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DOI: 10.14526/2070-4798-2019-14-2-131-137
Comparison of balance among asymptomatic population with
Egyptian
and Greek foot- A cross sectional study
Vandana Patel*, Nidhi Vanani, Maitri Patel, Khushbu Vagh S.S. Agrawal Institute of Physiotherapy & Medical Care Education, Navsari, Guajrat, India
Abstract: Balance can be affected by injury, disease or disturbance in the interaction of nervous and musculoskeletal system. Along with these factors different types of foot may alter the biomechanics at foot level and in turn the load sharing. Variation in length of second metatarsal in human foot divides the foot in different types. These feet have different biomechanical changes which can affect the ability maintain balance. Purpose. To evaluate ability to maintain balance in two different types of foot i.e. Greek and Egyptian foot with help of the SEBT in healthy young adults. Procedure. The purpose and the procedure of the research were explained to the subjects and On the basis of inclusion and exclusion criteria, the subjects were requested and those who were willing to participate in the research were selected. Total n=30 subjects were included in each group based on the observation of the type of foot. The procedure was explained before starting the test of SEBT. Each subject performed on SEBT layout. The three trials were performed and the average value was taken as a final value. Results: Data collected were entered and analyzed by SPSS version 16.0 for windows (IBM). Descriptive statistics was used to analyze baseline characteristics for both the groups. Mean scores of both the groups were taken and analyzed with the use of independent t test for difference in mean. The mean scores of subjects with Greek foot were more compared to subjects with Egyptian foot but the results were not significant for all the values with p > 0.05. Conclusion. There is no difference in the balance among asymptomatic individuals with different foot types.
Keywords: Balance, Greek foot, Egyptian foot, Types of foot, Star Excursion Balance-Test (SEBT).
For citation: Vandana Patel, Nidhi Vanani, Maitri Patel, Khushbu Vagh. Comparison of balance among asymptomatic population with Egyptian and Greek foot- A cross sectional study. Russian journal of Physical Education and Sport. 2019; 14(2): 111-116. DOI: 10.14526/2070-4798-2019-14-2-131-137
INTRODUCTION
Balance is essential to perform daily activities. According to the biomechanics balance is defined as an ability to maintain the vertical line from centre of gravity of a body within the base of support with minimal postural sway [1]. Change in balance would interfere with the performance of motor skills, which will lead to higher chances of falls and injuries [2, 3]. The arthro-kinematics of foot provides support as a powered lever and works as a shock absorber during walking and running. Therefore, proper arthro-kinematics within the foot has impact over body's ability to diminish forces [2].
The ankle joint form a complex system including 28 bones, 33 joints, 112 ligaments; controlled by 13 extrinsic and 21 intrinsic muscles. The foot is subdivided into the rear foot, mid foot, and forefoot. Within the foot structure, the metatarsals seem
to play an important role in the bio-mechanical function of the foot [4,5]. Metatarsophalangeal joints are connected proximally by convex head of the metatarsal and distally by the concave base of proximal phalanges. The etatarsophalangeal (MTP) joints are condyloid synovial joints with two degrees of freedom which are extension / flexion and abduction / adduction. During the late stance phase of walking, toes extension at the MTP joint permits the foot to pass over the toes, whereas the metatarsal heads and toes help to balance the super imposed body weight through activity of the intrinsic and extrinsic toe flexor muscles [6]. Based on the length of the metatarsal bones in the forefoot there are mainly three types of feet in normal population. The types are:
1. INDEX PLUS TYPE: In these types of feet, the 1st metatarsal is longer than the 2nd metatarsal. It
n
is also called as "Egyptian foot". The length of the metatarsals progressively decreases [7].
2. INDEX PLUS-MINUS TYPE: In these kinds of feet the sizes of 1st and 2nd metatarsals are equal in size. It is also called as "Squared foot". In these type of feet length of metatarsals are 1=2>3>4>5 [7].
3. INDEX MINUS TYPE: In these types of feet, the 2nd metatarsal is longer than the 1st metatarsal. It is also called as "Greek foot" or "Morton's foot". The 4th and 5th metatarsals are shorter than 3rd metatarsal [7].
Metatarsal break has an important role in maintaining the balance in normal individual. During walking, in the phase of heel rise the break which occurs at MTP joints is useful in sharing load of body. The metatarsal heads and toes become major weight bearing regions of the body. The metatarsal break creates MTP extension. A single oblique axis passing from 2nd to 5th metatarsal heads forms the inclination which distributes the forces equally from 2nd through 5th toes [6].
The Star Excursion Balance Test (SEBT) is a dynamic test that is used to assess strength, flexibility, proprioception, and physical performance and deficits in dynamic postural control [9]. It offers sufficient challenge for the detection of balance deficits. It is a sensitive test for detecting performance deficits in various subjects in a lesser amount of time. It has eight direction measurement which include the anterior, anterior-medial, medial, posterior-medial, posterior, posterior-lateral, lateral, and anterior-lateral direction. It has high intra-rater (ICC value 0.88 to 0.96) and inter-rater reliability (ICC value 0.83 to 0.93) [8-17].
