TRIPOD INDex: DIAgNOSTIC ACCURACy IN SyMPTOMATIC FlATFOOT AND CAvOvARUS FOOT: PART 2

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1 TRIPOD INDex: DIAgNOSTIC ACCURACy IN SyMPTOMATIC FlATFOOT AND CAvOvARUS FOOT: PART 2 Marut Arunakul, MD 1,2, Annunziato Amendola, MD 1, Yubo Gao, PhD 1, Jessica E. Goetz, PhD 1, John E. Femino, MD 1, Phinit Phisitkul, MD 1 ABSTRACT Background: The Index (TI) has been created to allow assessment of complex foot deformities. It utilizes tripod relationship between center of the heel, medial/lateral borders of the forefoot, and compare it to the center of the talar head. This study aimed to verify diagnostic accuracy of the TI in symptomatic flatfoot and cavovarus foot. Methods: Weightbearing radiographs including foot AP with a hemispherical marker around the heel, lateral, and views were obtained on 91 patients (110 feet) presenting with medial foot and ankle pain and on 89 patients (90 feet) presenting with lateral foot and ankle pain between June 2010 and May Radiographs were evaluated blindly for the TI,, lateral talo-first metatarsal angle, calcaneal, medial cuneiform-fifth metatarsal height, and coronal plane. The sensitivity, specificity, likelihood ratios, and predictive values were calculated. Clinically diagnosed flatfoot and cavovarus foot deformity indicated for surgical reconstruction by one of our foot and ankle orthopaedic surgeons was used as the accepted standard for diagnosis. Results: In flatfoot, sensitivity of the TI was 100%, comparable with lateral talo-first metatarsal angle (100%), and medial cuneiform-fifth metatarsal height (100%). Specificity of the TI was 93%, comparable with coronal plane (98%), but superior to other parameters. Positive likelihood ratio of the TI was 14.29, which was less than coronal plane hindfoot alignment (47.5), but more than other parameters. In cavovarus foot, sensitivity of the TI was 96%, comparable with coronal plane (100%), but superior to other parameters. Specificity of the TI 1 Department of Orthopaedics and Rehabilitation, University of Iowa 2 Department of Orthopaedics, Thammasat University, Pathumthani, Thailand Corresponding Author: Phinit Phisitkul, MD Department of Orthopaedics and Rehabilitation The University of Iowa 200 Hawkins Drive Iowa City, IA Phone: (319) Fax: (319) phinit-phisitkul@uiowa.edu was 95%, comparable with lateral talo-first metatarsal angle (94%), but superior to other parameters. Positive likelihood ratio of the TI was 19.2, which was more than other parameters. Conclusion: The Index showed high accuracy as a quantitative assessment in diagnosis of a symptomatic flatfoot and cavovarus foot. Keywords: Index; Diagnostic test; Flatfoot; Cavovarus foot INTRODUCTION Flatfoot and cavovarus foot are complex foot deformities commonly seen in clinical practice. The flatfoot deformity is characterized by a combination of collapse of the medial longitudinal arch, foot abduction at the talonavicular joint, and hindfoot valgus (subtalar joint eversion) 1-7. Patients with this deformity typically present with a gradual onset of medial foot and ankle pain 8. In very late stage of the disease, lateral pain may occur from subfibular impingement. Cavovarus foot is characterized by hindfoot varus (subtalar joint inversion), midfoot cavus, plantarflexion of the first metatarsal, and forefoot adduction Patients with this deformity typically present with lateral foot and ankle pain, painful callosities, difficulty with shoe wear, and ankle instability 9,12. Currently, several radiographic measurements are used to assess these deformities, but none of these radiographic parameters are able to integrate deformities at multiple planes and levels of the foot into a simple measurement 11. The Index (TI) has been created to allow quantitative assessment of complex foot deformities utilizing the tripod relationship between center of the heel, medial/lateral borders of the forefoot, and compare it to the center of the talar head on a standing anteroposterior radiograph. The TI has been previously developed in a study of normal feet, and it was found to be a very reliable and reproducible measure of overall foot alignment. The relationship between the foot tripod 11,13 and the center of the talar head 14 could theoretically demonstrate the effect of overall foot alignment on the subtalar joint. As the foot tripod is determined from landmarks on both the hindfoot and the forefoot, this measurement has the potential to appreciate the summation of deformity including hindfoot, midfoot, and forefoot in multiple planes. The objective of this study was to verify diagnostic accuracy of the Index in symptomatic flatfoot and cavovarus foot in cohorts of patients presenting with medial or lateral Volume 33 47

