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INTRODUCTION Identification of Baxter's nerve (BN) has proven challenging for less experienced practitioners using ultrasonography due to a lack of adequate landmarks. This study aimed to establish novel, user-friendly anatomical landmarks and to describe useful structures to localize BN. MATERIALS AND METHODS We examined 10 fresh cadaveric feet and identified the interobserver agreement of measuring three surface landmarks: the most medially protruded point on the medial malleolus (P), the navicular tuberosity (Q), and the center of the calcaneus (B). Next, 24 fresh cadaveric feet were used to identify the point of BN entry into the quadratus plantae (QP) muscle, which corresponds to the proximal BN impingement site. The rectangular coordinate system consisted of the origin (point P), X-axis, extension line P-Q, and Y-axis (the perpendicular line to the X-axis). To consider various foot sizes, the X and Y values were divided by the P-Q length and were designated as the ratios X and Y. RESULTS Points P and Q showed smaller interobserver differences than that of point B. Ratios X and Y were 61.25 and 99.80%, respectively, for the QP. BN arose from the lateral plantar nerve in 20 of 24 specimens. The adjacent vessel was

Background Existing clinical measures to describe foot morphology are limited in that they are commonly two-dimensional, low in resolution and accuracy, and do not accurately represent the multi-planar and complex changes during development across childhood. Using three-dimensional (3D) scanner technology provides the opportunity to understand more about morphological changes throughout childhood with higher resolution and potentially more relevant 3D shape measures. This is important to advance the prevailing arguments about the typical development of children’s feet and inform the development of appropriate clinical measures. 3D shape descriptors derived from 3D scanning can be used to quantify changes in shape at each point of the 3D surface. The aim of this study was to determine whether 3D shape descriptors derived from 3D scanning data can identify differences in foot morphology between children of different ages. Methods Fifteen children were recruited from three age groups (2, 5, and 7 years of age). Both feet were scanned in bipedal stance, using the Artec Eva (Artec Group, Luxembourg, Luxembourg) hand-held scanner. Three dimensional shape descriptors were extracted from the 3D scans of the right foot, to create histograms for each age group and heat maps of representative participants for comparison. Results There were changes to the dorsal, medial and lateral surfaces of the feet with age. The surfaces became less round along with an increase in indented areas. This is supported by the heat maps which demonstrated that the surfaces of the anatomical landmarks (e.g. the malleoli and navicular tuberosity) became more rounded and protruding, with indented surfaces appearing around these landmarks. On the plantar surface, the concavity of the midfoot was evident and this concavity extended into the midfoot from the medial aspect as age increased. Conclusions The findings of this study indicated that with increasing age the foot becomes thinner in 3D, with bony architecture emerging, and the medial longitudinal arch (MLA) increases in area and concavity. Three-dimensional shape descriptors have shown good potential for locating and quantifying changes in foot structure across childhood. Three-dimensional shape descriptor data will be beneficial for understanding more about foot development and quantifying changes over time.

Background The human foot has adapted specifically to support body weight when standing upright. At the base of the postural control system, the unique arch structure of the foot still has an uncertain role in human upright standing. Because the toe flexor muscles help to support the foot arches, they might be an important contributor to postural stability. However, no research has identified the influence of the toe flexor strength or the foot arch height on postural stability in static upright standing. Research question: The aim of this study was to examine whether the toe flexor strength and the foot arch height were related to postural stability in static standing in healthy young individuals. Methods Fifty healthy young individuals were recruited into this cross-sectional study. Toe flexor strength was measured using a toe grip dynamometer, and it was normalised by body mass (rTFS). Foot arch height was assessed as the distance between the navicular tuberosity of the foot and the floor, and it was normalised by height (rFAH). Postural stability was evaluated using the path of the centre of pressure (COP) during double-leg standing with eyes open and single-leg standing with eyes open. Results rTFS and rFAH were 2.6 ± 0.8 N/kg and 2.8 ± 0.4%, respectively, and they were not significantly correlated (r = 0.094), indicating that they were independent variables. The results of Pearson’s correlation analysis revealed that any body size related variables (height, body mass, BMI) were not significantly correlated with COP variables under either double-leg or single-leg standing, rTFS was not significantly correlated with COP variables under either double-leg or single-leg standing and rFAH was not significantly correlated with COP variables under double-leg standing. Significance Toe flexor strength has no significant role in maintaining postural stability during static upright standing.

