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  • Journal of the American Podiatric Medical Association is published by MDPI from Volume 116 Issue 1 (2026). Previous articles were published by another publisher in Open Access under a CC-BY (or CC-BY-NC-ND) licence, and they are hosted by MDPI on mdpi.com as a courtesy and upon agreement with American Podiatric Medical Association.
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1 January 2019

Anthropometric and Psychomotor Development Factors Linked to Foot Valgus in Children Aged 6 to 9 Years

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Department of Nursing and Podiatry, University of Malaga, Malaga, Spain
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Author to whom correspondence should be addressed.
J. Am. Podiatr. Med. Assoc.2019, 109(1), 30-35;https://doi.org/10.7547/16-108
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Abstract

Background: Planovalgus foot prevalence estimates vary widely (0.6%–77.9%). Among the many factors that may influence planovalgus foot development, much attention has been given to body mass index, especially that of children’s feet; factors related to psychomotor development have been less studied. We sought to determine the presence of planovalgus foot in children and its association with anthropometric parameters and psychomotor development. Methods: A case-control study was conducted in Ma´laga, Spain, 2012–2013, of 104 schoolchildren (mean ± SD age, 7.55 ± 0.89 years; 45.2% were boys). Age, sex, body mass index, presence of valgus (valgus index, by pedigraphy), and personal history related to psychomotor development of the lower limbs (presence/absence of crawling, age at onset of crawling, age at onset of walking, use of mobility aids) were evaluated. Results: Of the children with obesity, 53.7% had valgus deformity in the left hindfoot (odds ratio [OR], 6.94; 95% confidence interval [CI], 2.72–17.70; P < .0001). In the right foot, the corresponding values were 54.5% (OR, 9.08; 95% CI, 3.38–24.36; P < .0001). Multivariate logistic regression showed an increased risk of left planovalgus foot in boys, in children with overweight or obesity, and in those who began walking later. For the right foot, the same risk factors applied except age at onset of walking. Conclusions: These results corroborate data from previous studies, which report an association between overweight and obesity and the onset of planovalgus foot in children. In addition, we identify a new risk factor: age at onset of walking.
Obesity is a chronic, complex, and multifactorial disease that usually begins in childhood and adolescence and originates from a genetic and environmental interaction in which the most important aspect is environmental or behavioral (lifestyle). It becomes established by an imbalance between energy intake and expenditure and is characterized by excess body weight and volume, with an accumulation of body fat.[1]
Obesity and overweight pose a global public health problem, and in children, the prevalence is increasing rapidly throughout the world.[2] In May 2004, the 57th World Health Assembly declared obesity the epidemic of the century and approved the creation of a strategy on nutrition, physical activity, obesity, and health.[3,4]
Diverse methods can be used to assess obesity in childhood and adolescence, but the approach most commonly used in clinical practice and epidemiology is to study the relation between age, sex, weight, height, and body mass index (BMI).[1] In adulthood (age ≥18 years), a BMI cutoff value of 25 kg/m2 (calculated as weight in kilograms divided by height in meters squared) is generally taken to define overweight, and a BMI of 30 defines obesity.[2] For children and adolescents, percentile curves (cutoff points between BMI and age) are normally used.[2,5]
To date, no consensus has been agreed on by the international scientific community concerning the definition of obesity for these age groups.[5,6] There is controversy around the cutoff point in this definition (95th percentile or 97th percentile, depending on the country), and diverse reference tables are used, making it difficult to compare studies performed in different countries.[5,6,7,8]
For children, the two criteria that have received greatest international acceptance are those proposed by the World Health Organization (WHO) and by the International Obesity Task Force (IOTF). The WHO defines weight according to percentiles, with overweight as the 85th to 95th percentile and obesity as greater than the 95th percentile,[6] and the IOTF has published the following BMI reference values for adults: overweight, 25 or greater and obesity, 30 or greater.[2,6]
In 2014, the WHO reported that approximately 44 million (6.7%) of the world’s children younger than 5 years were overweight or obese.[9] In 2012, according to the IOTF, overweight or obesity affected 64% of girls and 54.3% of boys in Mexico,[10,11] 35.2% of girls and 33.2% of boys in the United States,[10,12] and 25.4% of girls and 25.2% of boys in the United Kingdom.[10] In 2012, the ALADINO study reported that 26.2% of children in Spain were overweight and that 18.3% were obese, and other studies have reported overweight and obesity values ranging from 30.8% to 44.5%.[13]
Longitudinal studies suggest that childhood obesity, when present after age 3 years, is associated with an increased risk of obesity in adulthood and increased long-term morbidity and mortality, together with many cardiovascular and metabolic pathologic conditions, and even cancer.[14,15] In addition, overweight and obesity provoke important psychosocial consequences, such as low self-esteem, social isolation, discrimination, and abnormal behavior.[14]
Overweight and obesity have also been associated with orthopedic problems, accompanied by reduced physical mobility and inactivity.[14,15] Excess weight in childhood, as well as age, sex, race, joint laxity, place of residence, footwear, and physical activity, are considered risk factors for pediatric planovalgus foot (PPVF).[16,17,18,19,20,21] Obesity can have negative consequences on the development of the musculoskeletal system of the lower limbs, and especially on that of children’s feet, due to the immaturity of their structures.[22,23,24]
There is no universally accepted definition of PPVF. This condition consists of a valgus deformity of the hindfoot associated with a reduction or flattening of the inner longitudinal arch. Flatfoot takes diverse forms: it may be painful or painless, flexible or rigid, and functional or nonfunctional.[25,26] Pathologic or rigid PPVF is often characterized by stiffness of the foot that is incapacitating and requires treatment; physiologic or flexible PPVF is a normal variation that causes no disability and tends to improve over time.[26,27]
The estimated prevalence of PPVF varies widely, from 0.6% to 77.9%, due to the lack of criteria on distinguishing a pathologic condition from normality and to the absence of a universally accepted definition. For preschool-aged children, the estimated prevalence is approximately 45%, which falls to 15% for older children (at a mean age of 10 years). In other words, the prevalence tends to decrease with increasing age.[20,21]
In 1999, Garcı´a-Rodr´ıguez et al[28] reported a prevalence of 2.7% in 1,181 children aged 4 to 13 years. In contrast, in 2006 Pfeiffer et al[29] recorded 44% (among 835 children aged 3–6 years). The latter study observed an inverse relation between age and PPVF (3 years old, 54%; 6 years old, 24%) and a sex bias, with 52% of boys and 36% of girls being affected. Moreover, body weight was a relevant factor: PPVF was present in 51% of children with overweight, in 62% of those with obesity, and in only 42% of those with normal body weight.[29]
Further research is needed to reduce the disparity of criteria regarding the prevalence of PPVF because the absence of consensus means that the information provided is of very limited use in clinical practice. In addition, studies should be conducted of the factors that influence the appearance and development of PPVF. The focus has been centred in the BMI, although factors related to the psychomotor development have been less studied. Owing to the increasing incidence and prevalence of obesity and overweight in children, and the lack of knowledge about how psychomotor development can influence PPVF, there is a rising need to evaluate these factors to enlighten decision making in the provision of podiatric medical care to this population. Accordingly, in this study we aimed to determine the prevalence of PPVF and to analyze the associations between various anthropometric parameters and the psychomotor development of children as risk factors.