2 M. Arunakul, A. Amendola, Y. Gao, J. E. Goetz, J. E. Femino, P. Phisitkul Table 1: Demographic data of patients with medial foot and ankle pain Diagnosis Number (feet) Age (year) Symptomatic flatfoot ± 19 Tarsal tunnel syndrome 9 39 ± 15 FHL tenosynovitis 6 33 ± 11 Anteromedial ankle impingement ± 17 Plantar fasciitis ± 14 Age reported as mean ± standard deviation. Table 2: Demographic data of patients with lateral foot and ankle pain Diagnosis Number (feet) Age (year) Symptomatic cavovarus foot ± 16 Peroneal tendon pathology ± 16 Anterolateral ankle instability ± 13 Superficial peroneal nerve entrapment 6 45 ± 8 Subtalar Impingement ± 15 Anterolateral ankle impingement ± 15 Age reported as mean ± standard deviation. foot and ankle pain. We hypothesized that the Index has high accuracy in the diagnosis of symptomatic flatfoot and cavovarus foot. MATeRIAl AND MeTHODS The study was approved by our hospital s Institutional Review Board. Standard weightbearing radiographs including an AP foot view with a hemispherical marker around the heel, a lateral view, and a view were performed on two groups of patients presenting to the foot and ankle clinic over a period of 12 months (June 2010 to May 2011). The first group consisted of 110 feet in 91 consecutive patients (average age, 41.8 ± 15.1 years; range, 14 to 84; 58 females and 33 males) who presented with medial foot and ankle pain (Table 1). The second group consisted of 90 feet in 89 consecutive patients (average age, 37 ± 15.1 years; range, 14 to 70; 61 females and 28 males) who presented with lateral foot and ankle pain (Table 2). All patients were identified and recruited from three senior fellowship-trained orthopaedic surgeons database (PP, JEF, and AA). Demographic data was collected from patients charts. With the exception of patients treated non-operatively for plantar fasciitis, all the patients either had undergone a reconstructive surgery or had been consented for it due to failure of nonoperative treatment. Patients who had a previous ipsilateral foot surgery were excluded. Radiographic studies AP and lateral weightbearing radiographs were obtained in a standardized manner. For AP images, patients were Fig. 1: Measurement technique of the Index. A = center of heel (center of hemispherical marker), B = medial most of medial sesamoid of first metatarsal bone, C = lateral most of fifth metatarsal head, D = center of talar head, e = tripod angle created by the intersection of AB and AC, F = angle created by the intersection of AB and AD. Index (%) = (F/e) x 100. If the AD line is medial to AB line, the Index is positive, but if the AD line is lateral to AB line, the Index is then negative. The more positive Index, the more the center of the talar head is medial to the tripod of the foot as commonly seen in flatfoot deformity. asked to stand with equal weight on both feet. Properly sized hemispherical markers, made from a metal plate padded with half-inch polyethylene foam, were put snugly on the back of both heels. The radiographic beam was positioned 40 inches 48 The Iowa Orthopaedic Journal

