Effect of Foot Type on Plantar Pressure Distribution in Healthy Mexicans: Static and Dynamic Pressure Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

 

Objective of the Study and Research Question

The authors clearly state that the main objective of their work is to determine the effect of foot type (normal, flat, high) on plantar pressure distribution in healthy Mexicans aged 3–74 years. To do this, they analyze pressure in a static position and during walking. Thus, the research question comes down to how foot morphology (several types) is related to pressure distribution under different conditions. The question is justified in the text itself: “The main objective was to determine the effect of foot type … on plantar pressure distribution in healthy Mexicans … under static and dynamic conditions.” The authors also put forward two hypotheses (age affects foot type, and age affects pressure distribution), which demonstrates a systematic approach to the question.

Relevance and novelty of the topic

Studying the distribution of plantar pressure is an important task in clinical practice: it helps to identify predisposition to lower limb injuries, evaluate orthopedic disorders and the effectiveness of orthopedic insoles. The introduction of the work emphasizes that abnormal foot shape and altered plantar pressure are considered as risk factors for lower limb injuries. In this context, knowledge of the normal pressure distribution in healthy people of different ages and foot types is of practical value for podiatrists and rehabilitation specialists.

However, a review of the literature shows that most previous studies were limited to narrow groups (e.g., children, athletes, diabetics). The authors correctly note that "there are no studies on the dependence of pressure distribution on foot type in the population from early childhood to adulthood." There is a large study by McKay et al. (2017) [McKay MJ, Baldwin JN, Ferreira P, et al. Spatiotemporal and plantar pressure patterns of 1000 healthy individuals aged 3–101 years. Gait Posture. 2017;58:78–87.], where they collected data on 1000 healthy people aged 3–101 years, but they did not analyze the effect of foot type. Similar studies in other countries (e.g. Miguel-Andrés et al. 2021 [Miguel-Andrés I, Mayagoitia-Vázquez JJ, Orozco-Villaseñor SL, et al. Efecto de la morfología de las plantas de los pies en la distribución de presión plantar en atletas jóvenes. Fisioterapia. 2021;43:30–37.] - a study of young athletes with different feet) either do not cover the entire age range or focus on specific groups. In this sense, the work is new: it expands the understanding of the influence of foot type on pressure distribution specifically in the general healthy population.

As for other studies, related results were obtained by Mohd Said et al. (2016) [https://doi.org/10.1155/2016/8564020]: they examined elderly (∼70 years) and showed that in a pronate foot (free heel "inward") the maximum pressure in the forefoot was significantly lower than in a supinated foot. Chuckpaiwong et al. (2008) [Chuckpaiwong B, Nunley JA, Mall NA, Queen RM. The effect of foot type on in-shoe plantar pressure during walking and running. Gait Posture. 2008;28:405–11.] compared normal and flat feet in young people and found a significant effect of foot type on the force characteristics in the midfoot during walking and running. Buldt et al. (2018) [Buldt AK, Allan JJ, Landorf KB, Menz HB. The relationship between foot posture and plantar pressure during walking in adults: A systematic review. Gait Posture. 2018;62:56–67.]in a systematic review found that "flat valgus" (planus) feet are characterized by increased pressure in the medial part of the foot and the forefoot, and "cave" feet - in the heel and lateral part of the foot. This supports the idea that there are differences between foot types, but the review notes that foot type explains only a small portion of the pressure variance. Despite this, there are far fewer such studies than are needed to generalize, so the relevance of the topic and its novelty are supported by the lack of uniform data for the large Mexican sample.

How this work differs from previous ones

The article differs in the scale and design of the study. Firstly, a huge data set was used: 996 subjects aged 3–74 years (53.9% women), which significantly exceeds the number of subjects in most studies on foot biomechanics. Secondly, all three types of feet (normal, flat, cavus) are taken into account simultaneously, while many studies only compared flat feet with normal feet. Thirdly, the analysis is carried out for two conditions – static load (standing) and dynamic (walking). Many previous works are limited to either static or walking.

Methodologically, we highlight the use of the Chippaux-Smirak Index (CSI) for classifying foot type. This imprint index is easier to use than, for example, the Foot Posture Index or radiographic methods. The authors cite that the CSI has proven its reliability. In addition, they use a high-precision Sensormedica baropodometer and FreeStep software to obtain volumetric pressure maps and foot scans. Such complex data collection (foot images + numerical pressure indicators) in a given population is an innovation of this work. Finally, statistical analysis with a factorial ANOVA design (taking into account the factors: foot type, foot part, static/dynamic condition and age as a block) allowed for a deeper decomposition of the influence of factors. Such multivariate analysis in the context of this issue is rare in the literature.