Materials and Methods

In 2012 and 2013, a case-control observational study was performed of a population of schoolchildren in the first, second, and third years of primary school education (32.7%, 26.0%, and 41.3%, respectively) at five schools in the city of Ma´laga, Spain. No sampling was performed; the entire study population was initially selected. Children were included if they belonged to any of the courses defined, their parents gave consent for their participation, and they had no previous surgery on the foot or any congenital malformation of the foot.
Cases were defined as children with PPVF, and controls as those with normal foot. The presence or absence of valgus deformity was determined in each foot (for the diagnosis of planovalgus foot, although it is often associated with flatfoot, in the present study we considered only valgus deformity of the hindfoot, as reflected by the valgus index,[30] calculated by pedigraphy of each foot in situ, differentiating the left foot from the right). The pedigraphy was performed using an ink pedigraph (reliability versus pressure platform obtained an intraclass correlation coefficient of 0.797–0.829[31]) with the child in a standing position, arms close to the body, and standing evenly on both feet on a flat surface, With base angle standardized by the dimensions of the pedigraph, children were asked to position one foot on the part of the pedigraph sheet that did not have the ink and then the other foot on the other part of the pedigraph. Standing upright, the vertical projections of the malleoli, peroneal and tibial were marked, with the help of the Perthes rule. The main exposure variables were BMI and age at onset of walking. The BMI was obtained by anthropometric measurements of weight and height, taking into account international standardization measures[32] and by reference to the WHO international definition, namely, overweight in the range of the 85th to the 95th percentile and obesity as greater than the 95th percentile,[6] and to the reference tables published by the Orbegozo Foundation[33] which are frequently used in primary health care by pediatricians in Spain). These measurements were obtained using electronic scales (calibrated periodically) and with the children in their underwear and without shoes. Height was measured using standard portable measuring boards.
The children’s parents or guardians were asked to complete a questionnaire on personal background related to psychomotor development of the lower limbs (performance or otherwise of crawling, age at which crawling began, age at onset of walking, and the use of mobility aids, such as a walking frame or a brace). This questionnaire was designed specifically for the study and was previously subject to expert content validity by a panel integrated by seven podiatric physicians and one expert on clinimetrics research methods. A pilot version was tested with ten parents before its definitive use in the study.
Age in months (obtained from the administrative record of each school) and sex were also identified.

