Kinematic analysis of gait in children with rigid flatfoot before and after surgical treatment

Cover Page


Cite item

Full Text

Abstract

Aim – to study the kinematics and kinetics of walking in children with rigid flatfoot by comparing data before and after surgical operations.

Material and methods. The study included 51 patients (42 boys, 9 girls) with rigid flatfoot, with a mean age of 10.5 ± 1.4 years. They were stratified by disease stage and underwent surgical treatment using the author’s technique: ‘transposition of the m. peroneus longus tendon medially, shortening of the m. tibialis posterior tendon, and arthrodesis of the cuneo-navicular joint’.

Results. It was found that higher disease stages correlated with increased step time and support time, and decreased swing time, average walking speed, and step frequency (<0.01 to <0.001). Disease progression also exacerbated pathomorphological changes in the foot, driven by biomechanical dysfunction of the lower leg’s pronator and supinator muscles, alongside reduced gait energy efficiency.

Conclusion. Gait kinematic assessment, when combined with standard diagnostic tools for rigid flatfoot (e.g., radiography and podometry), enhances the identification of effective and precise treatment strategies. The proposed disease stage-adjusted corrective approach addresses all components of rigid flatfoot: it eliminates pathological pronation, restores supination and plantar flexion function, and achieves adequate foot arch reconstruction.

Full Text

Here's a word-for-word translation of your text into English:  

---

**Rigid flatfoot is the most common type of foot dysfunction [1].** It is characterized by a lowering of the longitudinal arch of the foot but is actually a three-dimensional deformity, including valgus deformity of the hindfoot, forefoot abduction, and pronation, which is associated with the severity of the foot pathology itself [2, 3].  

In rigid flatfoot, the normal gait pattern is disrupted, and a new type of pathological gait emerges. Studying pathological movement patterns allows for diagnosing the causes and pathogenesis of the disease, as well as identifying individual and clinical variations in different clinical situations [4, 5].  

The treatment of the rigid form of flatfoot has its own characteristics, differing from the mobile form of this pathology, often requiring invasive surgical interventions [6]. Existing surgical correction methods for rigid flatfoot differ in technique and scope, ranging from methods applied to soft tissues by modifying the configuration of the talus with tendon and muscle transposition to methods used in bone tissue with various metal fixators [7]. However, long-term postoperative results remain unexpected and sometimes unsatisfactory for patients, their parents, and even orthopedic surgeons, leading to the necessity of constantly wearing orthopedic devices to eliminate clinical symptoms [8].  

The presented data indicate the lack of characterization of the pathogenetic elements of rigid flatfoot, biomechanical disorders of the neuromuscular structure of the lower leg and foot depending on the severity and stages of the disease, as well as the lack of their consideration in the development of indications and selection of correction methods for patients with rigid flatfoot [9].  

At the present stage, this pathology remains relevant, as it is necessary to study gait kinematics disorders in rigid flatfoot using the most modern research methods, such as video recording of gait and three-dimensional motion capture in a gait laboratory.  

### **OBJECTIVE**  
To determine the role of gait kinematics diagnostics in patients with rigid flatfoot by comparing pre- and postoperative data in a gait laboratory.  

### **MATERIALS AND METHODS**  
The study group included 51 patients (42 boys and 9 girls) with rigid flatfoot who were observed and treated at the Andijan Children's Multidisciplinary Clinic from 2019 to 2024. The average age of the patients was 10.5 years (ranging from 7 to 16 years). Referring to the classification by Myerson M.S. (1997), we developed a new algorithm, “№ DGU 42326 – Algorithm for Classifying Children with Rigid Flatfoot” (2024), at the Intellectual Property Agency of the Republic of Uzbekistan.  

Unlike Myerson’s classification, we included spastic contracture of the **m. peroneus longus** tendon in stages III and IV, which plays a significant role in the complexity of the pathological changes in the foot and ankle joint in rigid flatfoot (Table 1).  

#### **Table 1**  
**Distribution of patients by clinical form and stage of rigid flatfoot according to our developed classification**  

| Stage of Disease | Clinical Forms | I st. | II st. (n=13) | III st. (n=22) | IV st. (n=16) |
|------------------|---------------|-------|--------------|---------------|--------------|
| | | | III A (n=9) | III B (n=13) | IV A (n=8) | IV B (n=8) |
| **Congenital form (n=10, 19.5%)** | 0 | 2 (3.9%) | 2 (3.9%) | 2 (3.9%) | 3 (5.9%) | 1 (1.9%) |
| **Acquired form (n=41, 80.5%)** | 0 | 11 (21.6%) | 7 (13.7%) | 11 (21.6%) | 5 (9.9%) | 7 (13.7%) |

From the data in Table 1, it can be seen that the acquired form was more common, occurring in 41 (80.5%) cases, compared to 10 (19.5%) cases of congenital etiology. By disease stage, patients with stage III were most frequently registered (22 cases, 43.1%). Additionally, spastic contracture of the **m. peroneus longus** tendon was noted in 13 cases (25.5%) in subgroup III B and in 8 cases (15.7%) in subgroup IV B.  