Thus, the work is unique in its combination of a wide age range, a large sample and a complex approach (statics + dynamics + CSI classification + modern statistics). This significantly expands the specifics of the study compared to previous publications.

Assessment of the methodology: Despite the advantages, some limitations can be noted. The convenience selection may introduce bias (e.g., may underrepresent certain population groups). No mention is made of the interrater reliability of the foot scans (but it is stated that the tests were performed by an experienced physiotherapist). The pressure analysis only differentiates two segments of the foot (forefoot and hindfoot), whereas the CSI footprints consider the midfoot. Forefoot/hindfoot averaging divides the pressure proportion into two parts, but many studies also differentiate the midfoot. Including the midfoot would provide a more complete picture. In addition, walking speeds vary significantly by age (Table 1), and speed itself influences foot pressures. This factor should be controlled (e.g., by analyzing speed as a covariate or standardizing walking). In statics, it is unclear whether the result was averaged over several measurements or taken from a single image - it would be worth clarifying and ensuring several repetitions. The classification of foot type by CSI is simple and non-destructive, but it could be further compared with other scales (e.g. Foot Posture Index) to check for reliability. Finally, the analysis considers data for each foot separately, not taking into account possible asymmetry within an individual (if a person has one flat foot and one normal foot, how is this accounted for in the ANOVA?).

Conclusion: Novelty and Significance of the Article

This article provides new information on how foot type and age affect plantar pressure in a wide sample of healthy individuals. The results show that the proportion of flat feet decreases significantly with age (from ~80–89% in children to ~16–19% in the elderly), while the proportion of normal feet increases. This is confirmed by regression analysis (low p-value and high R² for the proportion depending on age). As for the pressure distribution, the authors found a typical result: when standing statically, the heel takes on more weight (~54–56% on the heel vs. 44–46% on the forefoot), while when walking, the opposite is true (forefoot ~56–57% vs. 43–44% on the heel). Interestingly, this difference is smoothed out with age in statics (in older groups, the loads are more evenly distributed), while when walking, the difference remains approximately constant.

Comparison with other studies: In general, these findings are consistent with the data of Buldt et al. (2018), who also showed increased pressure at the forefoot in planus feet and at the heel in cavus feet. However, in Buldt, the altruism of the effect was moderate. Our authors found that in the ANOVA analysis, the direct effect of foot type on the overall pressure distribution was statistically insignificant (p=1.000, SS=0), although the interactions “foot type × section” gave a weak p<0.05. This is consistent with the idea that foot morphology affects local pressure characteristics (as in the thoughts of the systematic review), but when normalized for body weight in percent, these differences are insignificant.

Overall, the article is quite novel: the combination of a broad age cohort, number of participants, and consideration of static and dynamic data is a rare combination in the literature. The results complement existing knowledge of foot biomechanics and can serve as a starting point for clinicians and researchers when comparing with pathological cases or when developing orthoses. The improvements suggested above will only make the conclusions even more convincing.

Author Response

Manuscript ID: Physiologia-3828179

Thanks for reviewing the manuscript entitled “Effect of foot type on plantar pressure distribution in healthy Mexicans: Static and dynamic pressure analysis”. We sincerely appreciate the comments that allow us to improve the article.

We have carefully attended to each comment made, so we proceed to send the manuscript again for review. The observations made and the responses by the authors are described below. We hope that the modifications made will achieve the final approval of the manuscript. Thanks in advance.

 

Kind Regards,

The authors

 

*************************************************************************

Reviewer 1

*************************************************************************

Dear Reviewer, thank you very much for revising our manuscript. We sincerely appreciate your comments. We have made some changes according to your suggestions to improve the quality of the document. Please find below the responses to each commentary made. 

 

Objective of the Study and Research Question

The authors clearly state that the main objective of their work is to determine the effect of foot type (normal, flat, high) on plantar pressure distribution in healthy Mexicans aged 3–74 years. To do this, they analyze pressure in a static position and during walking. Thus, the research question comes down to how foot morphology (several types) is related to pressure distribution under different conditions. The question is justified in the text itself: “The main objective was to determine the effect of foot type … on plantar pressure distribution in healthy Mexicans … under static and dynamic conditions.” The authors also put forward two hypotheses (age affects foot type, and age affects pressure distribution), which demonstrates a systematic approach to the question.