3 Index: Diagnostic Accuracy in Symptomatic Flatfoot and Cavovarus Foot: Part 2 Fig. 3: Measurement technique of the lateral talo-first metatarsal angle, the calcaneal pitch, and the medial cuneiform-fifth metatarsal height. The lateral talo-first metatarsal angle; the longitudinal axis of the talus (line B1-B2) is established by placing a mark at the halfway point between the superior and inferior surfaces of the talus at the middle of the talus and the neck of the talus, and connecting these two points. A similar method is used to determine the lateral longitudinal axis of the first metatarsal (line C1-C2), with mid-diaphyseal reference points used to form this axis. The angle formed by these two lines is the lateral talo-first metatarsal angle (angle A). This angle is considered negative when there is a cavus relationship between the axis of the talus and the first metatarsal. The calcaneal pitch; it is defined as the angle (angle D) formed by the intersection of a line drawn tangentially along the inferior aspect of the calcaneus (line e1-e2) and a line drawn along the plantar aspect of the soft tissue shadow of the hindfoot when weightbearing (line F). The medial cuneiform-fifth metatarsal height; the most inferior surface of the distal aspect of the medial cuneiform is marked, and a line (line H) is extended from this point parallel to the floor. A similar line is marked (line I) on the most inferior portion of the base of the 5th metatarsal. The perpendicular distance between these two lines is measured with an electronic caliper, and is designated the medial cuneiform-fifth metatarsal height (line J). A Fig. 2: Measurement technique of the coverage angle. Points a, b = medial and lateral margins (respectively) of the articular surface of the talus. Points c, d = medial and lateral margins (respectively) of the articular surface of the navicular. line A is perpendicular to ab, and line B is perpendicular to cd. AP talonavicular is the angle created by the intersection of lines A and B. from the digital cassette and angled 15 degrees posteriorly toward the heels. Laser guides were used to align the center of the heel and second toe along the vertical axis of the cassette. For weightbearing, subjects stood on a radiolucent platform with equal weight on both feet. The platform consisted of a 0.5 inch x 20 inch x 18 inch sheet of Plexiglas mounted on a 6-inch high metal frame. The frame included a slot for holding the x-ray cassette at a 20 degree angle from vertical. A 3 mm x 2 mm x 6 cm lead strip was placed tangentially to the most posterior aspect of the heel and was oriented perpendicular to the longitudinal axis of the foot. The x-ray tube was oriented 20 degrees from horizontal, so that it was perpendicular to the plane of the film. The beam was centered at the level of the ankle, and the field of exposure was from midshaft of tibia to below the calcaneus. The source-to-film distance was 40 inches 15. The AP radiographs were examined for the Index (Figure 1) and the 16 (Figure 2). The lateral radiographs were examined for the lateral talo-first metatarsal angle 17, the calcaneal 18, and the medial cuneiform-fifth metatarsal height 19 as shown in Figure 3. The radiographs were examined Volume 33 49

4 M. Arunakul, A. Amendola, Y. Gao, J. E. Goetz, J. E. Femino, P. Phisitkul Diagnosis Table 3: Radiographic parameter values for all subjects presented with medial foot and ankle pain categorized by diagnosis Index (%) (mm) Lateral talofirst Medial cuneiform- fifth MT height (mm) Symptomatic flatfoot 64 ± ± 6 26 ± 8 19 ± 9 15 ± 3 1 ± 4 Tarsal tunnel syndrome -7 ± 40-2 ± 5 12 ± 11 3 ± 5 20 ± 5 8 ± 4 FHL tenosynovitis 0 ± 31-3 ± 6 12 ± 4 3 ± 3 21 ± 2 9 ± 5 Anteromedial ankle impingement -17 ± 31-3 ± 6 12 ± 6 2 ± 5 22 ± 5 10 ± 3 Plantar fasciitis -7 ± 29-3 ± 5 13 ± 7 1 ± 6 21 ± 5 10 ± 4 Data reported as mean ± standard deviation. Diagnosis Table 4: Radiographic parameter values for all subjects presented with lateral foot and ankle pain categorized by diagnosis Index (%) (mm) Lateral talofirst Medial cuneiform- fifth MT height (mm) Symptomatic cavovarus foot -116 ± ± 4-11 ± ± 5 27 ± 5 19 ± 7 Peroneal tendon pathology 4 ± 28-2 ± 7 14 ± 7 8 ± 6 19 ± 3 8 ± 7 Anterolateral ankle instability 0 ± 36-3 ± 7 9 ± 9 6 ± 9 23 ± 5 10 ± 6 Superficial peroneal nerve entrapment 20 ± 30-1 ± 5 16 ± 7 12 ± ± 4 8 ± 6 Subtalar Impingement 12 ± 36-1 ± 6 14 ± 8 6 ± 7 21 ± 5 10 ± 3 Anterolateral ankle impingement 10 ± 49 0 ± 7 16 ± 12 8 ± ± 5 8 ± 6 Data reported as mean ± standard deviation. for the coronal plane 20 (apparent moment arm) as shown in Figure 4. All radiographic measurements were performed using isite Enterprise 3.5 image analysis software (Philips Medical Systems Nederland B.V., The