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 Table of Contents  
Year : 2019  |  Volume : 13  |  Issue : 1  |  Page : 38-42

Comparison of foot structure between urban and rural Indian school children

MGM School of Physiotherapy, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India

Date of Submission06-Apr-2018
Date of Acceptance30-Oct-2018
Date of Web Publication29-Jun-2019

Correspondence Address:
Dr. Yuvraj Lalit Singh
MGM School of Physiotherapy, MGM Institute of Health Sciences, MGM Educational Campus, Sector 1, Kamothe, Navi Mumbai - 410 209, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/PJIAP.PJIAP_10_18

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INTRODUCTION: Limited information on morphological characteristics of feet among rural (walking predominantly bare foot) and urban Indian children motivated this study. The objective was to study and compare foot characteristics of Indian rural and urban school children.
METHOD: A convenience sample of 200 healthy children aged 6-15 yrs with no history of foot pain was studied. 100 rural children were matched on marginal distributions for age and body mass with 100 urban children for comparison. Plantar pressure and foot geometry measurements were collected using EMED-SF system. Medial longitudinal arch height was recorded using Arch Index (AI). ANCOVA and Independent sample t-test were used for between group comparisons.
RESULTS AND CONCLUSION: Rural Indian children presented with 24 % lower body weight (BMI rural children = 15.35; BMI urban children = 18.17) and 5% lower height. When corrected for stature, they had 4% shorter feet, 3% wider forefoot, 28% narrower mid foot and 15% higher arches compared to urban children. When corrected for body weight, rural children demonstrated approximately 22% lower pressures in forefoot and 5% in the mid foot. Foot characteristics of rural children can be considered favorable in development of MLA and prevention of forefoot injuries resulting from overuse.

Keywords: Barefoot, India, tribal

How to cite this article:
Thomas B, Singh YL, Mullerpatan RP. Comparison of foot structure between urban and rural Indian school children. Physiother - J Indian Assoc Physiother 2019;13:38-42

How to cite this URL:
Thomas B, Singh YL, Mullerpatan RP. Comparison of foot structure between urban and rural Indian school children. Physiother - J Indian Assoc Physiother [serial online] 2019 [cited 2023 Feb 9];13:38-42. Available from: https://www.pjiap.org/text.asp?2019/13/1/38/261812

  Introduction Top

Development of the foot continues up to 12 years of age.[1],[2] It is also known that foot anthropometry varies across populations.[3] Yet, there is scarce information on morphological characteristics of the feet in various populations. A growing structure in the first decade of life which varies globally demands extensive study. In countries like India where children continue to walk bare feet predominantly in rural parts, it is particularly essential to explore foot characteristics with an intention to safeguard their foot health and consequently lower extremity function. Among the common abnormalities encountered in growing phase of life, the development of longitudinal arch has received maximum attention possibly due to deeper understanding of its implications on lower extremity function.[3],[4],[5],[6],[7]

The habitual use of footwear from early childhood may influence shape and probably function of the foot. Traditional Chinese foot binding is an extreme example showing that human foot is a highly plastic structure, but even daily footwear is known to influence foot.[8] Studies on Chinese and medieval British populations reported foot deformities resulting from restrictive footwear.[9],[10] In the USA, 88% of healthy women surveyed walked with shoes smaller than their feet and 80% of them had some sort of foot deformity.[11] However, differences between habitual shod and unshod foot are not well understood although researchers posed this question a century ago. Hoffmann, using a limited sample size, noticed that habitual, or native, barefoot walkers universally have wider toe regions, a trend also observed in classical sculptures.[12]

Recently, a few studies have reported descriptive findings on foot shape and function in habitually unshod populations. Habitual barefoot adult walkers from Java had relatively long and wide feet; whereas in China, a relatively spread anterior part was reported in habitually barefoot adults.[9],[13] In Congo, urban (predominantly shod) children had higher proportion of flat feet than in rural (predominantly unshod) children.[14] Similarly, in India, the incidence of flat feet was most common in children who wore closed-toe shoes, less common in those who wore sandals or slippers, and least in the unshod.[15]