Thank you for your comments.

 

Relevance and novelty of the topic

Studying the distribution of plantar pressure is an important task in clinical practice: it helps to identify predisposition to lower limb injuries, evaluate orthopedic disorders and the effectiveness of orthopedic insoles. The introduction of the work emphasizes that abnormal foot shape and altered plantar pressure are considered as risk factors for lower limb injuries. In this context, knowledge of the normal pressure distribution in healthy people of different ages and foot types is of practical value for podiatrists and rehabilitation specialists.

Thank you for your comments.

 

However, a review of the literature shows that most previous studies were limited to narrow groups (e.g., children, athletes, diabetics). The authors correctly note that "there are no studies on the dependence of pressure distribution on foot type in the population from early childhood to adulthood." There is a large study by McKay et al. (2017) [McKay MJ, Baldwin JN, Ferreira P, et al. Spatiotemporal and plantar pressure patterns of 1000 healthy individuals aged 3–101 years. Gait Posture. 2017;58:78–87.], where they collected data on 1000 healthy people aged 3–101 years, but they did not analyze the effect of foot type. Similar studies in other countries (e.g. Miguel-Andrés et al. 2021 [Miguel-Andrés I, Mayagoitia-Vázquez JJ, Orozco-Villaseñor SL, et al. Efecto de la morfología de las plantas de los pies en la distribución de presión plantar en atletas jóvenes. Fisioterapia. 2021;43:30–37.] - a study of young athletes with different feet) either do not cover the entire age range or focus on specific groups. In this sense, the work is new: it expands the understanding of the influence of foot type on pressure distribution specifically in the general healthy population.

Thank you for your comments.

 

As for other studies, related results were obtained by Mohd Said et al. (2016) [https://doi.org/10.1155/2016/8564020]: they examined elderly (∼70 years) and showed that in a pronate foot (free heel "inward") the maximum pressure in the forefoot was significantly lower than in a supinated foot. Chuckpaiwong et al. (2008) [Chuckpaiwong B, Nunley JA, Mall NA, Queen RM. The effect of foot type on in-shoe plantar pressure during walking and running. Gait Posture. 2008;28:405–11.] compared normal and flat feet in young people and found a significant effect of foot type on the force characteristics in the midfoot during walking and running. Buldt et al. (2018) [Buldt AK, Allan JJ, Landorf KB, Menz HB. The relationship between foot posture and plantar pressure during walking in adults: A systematic review. Gait Posture. 2018;62:56–67.]in a systematic review found that "flat valgus" (planus) feet are characterized by increased pressure in the medial part of the foot and the forefoot, and "cave" feet - in the heel and lateral part of the foot. This supports the idea that there are differences between foot types, but the review notes that foot type explains only a small portion of the pressure variance. Despite this, there are far fewer such studies than are needed to generalize, so the relevance of the topic and its novelty are supported by the lack of uniform data for the large Mexican sample.

Thank you for your comments.

 

How this work differs from previous ones

The article differs in the scale and design of the study. Firstly, a huge data set was used: 996 subjects aged 3–74 years (53.9% women), which significantly exceeds the number of subjects in most studies on foot biomechanics. Secondly, all three types of feet (normal, flat, cavus) are taken into account simultaneously, while many studies only compared flat feet with normal feet. Thirdly, the analysis is carried out for two conditions – static load (standing) and dynamic (walking). Many previous works are limited to either static or walking.

Thank you for your comments.

 

Methodologically, we highlight the use of the Chippaux-Smirak Index (CSI) for classifying foot type. This imprint index is easier to use than, for example, the Foot Posture Index or radiographic methods. The authors cite that the CSI has proven its reliability. In addition, they use a high-precision Sensormedica baropodometer and FreeStep software to obtain volumetric pressure maps and foot scans. Such complex data collection (foot images + numerical pressure indicators) in a given population is an innovation of this work. Finally, statistical analysis with a factorial ANOVA design (taking into account the factors: foot type, foot part, static/dynamic condition and age as a block) allowed for a deeper decomposition of the influence of factors. Such multivariate analysis in the context of this issue is rare in the literature.

Thank you for your comments.