Netherlands). The measurements for this study were made by an independent foot and ankle orthopaedic fellow (MA). Statistical analysis The sensitivity, specificity, likelihood ratios, and predictive values were calculated by using cut-off point for diagnosing symptomatic flatfoot and cavovarus foot from Index part 1 data. Clinically diagnosed flatfoot and cavovarus foot deformity indicated for surgical reconstruction by one of the senior foot and ankle orthopaedic surgeons was used as the accepted standard for diagnosis. Analysis of the radiographic parameter values was descriptive, using mean values and standard deviations. ReSUlTS Radiographic parameters for all subjects categorized by diagnosis are shown in Table 3 and 4. In flatfoot, the sensitivity of the Index was 100%, comparable with the coronal plane (95%), the (95%), the lateral talofirst metatarsal angle (100%), and the medial cuneiform-fifth metatarsal height (100%). The specificity of the Index was 93%, comparable with the coronal plane (98%) and the lateral talo-first metatarsal angle (87%), but superior to the (64%), the calcaneal (61%), and the medial cuneiformfifth metatarsal height (82%). The positive likelihood ratio of the Index was 14.29, which was less than the coronal plane (47.5), but more than the (2.64), the lateral talo-first metatarsal angle (7.69), the calcaneal (2.31), and the medial cuneiform-fifth metatarsal height (5.56). The negative likelihood ratio of the Index was 0. The positive and negative predictive values of the Index were 77% and 100%, respectively (Table 5). In cavovarus foot, the sensitivity of the Index was 96%, comparable with the coronal plane (100%), but superior to the coverage angle (88%), the lateral talo-first metatarsal angle (88%), the calcaneal (65%), and the medial cuneiform-fifth metatarsal height (88%). The specificity of the Index was 95%, comparable with the lateral talo-first metatarsal angle (94%), but superior to the coronal plane (88%), the (91%), the calcaneal (83%), and the medial cuneiform-fifth metatarsal height (78%). The positive likelihood ratio of the Index was 19.2, which was more than the other parameters. The negative likelihood ratio of the Index was The positive and negative predictive values of the Index were 89% and 98%, respectively (Table 6). 50 The Iowa Orthopaedic Journal

5 Index: Diagnostic Accuracy in Symptomatic Flatfoot and Cavovarus Foot: Part 2 Table 5: Cut-off point, sensitivity, specificity, likelihood ratios, and predictive values of the Index and other current accepted radiographic parameters for diagnosing symptomatic flatfoot. Diagnosis accuracy parameters Index Lateral talo-first Medial cuneiformfifth MT height Cut-off point for flatfoot* 26 % 8 mm 14 degree 8 degree 19 degree 6 mm Sensitivity 100% 95% 95% 100% 90% 100% Specificity 93% 98% 64% 87% 61% 82% Positive likelihood ratio Negative likelihood ratio Positive predictive value 77% 95% 59% 63% 34% 56% Negative predictive value 100% 99% 98% 100% 96% 100% *Data from Index Part 1: New radiographic parameter assessing foot alignment Table 6: Cut-off point, sensitivity, specificity, likelihood ratios, and predictive values of the Index and other current accepted radiographic parameters for diagnosing symptomatic cavovarus foot. Diagnosis accuracy parameters Index Lateral talo-first Medial cuneiformfifth MT height Cut-off point for cavovarus foot* -39% -9 mm 0 degree -5 degree 26 degree 13 mm Sensitivity 96% 100% 88% 88% 65% 88% Specificity 95% 88% 91% 94% 83% 78% Positive likelihood ratio Negative likelihood ratio Positive predictive value 89% 76% 79% 85% 61% 62% Negative predictive value 98% 100% 95% 95% 85% 94% *Data from Index Part 1: New radiographic parameter assessing foot alignment Pertaining to the index, the false positive results consisted of five patients with plantar fasciitis and one patient with FHL tenosynovitis in the medial foot and ankle pain group. There was no false negative diagnosis. In the lateral foot and ankle pain group, the false positive results included one patient with anterolateral ankle impingement, one patient with subtalar impingement, and one patient with anterolateral ankle instability. The false negative