However, a major limitation with these studies is the reliability of outcome measure used. Some of them have used static footprints to record foot geometry. Reliability of footprints is challenged.[3] Moreover, value of static footprints in informing foot geometry during dynamic functional activities like gait is limited. Second, only a few have studied plantar pressures among barefoot walkers which can provide robust information on foot geometry and loading during walking to indicate dynamic foot function.[16]

The present study compared foot structure between rural and urban Indian children using robust objective outcome measures during dynamic condition, i.e., walking. Findings from the present analysis also help explore whether daily footwear influences normal function of the foot and if so, does this have implications for clinicians and footwear manufacturers?

  Materials and Methods Top

The study was approved by the Institutional Review Board of MGM Institute of Health Sciences. [Table 1] provides definitions of geometric and pressure measurements. Informed consent was sought from all parents and school authorities. A convenience sample of 200 healthy children aged 6–15 years with no history of foot pain was studied. One hundred rural children from Municipal Schools of Ransai and Chikale villages located in Raigad district of Maharashtra were matched on marginal distributions for age, height, and body mass with 100 urban children from MGM School, Navi Mumbai, Maharashtra, for comparison.
Table 1: Definitions of geometric and pressure measurements

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Foot geometry and plantar pressure measurements were collected using EMED-SF system (Novel GmbH, Munich, Germany), which is a capacitance transducer-based system to record foot geometry and pressures of a person walking barefoot. Foot length (FL), forefoot width, mid-foot width, hindfoot width, and maximum peak pressure (MPP) over forefoot, mid-foot, and hindfoot (MPPFF, MPPMF, and MMPHF) were recorded. The platform was integrated into a wooden walkway to ensure level surface. All children were asked to walk bare feet across the platform at self-selected speed and five right and five left steps of mid-gait were recorded for analysis [Figure 1]. Average of data from five right and five left steps was used for further analysis.[17]
Figure 1: Use of EMED platform for measuring foot structure and pressures

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Arch index (AI) was recorded to study medial longitudinal arch (MLA) height because of strong correlation with radiographic measures of calcaneal inclination.[18] AI was computed as a ratio of surface area of mid-foot and total foot, excluding toe region [Figure 2] based on values provided by the EMED system. The MLA is classified as elevated (AI < 0.21), normal (0.22 < AI < 0.26), or low (AI > 0.26).[19]
Figure 2: Calculation of arch index

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ANCOVA and independent sample t- test were used for between-group comparisons.

  Results Top

Average height, body weight, and body mass index varied significantly between two groups [Table 2]. Rural children presented mean shorter FL compared to urban children [Table 2]. Expressed as a percentage of total body stature, rural children had 4% significantly shorter feet. Comparison of foot width as a percentage of FL (a measure for overall foot shape), significant differences between two groups emerged. Rural children presented with 3% wider forefoot and 29% narrower mid-foot.
Table 2: Comparison of age, height, weight and body mass index between rural and urban children

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(AI) based on areas of MPPFF, MPPMF, and MMPHF using the EMED-SF system. Rural children presented with 15% higher arch compared to the urban counterparts [Table 3].
Table 3: Comparison of foot geometry between rural and urban children

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Differences in pressure distribution were most prominent on the heel and in metatarsal region despite similar gait line speeds. Rural children demonstrated approximately 22% lower peak pressures over entire foot with forefoot showing maximum difference. Twenty-two percent lower pressures were recorded in the forefoot region, approximately 5% in the mid-foot, and 17% in the hind foot; the differences in forefoot and mid-foot regions being statistically significant [Table 4].
Table 4: Comparison of plantar pressures between rural and urban children

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  Discussion Top

Literature describing unshod foot is scarce. Findings from the present study supplement existing knowledge on pediatric foot structure. Rural Indian children presented with approximately 4% shorter feet with 3% wider forefoot, 28% narrower mid-foot, and 15% higher MLA compared to urban children. Interesting observations (similarities and variations) emerge from comparison of our findings with findings reported from other Asian populations.

