time point, the MOXFQ score of the whole population did not improve significantly compared to that of the initial state (p = 0.131). Generalized estimating equation modeling demonstrated that there was no significant difference in the improvement of the MOXFQ score between groups A and B during follow-up (p = 0.826). In addition, no group-by-time interactions were observed (p = 0.457). Conclusions: The efficacy of an application-linked massage ball for the treatment of plantar fasciitis was not as definite as that of a traditional simple stretching ball in patients whose symptoms persisted for at least six months. Future studies that include patients with acute plantar fasciitis are required.

Prolonged Union in Conservative Treatment of Symphalangeal Toe Fractures: Case Series.

Background: Toe symphalangism is characterized by a fusion of the interphalangeal joint between the middle and distal phalanges. While typical lesser toe fractures heal well with conservative treatment, in our clinical experience, we encountered patients with symphalangeal toe fractures who experienced long-lasting pain and delayed radiographic union. Therefore, this study aimed to report radiographic outcomes following conservative treatment of symphalangeal fractures of the lesser toes. Methods: We retrospectively reviewed 14 patients with symphalangeal lesser toe fractures who were treated conservatively. We investigated the mechanism of injury and measured the time from the initial injury date to the complete radiographic union. The fracture gap distance was measured on an initial lateral radiograph. Results: Symphalangeal fractures involved the fourth toe in 4 patients (28.5%) and the fifth toe in 10 patients (71.4%). Regarding the mechanism of injury, 6 patients (42.9%) were injured by stubbing or bumping into the door, 5 patients (35.7%) were injured by tripping, 2 patients (14.3%) were injured by heavy objects falling directly on their toes, and 1 patient (2.3%) complained of pain after wearing pointed shoes for half a day. The mean time to complete union was 9.1 months, and the median period was 5.5 months (range, 0.8-29 months). The initial gap of the fracture was 0.60 mm (range, 0.30-1.04 mm). Conclusions: The results of our case series may help counsel patients in the outpatient clinic that prolonged healing time may be required for the union of symphalangeal toe fractures.

Management of Checkrein Deformity.

Checkrein deformity is characterized by the dynamic status of the hallux, in which flexion deformity is aggravated by ankle dorsiflexion and relieved by ankle plantarflexion. In most cases, a checkrein deformity occurs secondary to trauma or following surgery. It has been suggested that the flexor hallucis longus tendon tethers or entraps scar tissue or fracture sites. Improvement with conservative treatment is difficult once the deformity has already become entrenched, and surgical management is usually required in severe cases. Various surgical options are available for the correction of checkrein deformities. It includes a simple release of adhesion at the fracture site; lengthening of the flexor hallucis longus by Z-plasty at the fracture site combined with the release of adhesion; lengthening of the flexor hallucis longus by Z-plasty at the midfoot, retromalleolar, or tarsal tunnel area; and flexor hallucis longus tenotomy with interphalangeal arthrodesis for recurrent cases. This review aimed to summarize the overall etiology, relevant anatomy, diagnosis, and treatment of checkrein deformities described in the literature.

Clinical outcomes following tibiotalocalcaneal arthrodesis with intramedullary nailing combined with partial fibulectomy and onlay bone graft.

INTRODUCTION: Although intramedullary nailing is a popular method for tibiotalocalcaneal arthrodesis, nonunion is one of the most commonly reported complications. This study aimed to evaluate the fusion rate, improvement in functional outcomes, and occurrence of complications in tibiotalocalcaneal arthrodesis using retrograde intramedullary nailing with partial fibulectomy and onlay bone graft technique. MATERIALS AND METHODS: Twenty-six consecutive patients using the proposed technique were retrospectively reviewed. For radiographic outcomes, the union rate, alignment, and any related complications were assessed. Functional outcomes were evaluated using the American Orthopedic Foot and Ankle Society hindfoot scale, Foot and Ankle Outcome Score, and visual analog scale, preoperatively and at the final follow-up. RESULTS: The mean follow-up period was 38.2 months. The tibiotalar joint achieved complete union in 80.8% at six months postoperatively, while all the cases achieved complete union at 12 months postoperatively. However, the subtalar joint achieved complete union in 26.9% at six months postoperatively, which gradually increased to 73.1% at 12 months postoperatively, and 80.8% at the final follow-up without revision surgery. A subgroup analysis showed there was a trend of higher subtalar fusion rate when an additional screw for the subtalar joint fixation was placed (86.7% vs. 54.5%). The functional outcomes significantly improved at the final follow-up. A few minor complications occurred, including surgical site infection, irritational symptoms, and metal failure; however, they eventually resolved. CONCLUSIONS: Our technique of tibiotalocalcaneal arthrodesis with partial fibulectomy and onlay bone grafting could be a good option where both the tibiotalar and subtalar joints need to be fused.