 

Thus, the work is unique in its combination of a wide age range, a large sample and a complex approach (statics + dynamics + CSI classification + modern statistics). This significantly expands the specifics of the study compared to previous publications.

Thank you for your comments.

 

Assessment of the methodology: Despite the advantages, some limitations can be noted. The convenience selection may introduce bias (e.g., may underrepresent certain population groups). No mention is made of the interrater reliability of the foot scans (but it is stated that the tests were performed by an experienced physiotherapist). The pressure analysis only differentiates two segments of the foot (forefoot and hindfoot), whereas the CSI footprints consider the midfoot. Forefoot/hindfoot averaging divides the pressure proportion into two parts, but many studies also differentiate the midfoot. Including the midfoot would provide a more complete picture. In addition, walking speeds vary significantly by age (Table 1), and speed itself influences foot pressures. This factor should be controlled (e.g., by analyzing speed as a covariate or standardizing walking). In statics, it is unclear whether the result was averaged over several measurements or taken from a single image - it would be worth clarifying and ensuring several repetitions. The classification of foot type by CSI is simple and non-destructive, but it could be further compared with other scales (e.g. Foot Posture Index) to check for reliability. Finally, the analysis considers data for each foot separately, not taking into account possible asymmetry within an individual (if a person has one flat foot and one normal foot, how is this accounted for in the ANOVA?).

Thank you for your observations. Please find below the answer to address each point:

1. We acknowledge the relevance of differentiating the midfoot. However, in our current dataset and methodology, we focused on forefoot and hindfoot segmentation to maintain consistency with similar studies. We will consider the whole plantar pressure region in future studies.
2. We agree that walking speed can vary across different age groups. However, our objective was to measure plantar pressure in a natural walking pattern without imposing a fixed speed, particularly in adult and elderly participants. As it can be seen in Table 1, elderly people tend to decrease the velocity.
3. Plantar pressure in static conditions was measured for 10 seconds, and the reported results were averaged. We clarified this in the methods section of the manuscript.
4. Thank you for your valuable comment. We agree that comparing the CSI classification with other scales, such as the Foot Posture Index, could provide additional information on reliability. While this comparison was beyond the scope of the current study, we have acknowledged it as a limitation and suggested it as a direction for future research.
5. Thank you for your observation. We acknowledge that analyzing each foot separately does not account for possible asymmetry within individuals. In our study, each foot was treated as an independent observation for the ANOVA analysis. Future studies should be done considering this variable.

 

Conclusion: Novelty and Significance of the Article

This article provides new information on how foot type and age affect plantar pressure in a wide sample of healthy individuals. The results show that the proportion of flat feet decreases significantly with age (from ~80–89% in children to ~16–19% in the elderly), while the proportion of normal feet increases. This is confirmed by regression analysis (low p-value and high R² for the proportion depending on age). As for the pressure distribution, the authors found a typical result: when standing statically, the heel takes on more weight (~54–56% on the heel vs. 44–46% on the forefoot), while when walking, the opposite is true (forefoot ~56–57% vs. 43–44% on the heel). Interestingly, this difference is smoothed out with age in statics (in older groups, the loads are more evenly distributed), while when walking, the difference remains approximately constant.

Thank you for your comments.

 

Comparison with other studies: In general, these findings are consistent with the data of Buldt et al. (2018), who also showed increased pressure at the forefoot in planus feet and at the heel in cavus feet. However, in Buldt, the altruism of the effect was moderate. Our authors found that in the ANOVA analysis, the direct effect of foot type on the overall pressure distribution was statistically insignificant (p=1.000, SS=0), although the interactions “foot type × section” gave a weak p<0.05. This is consistent with the idea that foot morphology affects local pressure characteristics (as in the thoughts of the systematic review), but when normalized for body weight in percent, these differences are insignificant.

Thank you for your comments.

 

Overall, the article is quite novel: the combination of a broad age cohort, number of participants, and consideration of static and dynamic data is a rare combination in the literature. The results complement existing knowledge of foot biomechanics and can serve as a starting point for clinicians and researchers when comparing with pathological cases or when developing orthoses. The improvements suggested above will only make the conclusions even more convincing.

Thank you very much for reviewing our manuscript. We sincerely appreciate your comments. We have made some changes according to your suggestions to improve the quality of the document.

Reviewer 2 Report

Comments and Suggestions for Authors

The article presents relevant data regarding the plantar pressure and foot type in a 996 participants.