Introduction: An accessory navicular is a plantar medial enlargement of the navicular bone of the foot. The accessory navicular is incorporated with the posterior tibial tendon which inserts into the navicular tuberosity. Patients with an accessory navicular present with a foot bump. This condition occurs in up to 12% of the population. Only some patients are symptomatic. The purpose of this study is to report the surgical outcomes in a consecutive series of adolescent athletes with symptomatic accessory navicular. Methods: The study was approved by the College of Medicine IRB. …

Whether practicing in judo influences the muscle strength and morphological characteristics of the foot is unknown. The purpose of this study was to determine the toe flexor muscle strength and morphological characteristics of the foot in judo athletes. Judo athletes (JUDO, men=24) and age-, gender- and body mass-matched physically active healthy subjects (CON, men=24) were recruited, and their toe flexor strength and morphological characteristics of the foot were compared. The maximum isometric toe flexor strength and foot intrinsic muscle thicknesses were measured using a toe grip dynamometer and a B-mode ultrasound, respectively. Foot arch height was assessed as the distance between the navicular tuberosity of the foot and the floor in the sitting and standing positions. JUDO showed a significantly lower foot arch height and smaller foot arch index than CON, whereas foot length and muscle thickness did not significantly differ between groups. The toe flexor strength relative to total muscle thickness was significantly larger in JUDO than CON. The foot arch dynamics was significantly larger in JUDO than CON. This study suggests that exercise training specific to judo may affect the force-generating capacity, morphological structure and arch function of the foot.

[Purpose] Flat feet frequently present in children with Down syndrome, necessitating a clinical evaluation and diagnosis. Therefore, a simple, low cost diagnostic method that can avoid radiation exposure is needed. This study was performed to investigate the intra-rater reliability of arch height ratio measurement using bone markers of the foot on the surface of the body in children with Down syndrome. [Participants and Methods] In total, 27 feet of 27 children with Down syndrome (16 male, 11 female) were included. We measured the length of each foot and the height of the navicular tuberosity on the surface of the body. The arch height ratio was calculated using the length and height. The same examiner performed three consecutive measurements of each of the two parameters. We calculated the arch height ratio using each of these measurements. The intraclass correlation coefficient [ICC(1,3)] of the length of the foot, height of the navicular tuberosity, and arch height ratio among the three measurements was obtained. [Results] The ICC of the height of the navicular tuberosity, length of the foot, and arch height ratio were quite high at 0.998, 0.999, and 0.997, respectively. [Conclusion] This study showed high intra-rater reliability of arch height ratio measurement using the length of the foot and height of the navicular tuberosity on the surface of the body in children with Down syndrome.

AB Purpose: The aim of this study was to investigate the muscle strength and arch height of the foot in the standing position and the relations between these indices and physical performances involving the lower limbs in children. Methods: A total of 301 elementary school children (third grade: n = 158, age = 8.6 +/- 0.5 yr; fifth grade: n = 143, age = 10.6 +/- 0.5 yr; means +/- SD) participated. The maximal isometric toe flexor strength (TFS) in the standing position was measured using a toe flexor dynamometer. Foot arch height was assessed as the distance between the navicular tuberosity of the foot and the floor in the standing position, and foot arch height relative to the foot length was represented by the foot arch index (FAI). For physical performance involving the lower limbs, 50-m sprint, standing broad jump, repeated side step, and rebound jump were measured. Results: There were no significant correlations between TFS and FAI and between relative TFS (relative TFS = TFS/body mass) and FAI. Relative TFS was significantly correlated with all physical performance tests. No significant correlations among FAI and physical performances were found, except for rebound jump ability in fifth graders. After multiple regression analyses adjusting for gender and body mass, TFS was the only significant correlating factor for all physical performances involving the lower limbs. Conclusions: This study showed that TFS was associated with enhancement of some measures of lower limb physical performance in children. These results suggest that foot function should be evaluated with both the muscle strength and arch height of the foot in children