Slightly shorter feet of rural children may be because rural children were 5% shorter in total body height compared to urban children. It is already known that people with shorter body height tend to have shorter feet.[20] Rural children may be shorter compared to their age-matched urban counterparts because it is likely that rural children consume less nutritious food and it is known that body nutrition is directly associated with body height.[21] In the absence of published studies comparing FL of rural versus urban children, it is not possible to comment on FL of rural children from other populations. However, it is interesting to discuss FL of adult rural and urban barefoot walkers (intentionally chose to walk barefoot) from India. Adult rural barefoot walkers presented with shorter body stature and shorter foot compared to urban barefoot walkers, which is similar to the present findings from children. However, rural adult barefoot walkers presented with longer foot after correcting to body stature, which leaves with speculation that rural children demonstrate a sudden sharp gain in body height at puberty w.r.t. FL, and therefore, in adulthood, rural people present with longer feet compared to urban children.[13],[16]

Wider forefoot of the rural children can be explained with greater prehensile activity of forefoot required to adapt to uneven terrain during push-off while walking barefoot for a large part of the day for indoor and outdoor activities which is noted even in adult rural Indian barefoot walkers.[16]

Narrow mid-foot in the rural children is consistent with higher MLA compared to urban children. Rural children presented with 15% higher MLA as compared to urban children. Rural children walked bare feet daily on uneven terrain for 2–4 h approximately while accompanying their parents on fields and walking and playing around house. Children walked on uneven terrain for approximately 4–8 km daily to and from school in footwear in the form of open slippers provided by school, which were mostly worn out. However, urban children walked shod for all outdoor activities. They traveled to school in buses or cars and generally walked lesser compared to their rural counterparts. It is known that walking bare feet challenges the use of intrinsic muscles which facilitates the development of MLA, resulting in higher prevalence of flat feet among children using footwear compared children walking bare feet.[15] These findings are similar to those reported in Brazilian and Central African schoolchildren, with the low prevalence of low feet among those walking predominantly bare feet.[3],[14]

Peak plantar pressure was lower over forefoot and mid-foot in habitually barefoot rural children than in urban shod peers, despite adjusting for body weight and both groups walking at similar gait velocity. Lower pressure over wider forefoot of rural children may be due to redistribution of pressure over larger contact surface area of forefoot.[22] However, lower mid-foot pressure in the rural children may result from lesser contact surface area owing to narrower mid-foot caused by higher medial arch.

To summarize, habitual use of footwear influences both overall shape of foot and peak plantar-pressure. Habitual barefoot walkers have wider forefoot, resulting (probably along with dynamic adaptations) in lower peak pressure, favorable in the prevention of forefoot injury in sports activities as forefoot injuries are common.[23] Second higher medial arch of the foot is known to enhance athletic performance in children.[24]

The present study was a one-time study with no periodic re-assessments. Further longitudinal studies are necessary to comment on clinical implications of foot characteristics of rural children on lower limb function. Second, it lacks exploration of influence of nutrition-related factors (body height and mass) and life style-related factors (barefoot walking) on developing feet.

  Conclusion Top

Rural Indian children presented with 24% lower body weight and 5% lower height. When corrected for stature, they had 4% shorter feet, 3% wider forefoot, 29% narrower mid-foot, and 15% higher arches compared to urban children. When corrected for body weight, rural children demonstrated approximately 22% lower pressures in the forefoot and 5% in the mid-foot. Foot characteristics of rural children can be considered favorable in the development of MLA and prevention of forefoot injuries resulting from overuse.


