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Year : 2021  |  Volume : 3  |  Issue : 1  |  Page : 46-50

Association of foot posture with lumbar lordosis angle in teachers

Departments of Community Based Rehabilitation, KAHER Institute of Physiotherapy, Belgavi, Karnataka, India

Date of Submission25-May-2019
Date of Decision11-Feb-2020
Date of Acceptance28-May-2021
Date of Web Publication31-Jul-2021

Correspondence Address:
Dr. Snehal Dharmayat
Department of Community Based Rehabilitation, KAHER Institute of Physiotherapy, Nehru Nagar, Belgavi - 590 010, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijptr.ijptr_70_19

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Context: Anatomical alteration in the alignment of the foot leads to changes in proximal joints that in turn cause mechanical variations in the spine. Changes in the lower kinematic chain can have functional consequences in the form of low back pain and may be seen in professions requiring long-standing. This is often an unexplored, under-evaluated component of low back pain and hence proves its need.
Aim: To study the relationship between ankle-foot complex and lumbar spine, and also to determine the association between Foot Posture and Lumbar Lordosis angle in teachers.
Settings and Design: Data for the observational study were collected from school and college teachers of Belagavi city.
Materials and Methods: Foot posture of 200 teachers in the age group of 20–50 years was assessed using Chippaux Index and Foot Posture Index-6 (FPI-6). Lumbar curvature was measured using Flexi curve ruler and angle was calculated. Functional limitation was assessed using Low Back Pain Rating Scale and Modified Oswestry Low Back Pain Disability Questionnaire.
Statistical Analysis Used: Spearman's rank correlation and t-test were used for analysis.
Results: Statistically significant association was noted between FPI-6, lumbar angle, Low back pain scores, and Modified Oswestry score with P = 0.0001. Gender comparison of the outcome measures did not reveal any significant relationship.
Conclusion: Alteration in foot posture leads to changes in lumbar lordosis angle, which in turn may cause low back pain.

Keywords: Chippaux index, Foot posture, Foot posture index-6, Lumbar lordosis angle, Teachers

How to cite this article:
Dharmayat S, Thakkar MP, Kolmule S. Association of foot posture with lumbar lordosis angle in teachers. Indian J Phys Ther Res 2021;3:46-50

How to cite this URL:
Dharmayat S, Thakkar MP, Kolmule S. Association of foot posture with lumbar lordosis angle in teachers. Indian J Phys Ther Res [serial online] 2021 [cited 2022 Nov 29];3:46-50. Available from: https://www.ijptr.org/text.asp?2021/3/1/46/322923

  Introduction Top

Weight of the body constantly exerts pressure on the foot, in long-standing position, which may lead to alterations in the foot and affects postural stability due to eversion observed at the foot and internal rotation of the tibia and femur.[1],[2] Prolonged standing over a period of time causes micro-trauma to the feet and leads to rotatory movement at the subtalar joint with the calcaneum moving medially and inferiorly and everting itself.[3] This causes various overuse injuries such as patellofemoral syndrome,[4] plantar fasciitis,[5] and mechanical low back pain.[6] Internal rotation of the femur leads to posterior movement of the head of the femur and shifting of the pelvis posteriorly. To maintain postural balance, trunk shifts anteriorly and so does the Centre of Mass of the body which forces the pelvis to tilt anteriorly thus increasing lumbar lordosis. A certain amount of adduction of the knees may also be seen.[1],[7] A lateral tilt of the pelvis is seen in cases of unilateral eversionof calcaneum leading to differences in the length of the lower limb which on further progression might show lumbar scoliosis.[7]

A common complaint among individuals in professions requiring long-standing hours is low back pain. On evaluation, it may not reveal any objective change in the spine but pain can persist. Hence, evaluation of the kinematic chain becomes important to rule out other factors leading to mechanical changes causing pain. Due to the demand of the profession in school and college teachers, early detection of foot posture changes becomes necessary in them to help in finding a possible link to the presence of back pain and to plan preventive/corrective measures to reduce morbidity and improve the quality of life. This study was undertaken to bridge the gap in the knowledge related to this connection between foot posture and back pain.