Background The accessory navicular bone is one of the most common accessory ossicles, which sometimes become symptomatic. Abnormalities in magnetic resonance (MR) image, e.g. edema-like bone marrow pattern, have been reported for symptomatic accessory navicular. However, it has not been completely understood the edema-like bone marrow pattern correlates to the symptom of navicular tuberosity. Methods We investigated the edema-like bone marrow pattern in correlation with alleviation of the symptom and the presence of accessory navicular bone. Ten adolescents with pain localized to the navicular tuberosity were recruited and seven cases were further examined with consecutive MR images. Results Edema-like bone marrow pattern was found in all symptomatic navicular but not in asymptomatic navicular. Intensity of the pattern diminished with alleviation of the symptom. Moreover, this correlation was recognized even in the patients who had no accessory navicular bones. Conclusions MR images could be used not only for diagnosis but for monitor of healing in adolescent symptomatic navicular. There may be different pathologic mechanism for adolescent symptomatic navicular tuberosity, such as an osteitis, in adolescents.

To investigate the relationship between magnetic resonance imaging (MRI) findings and clinical features in patients with os naviculare.All patients with a foot or ankle MRI study showing an os naviculare were identified from a specialist orthopaedic hospital between 2014 and 2017. A total of 110 patients with 133 os naviculare were included. The MRI features were recorded, as well as the presence or absence of medial foot pain and/or tenderness over the navicular tuberosity. Fisher's exact test was used for categorical data and unpaired t-tests for continuous data. Specificity and sensitivity were calculated for MRI features.There were 80 female and 30 male patients with a mean age of 46±1.7 years at time of MRI (range 11-90.6 years). There was a significant correlation between os naviculare oedema (p=0.008) and navicular tuberosity oedema (p=0.001) with a history of medial foot pain. There were significant associations between mean age (p=0.003), type of os naviculare (p=0.004), os naviculare oedema (p0.001), navicular tuberosity oedema (p=0.001), and soft tissue oedema (p=0.01) with examination findings of tenderness over the navicular tubercle. Oedema of the os naviculare, navicular tuberosity, or soft tissues were found to have a high specificity but low sensitivity for medial foot pain and tenderness.When present, certain MRI findings indicate that an os naviculare is likely to be a cause of patient symptoms, but when absent they do not exclude the possibility of it causing symptoms.

Previous studies have successfully used the longitudinal arch angle (LAA) to assess foot posture, but the measurement consistency and ability of the LAA to predict dynamic foot posture during activity in a variety of foot types have not been evaluated. The purpose of this study was to determine the reliability of the LAA as well as if the clinical method of assessing the LAA could be used to predict the LAA at midstance during walking for supinated, normal, and pronated foot types. The Arch Height Ratio was used to select 35 participants with 12 supinated, 46 normal, and 12 pronated feet. A standard goniometer was used to measure the LAA (CLINIC_LAA) on both feet while standing. Both feet were then filmed using a high speed camera while walking on a treadmill. The LAA was determined by the angle formed by two lines drawn between the markers placed on the first metatatarsal and medial malleolus with the apex the navicular tuberosity. The LAA in midstance (WALK_LAA) was determined using the mean of five walking trials. The reliability of the CLINIC_LAA assessed on both feet by two raters over two days were excellent. There was no difference between the left and right foot for the CLINIC_LAA. The Pearson correlation between CLINIC_LAA and WALK_LAA for all 70 feet was r=0.96 (r2=0.92). The results indicate the LAA is highly predictive of foot posture at midstance in walking explaining over 90% of the variance for a wide range of foot types.