A Modified 90-Degree Distal Chevron Metatarsal Osteotomy for Correcting Moderate Hallux Valgus Deformity.

Various modifications of distal chevron metatarsal osteotomy (DCMO) have been introduced for correcting moderate hallux valgus deformity; however, the amount of correction may be limited, and complications, such as the recurrence of the deformity and avascular necrosis of the metatarsal head, have been a problem. This study aimed to present a modified 90-degree DCMO technique that overcomes the previously reported shortcomings and to report a successful short-term radiographic outcome. Sixty-eight consecutive patients who underwent the operation with our modified DCMO technique and twenty-two consecutive patients with the conventional DCMO technique (control group) were retrospectively analyzed. The radiographic measurements were evaluated preoperatively, at two months post operation, and at the final follow-up. Both groups showed a significant correction of the hallux valgus angle, first-second intermetatarsal angle, distal metatarsal articular angle, and sesamoid position at the final follow-up, while the amount of correction was significantly greater in the modified DCMO group. In both groups, there were no cases of complications such as avascular necrosis of the metatarsal head, nonunion, and surgical site infection appearing throughout the follow-up period. Therefore, the modified 90-degree DCMO technique is effective and safe, which could serve as a favorable option to treat moderate hallux valgus deformity.

Optimal hinge level in opening wedge high tibial osteotomy: Biomechanical analysis using finite element method.

BACKGROUND: While the concept of a safe zone, which can minimize the hinge fracture when performing opening wedge high tibial osteotomy, has been introduced, there is a lack of understanding of the biomechanical environment at the lateral tibial cortex. This study aimed to evaluate the effect of the hinge level on the biomechanical environment at the lateral cortex of the tibia with heterogeneous finite element models. METHODS: Finite element models of biplanar opening wedge high tibial osteotomy based on computed tomography images of a control subject and three patients with medial compartment knee osteoarthritis were created. In each model, three different hinge levels (proximal, middle, and distal) were set. The process of opening the gap during the operation was simulated, and the maximum von Mises stress values at the lateral tibial cortex were calculated for each hinge level and correction angle. FINDINGS: The maximum von Mises stress value at the lateral tibial cortex was the lowest when the hinge was at the middle, while the value was the highest when the hinge was at the distal level. Furthermore, it was demonstrated that a higher correction angle yielded a higher probability of lateral tibial cortex fracture. INTERPRETATION: The findings of this study demonstrate that the hinge at the point where the upper end of the articular cartilage of the proximal tibiofibular joint is located provides the least possibility of lateral tibial cortex fracture, as this is an anatomically independent position from the fibula.

Preoperative incongruent subtalar joint predicts less favorable clinical outcome in total ankle arthroplasty.

BACKGROUND: This study aimed to determine the clinical effect of incongruent subtalar joint space on total ankle arthroplasty (TAA). METHODS: Thirty-four consecutive patients who underwent TAA were grouped according to the status of subtalar joint incongruency. A comparison of clinical and radiographic parameters between groups as well as multiple regression analysis was performed to identify contributing factors to the final functional outcome. RESULTS: The final American Orthopaedic Foot and Ankle Society (AOFAS) score was significantly higher in the congruent group compared to that of the incongruent group (p = 0.007). There were no significant differences between the two groups in measured radiographic angles. In multiple regression analysis, the female sex (p = 0.006) and incongruency of the subtalar joint (p = 0.013) were found to be significant contributing factors to the final AOFAS score. CONCLUSIONS: A thorough preoperative investigation should be taken into the state of the subtalar joint for TAA.

Foot and Ankle Motion after Tibiotalocalcaneal Arthrodesis: Comparison with Tibiotalar Arthrodesis Using a Multi-Segment Foot Model.