I have several comments.

Introduction.

• Replace palliative treatment with a more accurate term.
• I do not see a relevance of the exposure to ionizing radiation for the current research.

Results

• Replace the statement upper/lower corner of the graph with more scientific data (lines 242-253).
• Statistical results of the type of feet. What are the p values? The same observation for Table 2. 

Author Response

Manuscript ID: Physiologia-3828179

Thanks for reviewing the manuscript entitled “Effect of foot type on plantar pressure distribution in healthy Mexicans: Static and dynamic pressure analysis”. We sincerely appreciate the comments that allow us to improve the article.

We have carefully attended to each comment made, so we proceed to send the manuscript again for review. The observations made and the responses by the authors are described below. We hope that the modifications made will achieve the final approval of the manuscript. Thanks in advance.

 

Kind Regards,

The authors

 

*************************************************************************

Reviewer 2

*************************************************************************

Dear Reviewer, thank you very much for revising our manuscript. We sincerely appreciate your comments. We have made some changes according to your suggestions to improve the quality of the document. Please find below the responses to each commentary made. 

The article presents relevant data regarding the plantar pressure and foot type in a 996 participants.

I have several comments.

 

Introduction.

Replace palliative treatment with a more accurate term.

Thanks for your suggestion, the phrase “palliative treatment” was replaced by “conservative treatment”.

 

I do not see a relevance of the exposure to ionizing radiation for the current research.

Thank you for your comment. While we understand your concern, we consider that the mention of ionizing radiation is relevant, as it provides context regarding potential risks associated with the classification of the type of feet. Therefore, we have clarified its role in the manuscript to better highlight its connection to the current research.

 

Results

Replace the statement upper/lower corner of the graph with more scientific data (lines 242-253).

Thanks for your comments. We have replaced it with more accurate scientific data, specifically indicating the values on the axes to describe the position in the graph.

 

Statistical results of the type of feet. What are the p values? The same observation for Table 2.

Thanks for your comments. The p-values are included within the text; they contribute to determining if there is a significant change in the number of people for each foot type over time. In addition, the p-values in Table 2 identify the significant factors of the analysis.

Reviewer 3 Report

Comments and Suggestions for Authors

General Impression 

This study examined foot type and plantar pressure distribution under both static and dynamic conditions in 996 Mexican participants aged 3 to 74 years. The main findings are: 

1. The prevalence of flatfoot decreased with age, while the proportion of normal foot type increased.
2. Under static conditions, the hindfoot bore more load than the forefoot, whereas under dynamic conditions, the forefoot bore more load than the hindfoot. The static load discrepancy decreased with age, but the dynamic load pattern remained unchanged. 

Overall, the manuscript is well-written. However, the Results and Conclusion sections of the abstract, as well as the Conclusion in the main text, do not adequately reflect these key findings. This is the primary concern. 

Abstract 

The Results and Conclusion sections omit some of the study’s main findings. Please revise them to accurately reflect the core outcomes. 

Introduction 

No specific comments. 

Materials and Methods 

No specific comments. 

Discussion 

No specific comments. 

Conclusion 

The Conclusion section does not sufficiently capture the main findings. Please revise it to clearly reflect the study’s key results. 

Author Response

Manuscript ID: Physiologia-3828179

Thanks for reviewing the manuscript entitled “Effect of foot type on plantar pressure distribution in healthy Mexicans: Static and dynamic pressure analysis”. We sincerely appreciate the comments that allow us to improve the article.

We have carefully attended to each comment made, so we proceed to send the manuscript again for review. The observations made and the responses by the authors are described below. We hope that the modifications made will achieve the final approval of the manuscript. Thanks in advance.

 

Kind Regards,

The authors

 

*************************************************************************

Reviewer 3

*************************************************************************

Dear Reviewer, thank you very much for revising our manuscript. We sincerely appreciate your comments. We have made some changes according to your suggestions to improve the quality of the document. Please find below the responses to each commentary made. 

General Impression

This study examined foot type and plantar pressure distribution under both static and dynamic conditions in 996 Mexican participants aged 3 to 74 years. The main findings are:

1. The prevalence of flatfoot decreased with age, while the proportion of normal foot type increased.
2. Under static conditions, the hindfoot bore more load than the forefoot, whereas under dynamic conditions, the forefoot bore more load than the hindfoot. The static load discrepancy decreased with age, but the dynamic load pattern remained unchanged.