According to the available literature sources, none of the balance studies have directly evaluated the influence of different types of foot based on various length of metatarsal in the form of the impact of that biomechanical changes and its effect on balance performance.
STATEMENT OF PROBLEM:
Different types of foot have different biomechanical changes which can affect the ability maintain balance which is yet not established in the available literature.
OBJECTIVES:
1. To evaluate the balance score in subjects with Egyptian foot using SEBT.
2. To evaluate the balance in subjects with Greek foot using SEBT.
3. To evaluate the difference in ability to maintain balance in subjects with two different types of foot.
NULL HTPOTHESIS:
There will be no change in balance among populations with two different foot types.
METHODOLOGY
Study design: A cross sectional study Studysetting: Study was conducted in Physiotherapy Department of S.S Agrawal Institute of Physiotherapy, Navsari, Gujarat, India. Study population: Healthy Young Adult-Age Group (18-22 years). Study duration:6-Months Sampling method: Purposive Sampling Sample size: n = 30 subjects in each group.
INCLUSION CRITERIA: 1) Young healthy adults within age range of whose age is 18-22 Years. 2) Subjects of both genders. 3) Subjects who were willing to participate. 4)
Asymptomatic subjects.5) Types of foot: Greek foot and Egyptian foot.
EXCLUSION CRITERIA: 1) Subjects with the history of Ankle sprain or any limb Trauma in past 3 months. 2) Any bone or joint abnormalities. 3) Subject with square foot 4) Subjects with known balance issues such as vertigo, dizziness, etc.
MATERIALS: 1) A measure tape For SEBT score measurement. 2) SEBT assessment sheet. 3) Record sheet. 4) Stadiometer for measuring height. 5) Weight scale for measuring weight
OUTCOME MEASURE: SEBT scores of subjects in centimeters.
PROCEDURE: The purpose and the procedure of research were explained to the subjects and on the basis of inclusion and extrusion criteria, the subjects were requested and those who were willing to participate in the research were selected. An informed written consent was taken from each participant well before the starting of procedure.
TEST PROCEDURE:
Star Excursion Balance Test:
All subjects were between the age group of 18 - 22 years. The subjects were selected as per the observation throughout naked eyes and depending
upon the length of second metatarsal they were categorized into each group. Those with longer 2nd metatarsal in comparison to great toe were included in Greek foot group and subjects with smaller 2nd metatarsal were included in Egyptian foot group.
Formation of star Excursion Balance Test: The star excursion test layout consisted of four lines, made on, the floor with measure tape: two forming vertical and horizontal lines and two positioned perpendicular to each other and at 45 degree with respect to the vertical and horizontal lines. The foot is placed at the center point where all the measure tape merged.
The distance on the measure tape from the center point to the point that each subject could reach along each quadrant was measured.
Procedure of Star Excursion Balance Test: The trial was initiated when the subject began to reach in one of the eight diagonal directions, Anterior, Antero-medial, Medial, Postero-medial, Posterior, Postero-lateral, Lateral, antero-lateral. Subjects were not allowed to touch the ground with the preceding leg at any time during the reach. First trial was initiated with dominant leg. The maximal reach distance was the furthest point along the directional line is marked and noted. The trial was completed after the subject returned to the starting point by performing in all directions and placing the preceding leg in the starting box with the supporting leg. The three trials were performed and the average
value was taken as a final value. Same procedure was followed with other side of the leg.
DATA ANALYSIS & RESULTS: Data collected were entered and analysed by SPSS
(Statistical package for social science) version 16.0 for windows (IBM). The normality of data was plotted on histograms & was assessed using normal distribution curve. Inspection of Q-Q plots & Box plots revealed that SEBT scores were normally distributed for both groups and that there was homogeneity of variance as assessed by Levene's test for equality.
Therefore, an independent t- test was run on the data with a 95% confidence interval (CI) for the mean difference. As per Levene's test the significant level was p > 0.05; Values from equal variances assumed were taken into consideration with 2-tailed significance of mean differences. The mean values for each group are mentioned in table no. 2. On observation the mean values for subjects in Greek foot were higher in comparison to Egyptian foot group.
However, It was found that the balance scores on SEBT scale for Greek foot group and Egyptian foot group were not significant with p > 0.05. Thus, indicates that the mean difference between both the groups were not significant. T- Test values are shown in table no. 3.