Background: Tibiotalocalcaneal arthrodesis is an established surgical procedure for treating patients with end-stage ankle joint arthritis and subtalar joint arthritis. Although it greatly relives pain, a major drawback is loss of range of motion. Although it is known to restrict an additional subtalar joint compared to tibiotalar arthrodesis, there is a lack of gait analysis studies comparing the two methods. This study aimed to evaluate the differences in kinematics of the foot and ankle joints between tibiotalar and tibiotalocalcaneal arthrodesis. We also compared preoperative and postoperative statuses for each surgical method. Methods: The study included 12 and 9 patients who underwent tibiotalar and tibiotalocalcaneal arthrodesis, respectively, and 40 healthy participants were included in the control group. The DuPont foot model was used to analyze intersegmental foot and ankle kinematics during gait. Results: Compared to controls, both tibiotalar and tibiotalocalcaneal arthrodesis resulted in slow gait speed with reduced stride length, increased step width, and decreased range of sagittal plane motion. Both fusion methods showed similar range of motion in all segments and planes following surgery. Coronal positions showed more supination of the forefoot and pronation of the hindfoot segment after each operation, particularly tibiotalocalcaneal arthrodesis. Gait after tibiotalocalcaneal arthrodesis did not significantly differ from that after tibiotalar arthrodesis, but there was a tendency of more pronation in the hindfoot segment. Conclusions: Both fusion methods limited foot and ankle motion in similar ways. Comparing tibiotalar and tibiotalocalcaneal arthrodesis suggests that additionally fusing the subtalar joint does not cause greater movement restriction in patients. Objectively comparing tibiotalar and tibiotalocalcaneal arthrodesis will facilitate further understanding of the effect of tibiotalocalcaneal arthrodesis on movement and the value of subtalar joint motion for improved preoperative counselling.

The effect of backpack load on intersegmental motions of the foot and plantar pressure in individuals with mild flatfoot.

BACKGROUND: The feet play an essential role in shock absorption, and foot posture is closely related to gait. The compensatory mechanism under heavy-load conditions in individuals with mild flatfoot is poorly understood. In the authors' country, individuals with mild flatfoot are drafted as active-duty soldiers and participate in military rucking wearing heavy backpacks. This study investigated the effect of backpack load on gait and foot plantar pressure and possible differences in participants with mild flatfoot. The average weight of the backpack during military rucking (approximately 20 kg), was simulated in this study. METHODS: This study prospectively enrolled 30 healthy young males, divided into a control group (CON, n = 15) and a mild low-arched group (MLA, n = 15), based on the presence of flatfoot. Segmental foot kinematics were evaluated using a three-dimensional multi-segment foot model, and gait data of the temporal and spatial parameters were obtained. The dynamic plantar pressure was simultaneously measured using a pedobarography platform with gait trials. The protocol was repeated with all participants wearing 20 kg backpacks. Comparisons between the baseline and loaded states, as well as comparison between groups, were conducted. RESULTS: Although the cadence, gait speed, and stride length decreased in the loaded condition, step time and proportion of the stance phase increased in both groups. Although the MLA group showed more supinated and abducted positions of the forefoot and more pronated positions of the hindfoot than the CON group, the change in intersegmental foot and ankle motion in each group after backpack loading was minimal. However, the former showed a larger step width and a greater increase in contact area in the midfoot region, while the latter demonstrated a greater increase in peak pressure. CONCLUSIONS: Individuals with mild flatfoot demonstrated significantly different gait curve patterns (waveforms) compared to the controls. In the loaded condition, the CON and MLA groups may have adopted different strategies to maintain balance during gait. We suggest that although individuals with asymptomatic mild flatfoot are drafted as active-duty soldiers, they should be thoroughly investigated under loaded conditions, and orthoses may be helpful.

Relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis.

PurposeThis study aimed to evaluate the relationship between talofibular impingement and increased talar tilt in incongruent varus ankle osteoarthritis. Methods: Incongruent varus ankle osteoarthritis was defined as a talar tilt of more than 4° on standard ankle anteroposterior radiographs. We retrospectively reviewed 30 patients with unilateral incongruent varus ankle osteoarthritis with normal alignment of the contralateral ankle. All patients underwent bilateral weightbearing computed tomography and standing plain radiographs. The talar tilt and the distance between the talar lateral process and lateral malleolar tip were measured from a standing ankle anteroposterior radiograph of both sides. Talar and fibular spurs were assessed on the coronal and axial views of weightbearing computed tomography. After simulating the correction of the talar tilt in varus ankle osteoarthritis, talofibular bony impingement was reassessed. Results: On the varus side, the distance between the talar lateral process and the lateral malleolar tip was significantly shorter than that on the contralateral side (p < .001). Talar spur was present in the varus side of all 30 patients on the axial view of weightbearing computed tomography and in the control side of 10 patients. After the simulation of talar tilt correction, talofibular impingement (overlap) occurred in all 30 patients with a larger extent in the severe talar tilt subgroup (p < .001). Conclusion: Talofibular impingement by lateral gutter osteophytes is closely related to increased talar tilt in patients with incongruent varus ankle osteoarthritis. Therefore, lateral gutter osteophytes should be resected to stabilize mortise and improve clinical outcomes.