result was from 1 patient indicated for cavovarus reconstruction but with the index of %. DISCUSSION The results from this study support the hypothesis that the Index on the AP radiograph has high accuracy in the diagnosis of symptomatic flatfoot and cavovarus foot. We have confirmed that the use of 26% or more and -39% or less were the most appropriate thresholds to diagnose symptomatic flatfoot and cavovarus foot, respectively, using the Index. The Index had a high sensitivity (100% for flatfoot and 96% for cavovarus foot) and a high specificity (93% for flatfoot and 95% for cavovarus foot). The high sensitivity and specificity of the Index go along with the high positive likelihood ratio (14.29 for flatfoot and 19.2 for cavovarus foot), which indicates a high probability that patients who have a positive Index will be diagnosed as having symptomatic flatfoot or cavovarus foot 21. The negative likelihood ratio (0 for flatfoot and 0.04 for cavovarus foot) indicates a high probability that patients who have a negative Index will not be diagnosed as having symptomatic flatfoot or cavovarus foot 21. Although the Index showed high accuracy in the diagnosis of symptomatic flatfoot and cavovarus foot, there were some misdiagnoses in both groups. Most of the false positive patients in the flatfoot group were clinically diagnosed as having plantar fasciitis. Although, these patients did not present with posterior tibial tendinitis, the plantar fasciitis might represent another manifestation of flatfoot deformity Huang et al 22. also reported higher incidences of plantar fasciitis in the flatfoot group than the normal arch control group. Due to the nature of retrospective studies it was impossible to delineate the co-existence of these conditions in our patient cohort. The coronal plane was developed to characterize the mechanical alignment of the hindfoot. This method yields a value representing the apparent moment arm between the presumed weightbearing axis of the leg and point of heel-floor contact 20. This measurement also had a high sensitivity (95% for flatfoot and 100% for cavovarus foot) and a high specificity (98% for flatfoot and 88% for cavovarus Volume 33 51

6 M. Arunakul, A. Amendola, Y. Gao, J. E. Goetz, J. E. Femino, P. Phisitkul foot). The high sensitivity and specificity of the coronal plane go along with the high positive likelihood ratio (47.5 for flatfoot and 8 for cavovarus foot), which indicates a high probability that patients who have a positive coronal plane will be diagnosed as having symptomatic flatfoot and a moderate shift in probability that patients who have a positive coronal plane will be diagnosed as having symptomatic cavovarus foot 21. The negative likelihood ratio (0.05 for flatfoot and 0 for cavovarus foot) indicates a high probability that patients who have a negative coronal plane will not be diagnosed with symptomatic flatfoot or cavovarus foot 21. This study has shown that both the Index and the coronal plane are the two most discriminating radiographic parameters in patients with symptomatic flatfoot and cavovarus foot. The view, however, requires an extra radiographic image taken with the patient on a specifically constructed platform while the index requires only radiographic markers on a standard AP view. The lateral talo-first metatarsal angle was shown to be a reliable measure for determination of arch height and was suggested as the preferable measurement for the diagnosis and evaluation of operative outcomes of flatfoot according to Younger et al 26 and others 1,3,17, We found that the sensitivity, the specificity, and the negative likelihood ratio were comparable to the Index and the coronal plane hindfoot alignment but the positive likelihood ratio for diagnosis of symptomatic flatfoot was inferior to both measurements. In addition, we have found that the lateral talo-first metatarsal angle had the worst interobserver reliability compared to all other measurements in our part 1 study. This was likely due to the difficulties in finding the common osseous landmarks on lateral radiographs. However, we consider the lateral talofirst metatarsal angle an excellent radiographic parameter for diagnosing