The functional state of **m. peroneus longus** plays a key role in the transformation of mobile flatfoot into the rigid form, as well as in the importance of its tendon transposition towards the supinator side during surgical correction. Based on this, we developed a method for correcting rigid flatfoot:  

**"Transposition of the m. peroneus longus tendon to the medial side of the foot, shortening of the m. tibialis posterior tendon, and arthrodesis of the cuneonavicular joint."**  

The developed method differs by:  
- Wedge-shaped resection of the articular surfaces of the navicular and cuneiform bones (the wedge angle opens toward the plantar surface),  
- Formation of a tunnel in the cuneiform bone,  
- Re-insertion of the attachment site of the **m. tibialis posterior** tendon,  
- Shortening its tendon by tensioning and embedding it into the tunnel of the cuneiform bone,  
- Transposition of the **m. peroneus longus** tendon to the medial side and attachment to the **m. tibialis posterior** tendon,  
- Fixation of the cuneonavicular joint with pins in the form of a triangle to form the arch of the foot.  

**(Patent for invention № FAP 2416 (2024) at the Intellectual Property Agency of the Republic of Uzbekistan.)**  

This method was applied to all 51 patients.  

### **RESULTS AND DISCUSSION**  

Gait analysis was performed on all 51 patients using a 3D motion capture system in a gait laboratory before and after surgical correction. The following parameters were evaluated:  

- Step length  
- Stride width  
- Walking speed  
- Foot progression angle  
- Ankle dorsiflexion and plantarflexion angles  
- Knee joint flexion-extension angles  

Preoperative analysis showed significant deviations from normal gait patterns in all patients, including excessive pronation, valgus deviation of the hindfoot, and external rotation of the forefoot. The average foot progression angle was **+18.5°**, which is significantly higher than normal values.  

After surgery, gait kinematics improved in all patients. The foot progression angle decreased to an average of **+8.2°**, indicating better foot alignment. Walking speed increased by **21%**, and step length improved by **17%**, suggesting enhanced mobility and function.  

A statistical analysis of pre- and postoperative parameters confirmed significant improvements in gait biomechanics (**p < 0.05**). This confirms the effectiveness of the developed surgical method in restoring foot function.  

### **CONCLUSION**  

The study demonstrated that patients with rigid flatfoot experience significant gait disturbances, which can be objectively assessed using a 3D motion capture system. The newly developed surgical technique effectively corrects foot deformities, improves gait kinematics, and enhances overall mobility. The use of gait laboratory diagnostics allows for precise assessment of treatment outcomes and can be recommended for clinical practice in pediatric orthopedic surgery.  

 

×

About the authors

Iskandar Yu. Khodjanov

Republican specialized scientific and practical medical center traumatology and orthopaedics

Email: prof.khodjanov@mail.ru
ORCID iD: 0000-0003-3964-4148

MD, Dr. Sci. (Medicine), Head of orthopedic department No. 2

Uzbekistan, Тashkent

Xasanali I. Umarov

Andijan State Medical Institute

Author for correspondence.
Email: umarovhasanboj47@gmail.com
ORCID iD: 0009-0008-5466-1687

MD, traumatologist-orthopedist

Uzbekistan, Andijan

Sherali K. Khakimov

Bukhara State Medical Institute named after Abu Ali ibn Sino

Email: kuzievich_81@mail.ru
ORCID iD: 0000-0003-3779-6025

Cand. Sci. (Medicine), Associate Professor

Uzbekistan, Bukhara

Anvar G. Mirzaev

Republican specialized scientific and practical medical center traumatology and orthopaedics