Overall, the manuscript is well-written. However, the Results and Conclusion sections of the abstract, as well as the Conclusion in the main text, do not adequately reflect these key findings. This is the primary concern.

Thank you for your constructive comment. We appreciate your feedback regarding the abstract and conclusion sections. In response, we have revised the Results and Conclusion in the abstract, as well as the Conclusion in the main text, to more accurately and clearly reflect the key findings of our study.

 

Abstract

The Results and Conclusion sections omit some of the study’s main findings. Please revise them to accurately reflect the core outcomes.

Thank you for your comment. We have carefully revised the Results and Conclusion sections of both the abstract and the main text to ensure that all the core outcomes of the study are accurately and clearly presented.

 

Introduction

No specific comments.

 

Materials and Methods

No specific comments.

 

Discussion

No specific comments.

 

Conclusion

The Conclusion section does not sufficiently capture the main findings. Please revise it to clearly reflect the study’s key results.

Thank you for your observation. We have revised the Conclusion section to clearly and accurately reflect the key results and main findings of the study.

Reviewer 4 Report

Comments and Suggestions for Authors

The manuscript presents an interesting and well-structured study on the effect of foot type on plantar pressure distribution in a large Mexican population, covering both static and dynamic conditions across a wide age range. The sample size is robust, the methodology is clearly described, and the statistical analyses (linear regression and factorial ANOVA) are appropriate and well executed. The inclusion of nearly one thousand participants provides valuable normative data, which can serve as a reference for clinicians, podiatrists, and physiotherapists. The findings are consistent with previous reports, confirming the higher prevalence of flatfoot in childhood and its reduction with age, as well as the redistribution of plantar pressures between forefoot and hindfoot depending on the condition.

However, there are several aspects that could be improved to strengthen the manuscript. First, the originality of the results is somewhat limited, as many of the conclusions are in line with previous studies. It would be helpful if the authors emphasized more clearly the novel contributions of their work, for instance the generation of a comprehensive normative database specific to the Mexican population or the combined evaluation of age, foot type, and pressure distribution. Second, the classification of foot types relied exclusively on the Chippaux-Smirak Index, which, while reliable, may introduce bias. This limitation is acknowledged, but a deeper discussion of its implications is encouraged. Third, the role of BMI is underdeveloped: although BMI data were collected, they were not fully explored in the analysis. Given the known influence of body mass on plantar pressures, at least a descriptive comparison or further discussion would add value.

The discussion could also benefit from a stronger connection with clinical implications. In particular, it would be useful to integrate references to recent literature on diabetic foot biomechanics, Charcot neuro-osteoarthropathy, and predictors of amputation risk, as these conditions are strongly linked to abnormal plantar loading and highlight the translational value of establishing normative databases (PMID: 36769345 - PMID: 40150109 - PMID: 39767688). Expanding this section would make the manuscript more relevant for clinicians and reinforce its practical significance.

The manuscript is overall well written, though the English language could be further polished to improve fluency and reduce redundancy. Figures and tables are clear and support the results appropriately. The limitations are acknowledged, but could be expanded further to reinforce transparency and critical appraisal.

In summary, this is a solid and relevant contribution that addresses an important topic in biomechanics and clinical assessment. I consider the study suitable for publication after minor revisions, particularly focusing on clarifying the novelty, improving the discussion of BMI and clinical implications, and refining the language.

Comments on the Quality of English Language

The English language is generally adequate, but there are areas that would benefit from editing. In particular, some sentences are overly long and could be shortened for clarity; there are occasional redundancies (e.g., “plantar pressure distribution tends to equalize with age” repeated in several sections), and a few expressions are not idiomatic. A professional language editing service is recommended.

Author Response

Manuscript ID: Physiologia-3828179

Thanks for reviewing the manuscript entitled “Effect of foot type on plantar pressure distribution in healthy Mexicans: Static and dynamic pressure analysis”. We sincerely appreciate the comments that allow us to improve the article.

We have carefully attended to each comment made, so we proceed to send the manuscript again for review. The observations made and the responses by the authors are described below. We hope that the modifications made will achieve the final approval of the manuscript. Thanks in advance.

 

Kind Regards,

The authors

 

*************************************************************************

Reviewer 4

*************************************************************************

Dear Reviewer, thank you very much for revising our manuscript. We sincerely appreciate your comments. We have made some changes according to your suggestions to improve the quality of the document. Please find below the responses to each commentary made. 