Statistical Analysis

Descriptive statistics were obtained as measures of central tendency (mean, median) and of dispersion (standard deviation and interquartile range) for the quantitative variables, depending on the normal distribution of variables. This normality was verified by the Kolmogorov-Smirnov test and by estimating the skewness and kurtosis of the distributions. For the qualitative variables, an analysis of percentages was performed. Bivariate analysis was conducted using the Student t test, the Wilcoxon test, and the Mann-Whitney U test, depending on whether the variables fit a normal distribution. Finally, we conducted a logistic regression, taking as dependent variables the development of valgus deformity on each foot and as predictors the presence of overweight or obesity, together with sex and age at onset of walking. In addition, the adjusted odds ratios (ORs) were calculated for each factor. Goodness of fit was evaluated with the Hosmer-Lemeshow test. All of the analyses were conducted for a confidence level of 95% and using a statistical software program (IBM SPSS Statistics for Windows, Version 22.0; IBM Corp, Armonk, New York).

Ethical Questions

The study was approved by the Ma´laga Provincial Committee for Research Ethics. In all of the cases, the parents or guardians of the participating children were asked for written informed consent, and the data obtained were treated confidentially and anonymized. The study was conducted in accordance with the principles of the Declaration of Helsinki and its subsequent amendments.

Results

The sample consisted of 104 children (47 boys [45.2%] and 57 girls [54.8%]), with a mean ± SD age of 7.53 ± 0.89 years. According to their BMI, 14.4% of the children were overweight and 29.8% were obese. Valgus deformity was more pronounced on the right foot than on the left (42.3% and 39.4%, respectively). Table 1 details the characteristics of the sample by sex, showing that hindfoot valgus was more prevalent in the boys than in the girls, for both feet.
Table 1. General Characteristics of the 104 Study Participants. 
By BMI, the children with obesity had a higher incidence of PPVF than those with overweight. Thus, of the children with overweight, 80.5% had no valgus on the left hindfoot, whereas it was present in 19.5%, although this difference was not statistically significant (P = .182). The same was true for the right foot, with values of 77.3% and 22.7%, respectively (P = .05) (Table 1).
Regarding hindfoot valgus in children with obesity, the opposite phenomenon was observed: in the left foot, hindfoot valgus was present in 53.7% of the children and absent in the remaining 46.3% (OR, 6.94 (95% confidence interval [CI], 2.72–17.70; P < .0001). The same was true for the right foot, with values of 54.5% and 45.5%, respectively (OR, 9.08; 95% CI, 3.38–24.36; P < .0001).
Multivariate logistic regression showed an increased risk of left foot valgus in boys, in children with overweight or obesity, and in those who began to walk later (Table 2). For the right foot, the risk factors were the same except for age at onset of walking (Table 3). The goodness of fit of both models was adequate: for the left foot, v28 = 10.62 (P = .224); and for the right foot, v28 = 8.13 ( P = .421).
Table 2. Risk Factors for Valgus of the Left Foot. 
Table 3. Risk Factors for Valgus of the Right Foot. 