Background:Foot problems are reported by approximately 70% to 80% of adults and 30% of children. One of the most important characteristics affecting its incidence is medial longitudinal arch. Assessing arch height provides valuable information for prescribing appropriate footwear that reduces the consequences of flatfoot. The main goals of this study were to explore epidemiologic factors that affect arch height and to predict arch height in children with flatfoot based on five variables using widely accessible, low-cost tools.Methods:This study examined plantar arch height in 80 children with flatfoot aged 7 to 15 years. The evaluation criteria included low arch height, correct knee and heel position, and correct body symmetry. To measure arch height, the children sat in a chair and placed their feet on level ground. A caliper was used to measure the height between the bottom of the navicular tuberosity and the floor. Using least mean square error scheme, a multivariable model was fitted to the plantar arch height for all of the participants using independent variables, including age, Cole index, sex, place of residence, and physical activity.Results:Arch height increased as age increased in boys and girls in rural and urban areas. A significant increase in arch height occurred in 12- to 15-year-old boys and 10- to 15-year-old girls. In boys, arch height was 30% lower than in girls (P= .05). In children in cities, arch height was lower by 26% than in children in rural areas (P= .05). Arch height increased by 41.8% in inactive boys and by 115.2% in inactive girls in rural areas. It was reduced by 59.4% in boys and by 47.4% in girls as the Cole index increased from 82.2 to 152.0. The suggested model predicted arch height using the child’s age, Cole index, sex, place of residence, and physical activity (r> 0.97, error < 0.04 mm [2%],P< .05).Conclusions:Flat feet in children may be affected by age, sex, Cole index, place of residence, and physical activity. The proposed model allows plantar arch heights in children with flat feet to be predicted without the need for sophisticated technology via controlling the child’s weight and physical activity for prescribing appropriate footwear. (J Am Podiatr Med Assoc 102(2): 114–121, 2012)

Purpose: Popular running magazines and running shoe companies advise using the shape of the weight-bearing plantar surface of the foot as a basis for selecting a proper type of running shoe to reduce injury risk. The imprint is assumed to reflect the height of the medial longitudinal arch (MLA). This study examined the assumption that plantar surface morphology was a surrogate for height of the MLA. Methods: Recruits (n = 3968) entering US Army Basic Combat Training had their plantar foot surfaces assessed visually as low, normal, or high by two raters who viewed imprints of the plantar foot surface. Actual arch height was measured with calipers as distance from the standing surface to the inferior medial border of the navicular tuberosity. Measured MLA heights were compared with plantar surface imprints to evaluate the effectiveness of visual inspection as a means of arch height classification. Results: For the right foot, individuals with low, normal, or high plantar shapes had a mean +/- SD arch height of 33.5 +/- 6.8, 40.4 +/- 7.2, and 43.1 +/- 7.3 mm, respectively (ANOVA, P < 0.01); however, the individuals' measured MLA heights fell into the corresponding plantar shape percentiles (low, normal, high) only 65% of the time. Increased body mass index (BMI) decreased correct assessment of the MLA. Conclusions: Visual assessment of indicating progressively higher plantar shapes corresponded to progressively higher average differences in measured arch heights; nonetheless, there was considerable overlap among the three plantar shapes with 35% of plantar shapes being misclassified compared with measured arch height, especially among individuals with higher BMI.

Background: The cause of navicular tuberosity pain in adolescents with flexible flatfeet is not well understood. We hypothesized that some of the navicular tuberosity pain may be related to insertional enthesopathy of the posterior tibial tendon at the navicular. Magnetic resonance imaging was performed to look for abnormal signal changes in a series of patients. Material and Method: Consecutive adolescent patients presenting with flexible flatfeet and navicular tuberosity pain were prospectively recruited. A detailed foot examination and body fat analysis was performed. Standing radiographs and Tekscan pedobarograph of both feet were obtained. Magnetic resonance examinations were performed on a 1.5-T whole-body magnetic resonance imaging system utilizing a standard extremity coil. Results: MRI abnormality was detected in 15 of the 36 feet in 18 adolescents examined. Abnormalities detected included thickening of the posterior tibial tendon insertion, marrow edema in the accessory navicular, marrow edema in the navicular tuberosity, and contrast enhancement at the posterior tibial tendon insertion site. Patients with MRI abnormalities were significantly taller, had a lower body mass index and a lower body fat percentage than those without MRI abnormality. Forward stepwise logistic regression analysis identified low body fat percentage and presence of an accessory navicular as independent predictors for abnormality on MRI. Conclusion: MRI abnormality was frequently detected in adolescents with painful flexible flatfeet. The MRI signal changes indicated an enthesopathy like process occurring at the posterior tibial tendon insertion to the navicular which could explain the origin of pain in flexible flatfeet patients without an accessory navicular. Early identification and appropriate treatment to prevent progression may be helpful. Level of Evidence: IV, Case Series