SEBT Component Side Greek foot Mean ± SD Egyptian foot Mean ± SD
Anterior Right 78.0083 ± 12.45 73.7753 ± 10.96135
Left 80.8957 ± 21.48 72.5750 ±11.19476
Antero- medial Right 83.2960 ± 12.91 78.6087 ± 12.64481
Left 73.1977 ± 20.13057 65.3393 ± 9.92202
Medial Right 84.7747 12.64500 79.4970 ± 13.43086
Left 57.0300 ± 12.45519 52.7640 ± 14.90400
Postero medial Right 85.4943 ± 13.31440 80.8073 ± 16.21575
Left 70.9623 ± 15.03735 67.4500 ±15.04761
Posterior Right 76.8847 ± 13.78594 73.6630 ± 16.19218
Left 75.5247 ± 14.49038 71.0403 ± 13.85360
Postero- lateral Right 76.4287 ± 13.75663 72.6260 ± 15.67836
Left 82.5520 ± 14.13507 79.3193 ± 14.40698
Table no.2: Difference of means among both the groups
R
Lateral Right 51.2077 ± 11.32985 49.9853 ± 11.19476
Left 84.7977 ± 13.85554 79.6410 ± 14.58987
Antero-lateral Right 66.6847 ± 11.65415 66.7853 ± 10.61518
Left 86.5067 ± 14.69946 81.0960 ± 16.04850
Table no. 3: Comparison of mean difference among both groups
SEBT Component Side t - value p -Value
Anterior Right 1.397 0.168
Left 1.855 0.161
Antero- medial Right 1.420 0.123
Left 1.918 0.226
Medial Right 1.567 0.410
Left 1.203 0.322
Postero medial Right 1.224 0.676
Left 0.904 0.972
Posterior Right 0.830 0.690
Left 1.225 0.600
Postero- lateral Right 0.999 0.234
Left 0.877 0.370
Lateral Right 0.420 0.225
Left 1.404 0.384
Antero-lateral Right -0.035 0.166
Left 1.362 0.179
DISCUSSION
Egyptian foot is the most common shape of foot which is found among maximum population across India. In this type of foot the second toe is comparatively tapering to the first toe. Maximum weight gets shared by the great toe rather than other tapered toes of the foot and thus makes it more disadvantageous in order to maintain balance with such foot type. While those with Greek foot will have load sharing between great toe as well as second metatarsal which is longer compared to other toes. This will make it more advantageous in terms of distributing the load. This could be the possible reason of lesser mean score of SEBT in Egyptian foot group compared to Greek foot group [21].
In this study, SEBT was used to examine the balance of healthy young adults. The SEBT test revealed that only certain reach directions were affected based on different foot types. The direction dependent effect further supports that structural stability changes the mobility of the foot, not proprioception. The different foot structures may affect range of motion (ROM) of joint when
reaching in certain directions and represent specific mechanical and neuromuscular advantages or disadvantages affecting the ultimate reach limits in those directions [22].
Cote et al. Proved that Postural sway and center of balance (COB) in static stance are unaffected by foot type. Hence, any change in surface contact pressures that may exist among the different types of foot are not sufficient to alter weight distribution or sway distance over the base of support in quite stance but that can play its role during different directional reaches. These can be the possible reason to have different mean scores among both the groups [22].
The strength of lower extremity muscles and core muscles are needed for maintenance of static and dynamic balance in normal population which can affect the ability to maintain balance in accordance with different foot shape. Heavier weight and a bigger foot size can provide better static stability in the form of lower mean sway velocity. The body weight and area of base of support are also one of the main factors affecting human balance during quite
standing since center of gravity should be located within the base of support to maintain standing balance. These were some of the factors which can contribute for better explanation of insignificant results in present study [23].
In current study only asymptomatic subjects have participated but those subjects were not scanned for sensory system such as visual, vestibular and proprioceptive; which can produce motor commands that coordinate the activation pattern of muscles. Proprioception has ability to integrate the sensory signals from various mechanoreceptors and thereby to determine body position and movements in space, and it plays a crucial role to control the postural balance [24].
Menz HB et.al suggested that tactile sensitivity of the plantar surface of the foot and ankle flexibility both are strongly correlated with postural sway which means postural response were impaired when sensory input is blocked in healthy persons. Planter mechanoreceptors provide important information regarding body position. Toe muscle function plays a particularly important role in the maintenance of balance. These factors were not considered in our study which could be the possible reasons for p valueto be greater than 0.05 [25].
The length of the second meta-tarsal in this study was not measured using X- Ray techniques so the difference in the length of second metatarsal among the subjects of both the groups cannot be analyzed for further statistical evaluation and hence the difference in the mean scores cannot be categorized for each subjects of the study. As this is a preliminary study the total numbers of subjects included are 30 for each group which is quite a small number to get a significant result among normal healthy study population. These could have influenced our study results.
In present study, all participants were compared for all components score of SEBT in both types of foot and results were found to be non-significant. (p > 0.05)
CONCLUSION
There is no significant difference in the balance among asymptomatic individuals
with different foot types.
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Submitted: 15.03.2019 Author's information:
Vandana Patel - Doctor, Assistant Professor, S.S. Agrawal institute of physiotherapy & medical care education, Navsari, Gujarat, India, email: [email protected]
Nidhi Vanani - Bachelor, S.S. Agrawal institute of physiotherapy & medical care education, Navsari, Gujarat, India. e-mail:[email protected]
Maitri Patel - Bachelor, S.S. Agrawal institute of physiotherapy & medical care education, Navsari, Gujarat, India, e-mail:[email protected]
Khushbu Vagh - Bachelor, S.S. Agrawal institute of physiotherapy & medical care education, Navsari, Gujarat, India, e-mail:[email protected]