Discussion

The aim of this study was to analyze the presence of PPVF in children and the potential risk factors in terms of anthropometry and psychomotor development. The data obtained clearly reflect a high frequency of PPVF (nearly half of the sample), with a greater presence on the right foot and in boys, together with a significant association between overweight/obesity and valgus deformity.
In the development of the structure of children’s feet, it is necessary to take into account the influence of factors such as overweight, age, sex, race, place of residence, joint laxity, footwear, and physical activity.[16,17,18,19,20,21,24]
The results obtained show that obesity, sex, age, unilateralism, and age at onset of walking are among the factors to be considered in the presence of hindfoot valgus.
With respect to the obesity factor, the present results coincide with those of most previous studies in this context. Pfeiffer[29] studied 835 children aged 3 to 6 years and recorded a three times greater probability of PPVF in overweight children than in those with normal weight. Chen et al,[18] in a sample of 1,024 children aged 7 to 13 years, also detected a significant difference in prevalence in obese (56%) and overweight (31%) children compared with the 27% in those with normal weight. In another study, of 2,083 children aged 7 to 12 years, Chang et al[34] found PPVF prevalence values of 75%, 65%, and 57% for those with obesity, overweight, and normal weight, respectively.
However, studies performed by Evans in 2011,[35] with 140 children aged 7 to 10 years, and by Garcı´aRodrı´guez et al[28] in 1999, with 1,181 children aged 4 to 13 years, failed to detect any clear relation between these two variables. These differences between studies may be due to the heterogeneity of inclusion criteria applied and/or to variations in the study populations. If so, it would be necessary to conduct multicenter studies with homogeneous samples, if possible randomized and population-based, to establish a more definitive association between this factor and the presence of PPVF. Nevertheless, most studies do report a positive association in this respect. In our own case, the results of the regression model, showing a strong association between obesity and overweight, in both feet, after adjusting for sex, with ORs greater than 8, suggest that this relationship is more than plausible.
Regarding the relation between sex and the presence of PPVF, the present results are consistent with those of other studies that have investigated this association.[18,28,29,34,36] The differences in prevalence are generally approximately 15%, with higher values for boys than for girls, although in the present study these differences were somewhat greater.
Although the age factor is addressed in most studies, reporting an inverse relation between age and valgus,[16,21] the present results in this respect were not statistically significant. However, when the sample was divided by age into three homogeneous groups (<78 months, 78–89 months< .89 months) then for both the left and right feet there was a higher percentage of PPVF in the oldest group. Chenen et al,[21] in a longitudinal study performed with 580 children aged 3 to 6 years, found that 9.9% of children with normal feet later developed PPVF.[21] Clarification of this issue, therefore, requires further a posteriori longitudinal studies.
Another important fact to consider is that there is a statistical association between PPVF and age at onset of walking, although a weaker one than for the anthropometric parameters. Thus, children who start walking later are at greater risk for presenting PPVF at age 6 to 9 years, especially in the left foot. This aspect, too, requires longitudinal studies to be performed to determine more precisely the extent to which this association may be influenced by other confounding factors or by interaction.
Regarding the possible relationship between the presence of PPVF in terms of dominance and laterality, a factor that has received little research attention, we disagree with Wozniacka et al,[36] according to whom there is a greater prevalence in the left foot (14.5%) than in the right (8.9%). In contrast, our own data reflect a stronger prevalence in the right foot (42.3%) than in the left (39.4%). This discrepancy calls for specific analysis in further studies to investigate possible explanations for these differences in the biomechanics and functionality of gait, balance, and posture.
Finally, we acknowledge that this study has some limitations: first, its cross-sectional design did not allow us to determine precisely the causal sequence of exposure factors and outcome. Moreover, the sample population was obtained from a particular location in Spain; a broader, more international sample might present variations due to factors such as lifestyle and the level of physical activity, areas that are strongly linked to variations in cultural patterns.
Conclusions
These results corroborate the data reported in previous studies regarding the existence of an association between overweight and obesity and the onset of PPVF, but it also highlights a new risk factor: age at onset of walking. For clinical practice, these findings underline the importance of strategies to avoid overweight and obesity in early childhood as the main instrument of intervention and the need to perform early podiatric medical evaluations in this at-risk child population. The combination of these factors could help clinicians and parents focus attention on these higher-risk situations to start early preventive measures—orthopedic, manipulative, or surgical in extreme cases.

Financial Disclosure

None reported.

Conflicts of Interest

None reported.

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