symptomatic flatfoot than can be used as an adjunct to the and the Index. Previous studies have supported the use of linear measurement to define arch height using the medial cuneiformfifth metatarsal height 2,16,19,31. Since Coughlin et al 32. found that the lowest medial cuneiform-fifth metatarsal height in their control group was 3 mm, and over 66% of their flatfoot group had a larger value, this measurement was found to be unreliable. We also found that the sensitivity, the specificity, and the positive and negative likelihood ratio of this measurement were inferior to the Index, the coronal plane, and the lateral talo-first metatarsal angle but were still high enough to evaluate flatfoot and cavovarus foot deformity. In addition, this measurement had statistically significant correlation with other accepted radiographic parameters and differences between flatfoot, cavovarus foot, and control group in our part 1 study. So, we consider the medial cuneiform-fifth metatarsal height a good radiographic parameter for evaluating symptomatic flatfoot and cavovarus foot as well. Due to the influence of the spectrum of disease to the accuracy of diagnosis, the use of a healthy normal control group often overestimates the ability of most diagnostic tests. This was confirmed in our part 1 study that all six radiographic parameters, including the Index, the AP talonavicular, the lateral talo-first metatarsal angle, the calcaneal, the medial cuneiform-fifth metatarsal height, and the coronal plane, had very high sensitivity and specificity for diagnosing symptomatic flatfoot and cavovarus foot. In addition, Younger 26 also reported the statistically significant differences between patients with flatfoot and a control group from the lateral talo-first metatarsal angle, the calcaneal, and the medial cuneiform-fifth metatarsal height. These radiographic parameters were found to be highly sensitive despite a significance level of p < To determine the true clinical utility of radiographic measurements, a study of diagnostic test must include a spectrum of cases that closely resembles clinical practice 33. As a result, we included patients that presented with medial foot and ankle pain for flatfoot group and patients presented with lateral foot and ankle pain for cavovarus group. The limitations to this study include selection bias and the lack of gold standard for diagnosis of symptomatic flatfoot and cavovarus foot. These limitations result from the fact that there is no widely accepted definition of what constitutes a flatfoot or a cavovarus foot in an adult 1,4,5,7,9,10,15,16. However, all patients with symptomatic flatfoot deformity and cavovarus foot deformity requiring surgical correction due to failure of nonoperative treatment were included and used as the accepted standard for diagnosis. The clinical assessment of a flatfoot and a cavovarus foot was subjective, but this is a common method used by experienced foot and ankle orthopaedic surgeons in everyday practice. We also did not aim to replace clinical diagnosis of foot deformities with a single measurement, but rather hoped to create a more integrated measurement as an adjunctive tool. Future studies may be required to evaluate the relationship between Index, plantar pressure and gait analysis, functional outcome, and the effect of foot reconstructive surgery on patients with flatfoot or cavovarus foot. The success of realignment of a planus or cavus foot, which usually includes multiple joints or planes, may be better represented with measurement of the TI versus a single measurement. Additional studies using index on other foot and ankle deformities e.g. metatarsus adductus, residual clubfoot, charcot arthropathies, and partially amputated foot may be useful. CONClUSION There are several useful radiographic measures of alignment that are currently widely used in reconstructive foot and ankle surgery. The Index consists of a quantitative assessment of foot alignment that may be a more global measure. It can be made from a standard weightbearing 52 The Iowa Orthopaedic Journal