A study was conducted to determine whether plantar surface contact area measures calculated from footprints collected during walking can be used to predict the height of the medial longitudinal arch. Thirty healthy women participated in the study. Arch height was determined by the distance from the navicular tuberosity to the floor and by the “bony” arch index. Dynamic plantar surface contact area was recorded using a pressure platform as the subjects walked across a 12-m walkway. The arch index and the total plantar surface contact area were determined from the pressure sensor data. The results indicated that plantar surface contact area could be used to estimate only approximately 27% of the height of the medial longitudinal arch as determined by navicular tuberosity height and the bony arch index. These findings demonstrate the inability of the clinician to predict the vertical height of the medial longitudinal arch on the basis of the amount of foot plantar surface area in contact with the ground during walking. (J Am Podiatr Med Assoc 96(6): 489-494, 2006)

Background: The spring ligament has been reported to be composed of the inferior calcaneonavicular and superomedial calcaneonavicular ligaments. We investigated the lower layer of the spring ligament fibrocartilage complex under the fibrocartilaginous surface, identified three distinct structures, and examined the morphology and running patterns of their fiber bundles. Methods: Forty-eight cadaveric feet were examined. After ablation of the ankle joint and extirpation of the talus, the surface cartilage of the spring ligament fibrocartilage complex was carefully removed with forceps, and the length, width, and thickness of the three components of the complex were measured with calipers. Results: The three components of the spring ligament complex are the superomedial calcaneonavicular ligament, the inferior calcaneonavicular ligament, and a structure that we termed the third ligament, which comprises fibers running from the notch between the calcaneal facets to the navicular tuberosity. Conclusions: We demonstrated a third component of the spring ligament; this component runs from the notch between the anterior and middle calcaneal facets to the tubercle of the navicular in the lower layer of the spring ligament complex, lying beneath the cartilaginous surface of the complex. Clinical Relevance: More accurate knowledge of the anatomy of the spring ligament complex will enhance our understanding of its role in the support of the head of the talus and, potentially, its critical interactions with the posterior tibial tendon in this regard.

The measure of navicular drop has been used as an indicator of pronation at the foot. It is defined as the distance the navicular tuberosity moves in standing, as the subtalar joint is allowed to move from its neutral position to a relaxed position. The purposes of this study were to test the reliability of a method to measure navicular drop and to assess the relationships among measures of forefoot to rearfoot position, subtalar joint neutral position, and navicular drop. The results support traditional biomechanical theory but indicate that other factors contribute significantly to navicular drop.

Background The navicular drop test is a measure to evaluate the function of the medial longitudinal arch, which is important for examination of patients with overuse injuries. Conflicting results have been found with regard to differences in navicular drop between healthy and injured participants. Normal values have not yet been established as foot length, age, gender, and Body Mass Index (BMI) may influence the navicular drop. The purpose of the study was to investigate the influence of foot length, age, gender, and BMI on the navicular drop during walking. Methods Navicular drop was measured with a novel technique (Video Sequence Analysis, VSA) using 2D video. Flat reflective markers were placed on the medial side of the calcaneus, the navicular tuberosity, and the head of the first metatarsal bone. The navicular drop was calculated as the perpendicular distance between the marker on the navicular tuberosity and the line between the markers on calcaneus and first metatarsal head. The distance between the floor and the line in standing position between the markers on calcaneus and first metatarsal were added afterwards. Results 280 randomly selected participants without any foot problems were analysed during treadmill walking (144 men, 136 women). Foot length had a significant influence on the navicular drop in both men (p < 0.001) and women (p = 0.015), whereas no significant effect was found of age (p = 0.27) or BMI (p = 0.88). Per 10 mm increase in foot length, the navicular drop increased by 0.40 mm for males and 0.31 mm for females. Linear models were created to calculate the navicular drop relative to foot length. Conclusion The study demonstrated that the dynamic navicular drop is influenced by foot length and gender. Lack of adjustment for these factors may explain, at least to some extent, the disagreement between previous studies on navicular drop. Future studies should account for differences in these parameters.