The difference of in-shoe plantar pressure between level walking and stair walking in healthy males.

Stair walking is more demanding locomotion than level walking and can aggravate discomfort of the foot. The purpose of this study is to analyze plantar pressure distribution and pressure patterns during gait cycle at stair walking compared to level walking. Thirty-five healthy males with 23.4 ± 2 years old were included in this study after examining normality. They performed level walking, stair ascending, and descending in same type of shoes. Measurements of in-shoe plantar pressure including peak pressure, pressure-time integral were done by Pedar-X system, masked 7 regions. Also, pressures in each region throughout the gait cycle were analyzed from each type of walking. Statistical analysis was performed using repeated measure one way analysis of variance. Peak pressure in all regions except for the midfoot was higher during level walking than stair walking. Pressure-time integral in the forefoot, midfoot during stair ascending, and the forefoot during stair descending was higher than level walking. In gait cycle, first peak was produced in the heel and the second peak was produced in the hallux during level walking, whereas during stair ascent, the heel and midfoot were in first peak, and the second peak was in the hallux. During stair descent, the first peak were in the forefoot and the midfoot, and the second peak was in the forefoot. In healthy young male adults, forefoot and midfoot are significant regions in the way that they have higher pressure burdens than other foot regions during stair walking.

Change in intersegmental foot and ankle motion after a high tibial osteotomy in genu varum patients.

High tibial osteotomy (HTO) is a well-established treatment for medial compartment knee osteoarthritis (OA), which shifts the weight-bearing axis from the medial to the lateral side of the knee. As the adjacent ankle joint may be directly affected by the change in biomechanics, this study aimed to evaluate the change in the intersegmental foot and ankle motion after HTO in patients with genu varum. The study included 24 patients who underwent HTO, and 48 older healthy participants as a control group. Segmental foot kinematics were evaluated using a 3D multisegment foot model, and gait data of temporal and spatial parameters were obtained. After HTO, normalized stride length significantly increased with a tendency for increases in gait speed. In hallux kinematics relative to the forefoot, the sagittal motions of both the patients and the control group were similar throughout the majority of the gait cycle. In forefoot kinematics relative to the hindfoot, the pre-HTO state revealed significant pronation throughout the gait cycle, while the post-HTO state showed a similar position and motion to the control group. In hindfoot kinematics relative to the tibia, coronal motions of the pre-HTO state showed supination throughout the gait cycle, while supination during the stance phase decreased after HTO. Genu varum patients with medial compartment knee OA showed different gait parameters and intersegmental motion during gait when compared with age- and gender-matched controls. The effect of HTO was demonstrated by the normalization of midfoot compensation in patients with genu varum.

A modified transfibular technique of ankle arthrodesis using partial fibular resection and onlay bone graft.

The transfibular approach is a common procedure for tibiotalar fusion. However, this technique has several concerns: inadequate stability to resist rotational and shearing forces, a fibula is suboptimal for bone grafting, and an onlay fibular graft that might prevent impacting and cause distraction. We present a modified transfibular technique using partial fibular resection and onlay bone graft, which may address these potential problems. This study aimed to evaluate whether the ankle joint is well fused with neutral alignment and functionally improved at the final follow-up. For this study, 27 consecutive patients (mean age, 68.5 years; range, 58-83) who underwent tibiotalar fusion with a follow-up period of >1 year were retrospectively included. A modified transfibular lateral approach was performed, in which the distal anterior half fibula was resected and fixed as an onlay graft to achieve fusion between the tibia, fibula, talus, and fibular onlay graft simultaneously. Radiographic outcomes were assessed using computed tomography at 4 months after operation and serial follow-up radiographs. Functional outcomes were assessed using the American Orthopedic Foot and Ankle Society hindfoot scale and Foot and Ankle Outcome Score. The mean follow-up period was 17.3 (range, 12-32) months. Four months after operation, complete union was achieved in 13 patients, near-complete union in 8 patients, and partial union in the remaining 6 patients. At the final follow-up, all the patients achieved complete union and maintained neutral ankle alignment. The functional outcome showed a significant increase between the preoperative and postoperative periods. One minor complication occurred, in which medial side ankle pain was relieved after screw removal. This modified technique is safe and effective, and has several merits, including saving the soft tissue of the anterior ankle, saving the course of the peroneal tendons by leaving the posterior half of the fibula, resected fibula serving as a good bone stock, and reducing the likelihood of valgus deformity after fibulectomy.