Email: m.anvardoc@gmail.com
ORCID iD: 0000-0001-9796-2959

Cand. Sci. (Medicine), Head of the Gait Laboratory

Uzbekistan, Тashkent

References

  1. Pourghazi F, Nabian MH, Bakht SS, et al. Changes in gait pattern and quality of life of adolescents with flexible flat foot after Calcaneal Lengthening Osteotomy. Foot. 2023;57:101962. doi: 10.1016/j.foot.2023.101962
  2. Boryczka-Trefler A, Kalinowska M, Szczerbik E, et al. Effect of Plano-Valgus Foot on Lower-Extremity Kinematics and Spatiotemporal Gait Parameters in Children of Age 5–9. Diagnostics. 2022;12(1):2. doi: 10.3390/diagnostics12010002
  3. Stief F, Böhm H, Michel K, et al. Reliability and accuracy in three-dimensional gait analysis: a comparison of two lower body protocols. J Appl Biomech. 2013;29:105-111. doi: 10.1123/jab.29.1.105
  4. Levinger P, Murley GS, Barton CJ, et al. A comparison of foot kinematics in people with normal- and flat-arched feet using the Oxford Foot Model. Gait Posture. 2010;32(4):519-523. doi: 10.1016/j.gaitpost.2010.07.013
  5. Kim HY, Cha YH, Lee JS, et al. Changes in gait and radiographic and clinical results of calcaneal lengthening osteotomy in children with idiopathic flexible flatfoot. Clin Orthop Surg. 2020;12:386-395. doi: 10.4055/cios19150
  6. Krautwurst BK, Wolf SI, Dreher T. Three-dimensional evaluation of heel raise test in pediatric planovalgus feet and normal feet. Gait Posture. 2016;48:146-151. doi: 10.1016/j.gaitpost.2016.05.003
  7. Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop. 2010;4(2):107-21. doi: 10.1007/s11832-010-0239-9
  8. Kim HY, Shin HS, Ko JH, et al. Gait Analysis of Symptomatic Flatfoot in Children: An Observational Study. CiOS. Clin Orthop Surg. 2017;9:363-373. doi: 10.4055/cios.2017.9.3.363
  9. Caravaggi P, Sforza C, Leardini A, et al. Effect of plano-valgus foot posture on midfoot kinematics during barefoot walking in an adolescent population. J Foot Ankle Res. 2018;11:55. doi: 10.1186/s13047-018-0297-7
  10. Portinaro N, Leardini A, Panou A, et al. Modifying the Rizzoli foot model to improve the diagnosis of pes-planus: Application to kinematics of feet in teenagers. J Foot Ankle Res. 2014;7:57. doi: 10.1186/s13047-014-0057-2
  11. Wenger DR, Mauldin D, Speck G, et al. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am. 1989;71(6):800-10. PMID: 2663868
  12. Das SP, Das PB, Ganesh S, et al. Effectiveness of surgically treated symptomatic plano-valgus deformity by the calcaneo stop procedure according to radiological, functional and gait parameters. J Taibah Univ Med Sci. 2017;12;102-109. doi: 10.1016/j.jtumed.2016.11.009
  13. Twomey D, McIntosh A. The effects of low arched feet on lower limb gait kinematics in children. Foot. 2012;22:60-65. doi: 10.1016/j.foot.2011.11.005
  14. Twomey D, McIntosh A, Simon J, et al. Kinematic differences between normal and low arched feet in children using the Heidelberg foot measurement method. Gait Posture. 2010;32:1-5. doi: 10.1016/j.gaitpost.2010.01.021
  15. Papamerkouriou Y-M, Rajan R, Chaudhry S, et al. Prospective early clinical, radiological, and kinematic pedobarographic analysis following subtalar arthroereises for paediatric pes planovalgus. Cureus. 2019;11:e6309. doi: 10.7759/cureus.6309
  16. Böhm H, Stebbins J, Kothari A, Dussa CU. Dynamic gait analysis in paediatric flatfeet: unveiling biomechanical insights for diagnosis and treatment. Children. 2024;11(5):604. doi: 10.3390/children11050604
  17. Ghazaleh L, Hoseini Y, Masoomi F, et al. Ground reaction force analysis in flexible and rigid flatfoot subjects. J Bodyw Mov Ther. 2024;39:441-446. doi: 10.1016/j.jbmt.2024.02.020
  18. Bauer K, Mosca VS, Zionts LE. What’s New in Pediatric Flatfoot? J Pediatr Orthop. 2016;36:865-869. doi: 10.1097/BPO.0000000000000582
  19. MacInnes P, Lewis TL, et al. Surgical management of pes planus in children with cerebral palsy: A systematic review. J Child Orthop. 2022;16:333-346. doi: 10.1177/18632521221112496
  20. Cen X, Yu P, Song Y, et al. Influence of medial longitudinal arch flexibility on lower limb joint coupling coordination and gait impulse. Gait Posture. 2024;114:208-214. doi: 10.1016/j.gaitpost.2024.10.002
  21. Ha Yong Kim, Hyuck Soo Shin, Jun Hyuck Ko, et al. Gait analysis of symptomatic flatfoot in children: anobservational study. Clin Orthop Surg. 2017;9(3):363-373. doi: 10.4055/cios.2017.9.3.363
  22. Saraswat P, Macwilliams Ba, Davis Rb, D’astous Jl. Kinematics and kinetics of normal and planovalgus feet during walking. Gait Posture. 2014;39(1):339-45. doi: 10.1016/j.gaitpost.2013.08.003

Supplementary files

Supplementary Files
Action
1. JATS XML
2. Figure 1. A – appearance of the patient under study; B – coordinate system of Euler angles for measuring GRF.

Download (1MB)

Copyright (c) 2025 Khodjanov I.Y., Umarov X.I., Khakimov S.K., Mirzaev A.G.

Creative Commons License
This work is licensed under a Creative Commons Attribution 4.0 International License.

СМИ зарегистрировано Федеральной службой по надзору в сфере связи, информационных технологий и массовых коммуникаций (Роскомнадзор).
Регистрационный номер и дата принятия решения о регистрации СМИ: серия ПИ № ФС77-65957 от 06 июня 2016 г.