The manuscript presents an interesting and well-structured study on the effect of foot type on plantar pressure distribution in a large Mexican population, covering both static and dynamic conditions across a wide age range. The sample size is robust, the methodology is clearly described, and the statistical analyses (linear regression and factorial ANOVA) are appropriate and well executed. The inclusion of nearly one thousand participants provides valuable normative data, which can serve as a reference for clinicians, podiatrists, and physiotherapists. The findings are consistent with previous reports, confirming the higher prevalence of flatfoot in childhood and its reduction with age, as well as the redistribution of plantar pressures between forefoot and hindfoot depending on the condition.

Thank you for your positive and encouraging feedback. We appreciate your recognition of the robustness of the sample, the clarity of the methodology, and the relevance of the findings. We are glad that our study can contribute valuable normative data for clinicians and researchers.

 

However, there are several aspects that could be improved to strengthen the manuscript. First, the originality of the results is somewhat limited, as many of the conclusions are in line with previous studies. It would be helpful if the authors emphasized more clearly the novel contributions of their work, for instance the generation of a comprehensive normative database specific to the Mexican population or the combined evaluation of age, foot type, and pressure distribution. Second, the classification of foot types relied exclusively on the Chippaux-Smirak Index, which, while reliable, may introduce bias. This limitation is acknowledged, but a deeper discussion of its implications is encouraged. Third, the role of BMI is underdeveloped: although BMI data were collected, they were not fully explored in the analysis. Given the known influence of body mass on plantar pressures, at least a descriptive comparison or further discussion would add value.

Thank you for your thoughtful and constructive comments. We appreciate your suggestions to strengthen the manuscript. In response:

1. We have revised the Discussion and Conclusion sections to more clearly highlight the novel contributions of our study, specifically the generation of a large normative database specific to the Mexican population and the combined evaluation of age, foot type, and pressure distribution.
2. Regarding the classification of foot types, we acknowledge the limitation of relying exclusively on the Chippaux–Smirak Index. We have expanded the discussion on the potential biases of this method and its implications for interpretation, while also noting its widespread use and practicality in large-scale studies.
3. We agree that BMI plays an important role in plantar pressure distribution. However, the comparison of BMI across groups was beyond the scope of this study.

 

The discussion could also benefit from a stronger connection with clinical implications. In particular, it would be useful to integrate references to recent literature on diabetic foot biomechanics, Charcot neuro-osteoarthropathy, and predictors of amputation risk, as these conditions are strongly linked to abnormal plantar loading and highlight the translational value of establishing normative databases (PMID: 36769345 - PMID: 40150109 - PMID: 39767688). Expanding this section would make the manuscript more relevant for clinicians and reinforce its practical significance.

Thank you for this valuable suggestion. We agree that a stronger connection with clinical implications will improve the relevance of the discussion. We have expanded this section by integrating references to recent literature on diabetic foot biomechanics, Charcot neuro-osteoarthropathy, and predictors of amputation risk.

 

The manuscript is overall well written, though the English language could be further polished to improve fluency and reduce redundancy. Figures and tables are clear and support the results appropriately. The limitations are acknowledged, but could be expanded further to reinforce transparency and critical appraisal.

In summary, this is a solid and relevant contribution that addresses an important topic in biomechanics and clinical assessment. I consider the study suitable for publication after minor revisions, particularly focusing on clarifying the novelty, improving the discussion of BMI and clinical implications, and refining the language.

The English language is generally adequate, but there are areas that would benefit from editing. In particular, some sentences are overly long and could be shortened for clarity; there are occasional redundancies (e.g., “plantar pressure distribution tends to equalize with age” repeated in several sections), and a few expressions are not idiomatic. A professional language editing service is recommended.

Thank you for your positive evaluation and constructive feedback. We appreciate your recognition of the relevance of our study. We have carefully revised the manuscript to improve the clarity, novelty, and readability of the English. Long sentences were shortened, redundancies were removed, and non-idiomatic expressions were corrected. We believe the revised version is clearer and more concise. Furthermore, the manuscript was sent for grammatical revision and fluency at the Center for English Learners. A certificate letter for English revision is attached.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

The issues I highlighted in my previous review have been thoroughly resolved, and I have no further concerns. I recommend that this paper be accepted.