Prevalence of Accessory Bones and Tarsal Coalitions Based on Radiographic Findings in a Healthy, Asymptomatic Population.

BACKGROUND: Accessory bones and tarsal coalitions are the most common developmental variations of the foot and ankle. However, their clinical implications are not well understood because there is no established prevalence data in the normal population and the reported prevalence varies widely. Therefore, we aimed to investigate the incidence of accessory ossicles and tarsal coalitions in a healthy, asymptomatic Korean population. METHODS: A total of 448 healthy, asymptomatic participants (224 men and 224 women; 896 feet) were enrolled and stratified by age and sex. To investigate the presence of accessory bones and tarsal coalitions in the foot and ankle, we obtained the weight-bearing standing radiographs (anteroposterior and lateral views) from each participant. RESULTS: Accessory ossicles were found in 49.2% of the healthy, asymptomatic Korean adults. The prevalence of accessory bones in adults was the highest with 34% for the accessory navicular, 5.8% for the os trigonum, 3.9% for the os peroneum, and 1.7% for the os subfibulare. The prevalence of tarsal coalitions in adults was 0.4% and that of symphalangism was 16% for the fourth toe and 80.6% for the fifth toe. The frequency of the accessory navicular and fifth toe symphalangism was significantly higher in women. Most of the accessory navicular and fourth and fifth toe symphalangism were bilateral, whereas the os subfibulare was mostly unilateral. CONCLUSIONS: The prevalence of accessory bones and tarsal coalitions in the healthy, asymptomatic Korean population showed some variation according to age and sex.

Morphological Characteristics of Os Subfibulare Related to Failure of Conservative Treatment of Chronic Lateral Ankle Instability.

BACKGROUND: The os subfibulare is usually asymptomatic and found incidentally on radiographs. However, sometimes it may cause subfibular pain and may be associated with chronic lateral ankle instability (CLAI). We hypothesized that os subfibulare could interrupt the talofibular space causing impingement, resulting in chronic pain and functional instability around the lateral malleolus. The purposes of this study were to analyze morphologic characteristics of os subfibulare, and to evaluate the clinical significance of the os subfibulare in patients with CLAI. METHODS: Between November 2011 and April 2015, 70 patients who had both computed tomography (CT) and magnetic resonance imaging (MRI) among 252 patients who visited our hospital with the symptom of lateral ankle instability were included in this study. The location of the ossicle was classified into 3 zones in reference to the attachment site of the lateral ankle ligaments. The impingement was classified into 2 groups according to the presence of talofibular encroachment. Digital radiographs were used to measure the ossicle width and shape determined by the length and width on an magnetic resonance (MR) image. RESULTS: The most common shape of ossicles was oval, and the most common location of ossicles was at the anterior talofibular ligament (ATFL) attachment site. Sixty-one percent of patients showed talofibular impingement on coronal MR images. In 48 cases, the dimension of fibula plus os subfibulare was larger than that of the contralateral normal fibula. The larger size and talofibular impingement of the ossicle were associated with greater need for operative treatment in patients with ankle instability. CONCLUSION: The morphologic analysis of the os subfibulare revealed that there might be impingement of the talofibular space by the ossicle in some patients. We suggest that morphologic characteristics of the os subfibulare should be considered when selecting treatment options in patients with CLAI and os subfibulare. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Flatfoot deformity affected the kinematics of the foot and ankle in proportion to the severity of deformity.

BACKGROUND: Flatfoot deformity is thought to affect gait kinematics, but the effect of flatfoot on segmental motion of the foot during gait remains unclear. Recently, multi-segmental foot models (MFMs) have been introduced for the in vivo analysis of dynamic foot kinematics. The objective of this study was to find the effect of flatfoot on segmental motion of the foot during gait in females by comparisons with age and gender controlled healthy adults. METHODS: Thirty six symptomatic flatfeet patients (52-80 years old) and 42 symptom-free female participants without flatfoot (60-69 years old) were included in this study. According to the Meary angle (MA) on standing lateral radiograph, flatfoot patients are divided into severe (SFF, MA>20°) and moderate (MFF, 10°