7 Index: Diagnostic Accuracy in Symptomatic Flatfoot and Cavovarus Foot: Part 2 radiograph with a heel marker. Based on the high accuracy of the Index in the diagnosis of symptomatic flatfoot and cavovarus foot in this study, further studies to determine the usefulness of this novel measurement are warranted. ReFeReNCeS 1. Chi TD, Toolan BC, Sangeorzan BJ, Hansen ST, Jr. The lateral column lengthening and medial column stabilization procedures. Clin Orthop Relat Res 1999: Dyal CM, Feder J, Deland JT, Thompson FM. Pes planus in patients with posterior tibial tendon insufficiency: asymptomatic versus symptomatic foot. Foot Ankle Int 1997;18: gould N. Evaluation of hyperpronation and pes planus in adults. Clin Orthop Relat Res 1983: Funk DA, Cass JR, Johnson KA. Acquired adult flat foot secondary to posterior tibial-tendon pathology. J Bone Joint Surg Am 1986;68: Kitaoka HB, luo ZP, An KN. Subtalar arthrodesis versus flexor digitorum longus tendon transfer for severe flatfoot deformity: an in vitro biomechanical analysis. Foot Ankle Int 1997;18: Pinney SJ, Hansen ST, Jr., Sangeorzan BJ. The effect on ankle dorsiflexion of gastrocnemius recession. Foot Ankle Int 2002;23: Myerson MS. Adult acquired flatfoot deformity: treatment of dysfunction of the posterior tibial tendon. Instr Course Lect 1997;46: Mizel MS, Hecht PJ, Marymont Jv, Temple HT. Evaluation and treatment of chronic ankle pain. Instr Course Lect 2004;53: Holmes JR, Hansen ST, Jr. Foot and ankle manifestations of Charcot-Marie-Tooth disease. Foot Ankle 1993;14: Tubby AH. Deformities including diseases of bones and joints. 2nd ed. London: Macmillan; Manoli A, 2nd, graham B. The subtle cavus foot, the underpronator. Foot Ankle Int 2005;26: Alexander IJ, Johnson KA. Assessment and management of pes cavus in Charcot-Marie-tooth disease. Clin Orthop Relat Res 1989: Cotton FJ. Foot statics and Surgery. N Engl J Med 1935;214: Inman vt. The Joints of Ankle. Baltimore: Williams & Wilkins; Cobey JC. Posterior roentgenogram of the foot. Clin Orthop Relat Res 1976: Sangeorzan B, Mosca v, Hansen SJ. Effect of calcaneal lengthening on relationships among the hindfoot, midfoot, and forefoot. Foot & ankle 1993;14: gould N. Graphing the adult foot and ankle. Foot Ankle 1982;2: Sherref MJ. Radiographic analysis of the foot and ankle. In: Jahss MH, ed. Disorders of the Foot and Ankle. 2nd ed. Philadelphia: WB Saunders; 1991: Pomeroy g, Pike R, Beals T, Manoli A. Acquired flatfoot in adults due to dysfunction of the posterior tibial tendon. J Bone Joint Surg Am 1999 Aug;81(8): ;81: Saltzman Cl, el-khoury gy. The view. Foot Ankle Int 1995;16: Jaeschke R, guyatt gh, Sackett Dl. Users guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA 1994;271: Huang yc, Wang ly, Wang HC, Chang Kl, leong CP. The relationship between the flexible flatfoot and plantar fasciitis: ultrasonographic evaluation. Chang Gung Med J 2004;27: Neufeld SK, Cerrato R. Plantar fasciitis: evaluation and treatment. J Am Acad Orthop Surg 2008;16: Roos e, engstrom M, Soderberg B. Foot orthoses for the treatment of plantar fasciitis. Foot Ankle Int 2006;27: Wearing SC, Smeathers Je, Sullivan PM, yates B, Urry SR, Dubois P. Plantar fasciitis: are pain and fascial thickness associated with arch shape and loading? Phys Ther 2007;87: younger AS, Sawatzky B, Dryden P. Radiographic assessment of adult flatfoot. Foot Ankle Int 2005;26: Aronson J, Nunley J, Frankovitch K. Lateral talocalcaneal angle in assessment of subtalar valgus: follow-up of seventy Grice-Green arthrodeses. Foot Ankle 1983;4: Johnson KA. Tibialis posterior tendon rupture. Clin Orthop Relat Res 1983: Pedowitz WJ, Kovatis P. Flatfoot in the Adult. J Am Acad Orthop Surg 1995;3: King DM, Toolan BC. Associated deformities and hypermobility in hallux valgus: an investigation with weightbearing radiographs. Foot Ankle Int 2004;25: Thomas Rl, Wells BC, garrison Rl, Prada SA. Preliminary results comparing two methods of lateral column lengthening. Foot Ankle Int 2001;22: Coughlin MJ, Kaz A. Correlation of Harris mats, physical exam, pictures, and radiographic measurements in adult flatfoot deformity. Foot Ankle Int 2009;30: Jaeschke R, guyatt g, Sackett Dl. Users guides to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid? Evidence-Based Medicine Working Group. JAMA 1994;271: Volume 33 53