We express their gratitude for all children for their voluntary participation. Furthermore, we wish to acknowledge their parents and the school teachers for helping us in data collection.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Leung AK, Cheng JC, Mak AF. A cross-sectional study on the development of foot arch function of 2715 Chinese children. Prosthet Orthot Int 2005;29:241-53.  Back to cited text no. 1
Volpon JB. Footprint analysis during the growth period. J Pediatr Orthop 1994;14:83-5.  Back to cited text no. 2
Onodera AN, Sacco IC, Morioka EH, Souza PS, de Sá MR, Amadio AC, et al. What is the best method for child longitudinal plantar arch assessment and when does arch maturation occur? Foot (Edinb) 2008;18:142-9.  Back to cited text no. 3
Staheli LT, Chew DE, Corbett M. The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am 1987;69:426-8.  Back to cited text no. 4
Murley GS, Menz HB, Landorf KB. Foot posture influences the electromyographic activity of selected lower limb muscles during gait. J Foot Ankle Res 2009;2:35.  Back to cited text no. 5
Nikolaidou M, Boudolos K. A footprint-based approach for the rational classification of foot types in young schoolchildren. Foot 2006;16:82-90.  Back to cited text no. 6
Hernandex A, Kimura L. Calculation of Staheli's plantar arch index and prevalence of flat feet: A study with 100 children aged 5 to 9 years. Acta Ortop Bras 2007;15:68-71.  Back to cited text no. 7
Jackson R. The Chinese foot-binding syndrome. Observations on the history and sequelae of wearing ill-fitting shoes. Int J Dermatol 1990;29:322-8.  Back to cited text no. 8
Sim-Fook L, Hodgson AR. A comparison of foot forms among the non-shoe and shoe-wearing Chinese population. J Bone Joint Surg Am 1958;40-A: 1058-62.  Back to cited text no. 9
Mays SA. Paleopathological study of hallux valgus. Am J Phys Anthropol 2005;126:139-49.  Back to cited text no. 10
Frey C, Thompson F, Smith J, Sanders M, Horstman H. American orthopaedic foot and ankle society women's shoe survey. Foot Ankle 1993;14:78-81.  Back to cited text no. 11
Hoffmann P. Conclusions drawn from a comparative study of the feet of barefooted and shoe-wearing peoples. J Bone Joint Surg 1905;3:105-36.  Back to cited text no. 12
Ashizawa K, Kumakura C, Kusumoto A, Narasaki S. Relative foot size and shape to general body size in Javanese, Filipinas and Japanese with special reference to habitual footwear types. Ann Hum Biol 1997;24:117-29.  Back to cited text no. 13
Echarri JJ, Forriol F. The development in footprint morphology in 1851 Congolese children from urban and rural areas, and the relationship between this and wearing shoes. J Pediatr Orthop B 2003;12:141-6.  Back to cited text no. 14
Rao UB, Joseph B. The influence of footwear on the prevalence of flat foot. A survey of 2300 children. J Bone Joint Surg Br 1992;74:525-7.  Back to cited text no. 15
D'AoÛt K, Pataky T, De Clercq D, Aerts P. The effects of habitual footwear use: Foot shape and function in native barefoot walkers. Footwear Sci 2009;1:81-94.  Back to cited text no. 16
Akins JS, Keenan KA, Sell TC, Abt JP, Lephart SM. Test-retest reliability and descriptive statistics of geometric measurements based on plantar pressure measurements in a healthy population during gait. Gait Posture 2012;35:167-9.  Back to cited text no. 17
Wong CK, Weil R, de Boer E. Standardizing foot-type classification using arch index values. Physiother Can 2012;64:280-3.  Back to cited text no. 18
Cavanagh PR, Rodgers MM. The arch index: A useful measure from footprints. J Biomech 1987;20:547-51.  Back to cited text no. 19
Grivas TB, Mihas C, Arapaki A, Vasiliadis E. Correlation of foot length with height and weight in school age children. J Forensic Leg Med 2008;15:89-95.  Back to cited text no. 20
McEvoy BP, Visscher PM. Genetics of human height. Econ Hum Biol 2009;7:294-306.  Back to cited text no. 21
Hills AP, Hennig EM, McDonald M, Bar-Or O. Plantar pressure differences between obese and non-obese adults: A biomechanical analysis. Int J Obes Relat Metab Disord 2001;25:1674-9.  Back to cited text no. 22
Zipfel Berger L. Shod versus unshod: The emergence of forefoot pathology in modern humans? Foot 2007;17:205-13.  Back to cited text no. 23
Robbins SE, Hanna AM. Running-related injury prevention through barefoot adaptations. Med Sci Sports Exerc 1987;19:148-56.  Back to cited text no. 24


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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