A 62-year-old woman with severe seizure disorder presented with right ankle and foot pain after being found down, presumably following a seizure recurrence. Imaging showed an acute comminuted fracture of the anterolateral aspect of the right calcaneus, as well as an acute avulsion fracture of the right navicular tuberosity at the site of insertion of the tibialis posterior tendon. This fracture pattern suggests forced abduction of the midfoot or forefoot with severe compression of the lateral column and failure of the medial column under tension, an entity that has previously been described as the nutcracker fracture. This mechanism of injury should prompt particularly careful evaluation of the navicular, cuboid, and calcaneus for any signs of injury. Subtle fractures of the navicular and calcaneus may be overlooked in the emergency setting, leading to a delay in surgical treatment and ultimately chronic foot deformities that can result in significant functional disability.

Background: The spring ligament complex (SLC) is a static support of the head of the talus and a major anatomical contributor to the integrity of the medial longitudinal arch, particularly if the dynamic support of the posterior tibial tendon is compromised. For this reason, we sought to further elucidate the anatomical components and dimensions of this ligamentous complex. Methods: Dissection was performed on 30 adult cadaver feet disarticulated at the ankle joint that were preserved by embalming technique. Results: The superomedial ligament (SML) averages 42.51 ± 3.93 mm and 33.44 ± 3.34 mm at the superomedial and inferolateral borders, respectively. The width at the level of sustentaculum tali and navicular tuberosity averaged 20.00 ± 2.35 mm and 10.26 ± 2.05 mm, respectively. The medioplantar oblique (MPO) ligament averaged 23.56 ± 2.15 mm and 21.20 ± 1.42 mm at the medial and the lateral borders, respectively. The widths at the navicular and calcaneal side were 2.71 ± 0.39 mm and 8.14 ± 0.56 mm, respectively. The inferoplantar longitudinal (IPL) ligament measured 4.26 ± 0.43 mm and 2.66 ± 0.42 mm at the medial and lateral borders, respectively. The width at the calcaneal and navicular insertions measured 5.21 ± 0.53 mm and 3.39 ± 0.39 mm, respectively. Conclusions: The distinction between the SML and MPO components of the spring ligament complex is difficult. This study tried to clarify the dimensions and configurations of these components of the SLC. Clinical relevance: This effort may aid surgeons who wish to repair this ligament with more precision.

The purpose of this study was to compare the ability of two methods of adhesive strapping to provide support to the medial longitudinal arch (MLA) before and after a standardized exercise of 10 minutes of jogging. Ten females, 19 to 35 years of age, were subjects. To determine the position of the MLA, the height of the navicular tuberosity from the floor was measured bilaterally while each subject was standing. Measurements were taken for the following three conditions: barefoot (BARE), before exercise with arches taped (PREEX), and after exercise with arches taped (POSTEX). Methods for taping the MLA were: 1) LowDye and 2) double X. Results of a two-way, within-subjects ANOVA were significant for conditions (F = 45.3, p0.0001) and tape methods x conditions interaction (F = 3.6, p0.05) but not for tape methods. The Tukey test resulted in a significant difference (p0.05) between BARE and PREEX and PREEX and POSTEX but not between BARE and POSTEX. Results indicate that support of the MLA by adhesive strapping was significantly diminished after exercise. J Orthop Sports Phys Ther 1991;14(1):18-23.

Of 14 patients with navicular tuberosity avulsion, seven had damage to the anterior process of the calcaneum at the calcaneocuboid joint--possibly the result of an occult subluxation of the midtarsal joint. These patients were all middle-aged women who had slipped or fallen a short distance. They were unable to bear full weight because of pain on the medial and lateral aspects of the foot. The associated midtarsal injury was initially missed in five of seven patients because of failure to interpret the radiographic appearance. All seven patients had prolonged symptoms, and three had persistent but not disabling pain at least three years after injury. Degenerative arthritis had developed in the calcaneocuboid joint in four of the five patients at follow-up examinations. Patients with occult subluxation of the midtarsal joint should be managed initially by a period of non-weight-bearing followed by application of a walking cast. The need for early surgical treatment is open to question.

We have described four cases of medial plantar neuropathy that was confirmed by the near-nerve sensory nerve conduction study. The common compression site in medial plantar neuropathy is at the entrance to the fibromuscular tunnel behind the navicular tuberosity, distal to the tarsal tunnel, where Tinel's sign is localized.