The objectives of the study were to evaluate foot posture using Chippaux Index and Foot Posture Index-6 (FPI-6) and lumbopelvic angle using lumbar lordosis angle in teachers and to determine the association between foot posture and lumbar lordosis with respect to presence or absence of low back pain and functional limitations, if any, as consequence of these changes.

  Materials and Methods Top

Two Hundred asymptomatic teachers (without any pre-diagnosed low back condition) in the age group of 20-50 years from primary, secondary, and higher secondary schools and from junior and professional colleges were evaluated after obtaining an ethical clearance for the protocol from the Institutional Ethical Committee. As there were no available statistics for sample size calculation, the sample was kept open-ended. Foot posture of all the teachers was examined using FPI-6[8] and Chippaux Index.[9] Lumbar lordosis angle[10],[11] was measured in standing position using Flexi curve ruler and was further calculated by plotting it on graph paper using the formula (Lordosis angle = 4 arc tan 2 h/l).[10],[11]

Visual Analog Scale (VAS), ModifiedOswestry Disability Questionnaire (MODQ),[12] and Low back Rating Scale (LBPRS)[13] were administered to study the presence and severity of back pain and functional limitation.

FPI-6 involves 6 different components, which were individually graded and the net result was documented for both feet. Palpation of the bones and tendons foot was done to grade the individuals as having supinated (−2), partial supinated (−1), neutral (0), partial pronated (1+) and pronated (2+) foot. Footprints of both feet were taken of all subjects to calculate the Chippaux index using the formula Chippaux Index = narrow area/widest area × 100. For measuring the lumbar lordosis, the subject was made to stand barefoot maintaining erect posture. The curvature obtained by placing a flexi curve ruler from the lower border of D12 to the lower border of L5 was traced on graph paper, following which its theta angle was calculated using the formula 4arctan 2 h/l. The severity of back pain was scored using the 10 cm VAS. Back endurance, physical disability and overall mobility were scored using LBPRS which has a total score of 130 with minimum score of 60 required to categorize a subject with the presence of pain and back problems. Greater the score, greater is the severity of pain. MODQ score was used to evaluate the percentage of disability an individual encounters while performing everyday activities, where a greater percentage indicates more disability.

The association between Foot Posture and Lumbar lordosis angle with presence or absence of Low Back pain was determined using Spearman's rank correlation method. Gender comparison of different variables was studied using t-test, while one-way ANOVA was used for comparing age and body mass index (BMI).

  Results Top

A total of 48 male and 152 female teachers with a mean age of 37.03 ± 8.22 years and mean BMI 25.07 ± 4.21 kg/m2 formed the sample of this study [Table 1]. Comparison of FPI-6 scores of both sides with average lumbar lordotic angle among different categories of teachers showed a strong association, P < 0.05 [Table 2]. FPI-6, LBP rating scale and Modified Oswestry score among teachers also revealed a positive correlation P < 0.05 [Table 3] and [Table 4]. LBP Rating Scale and MODQ scores, by Spearman's rank correlation method, revealed a significant relation with BMI [Table 5]. Age, years of service, no. of classes/week, and average lumbar angle showed a strong correlation between the genders with female teachers engaging more classes per week and having a greater lordotic angle than male teachers. Mean age and years of service was found to be greater in male teachers (P < 0.05) [Table 6].
Table 1: Demographic data

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Table 2: Correlation between foot posture index (right and left sides) and average lumbar angle

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Table 3: Correlation between foot posture index (right and left sides) and Low back Rating Scale scores

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Table 4: Correlation between foot posture index (right and left sides) and modified oswestry disability questionnaire scores (%)

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Table 5: Correlation between body mass index, Low back Rating Scale and modified oswestry disability questionnaire scores scores

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Table 6: Comparison of male and female teachers with mean of difference variables using t-test

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  Discussion Top

The present study aimed at evaluating an association between foot posture changes and secondary alterations in lumbar lordotic angle leading to low back pain in school and college teachers. 200 asymptomatic teachers of Belagavi city, in the age group of 20-50 years, were evaluated.

Low back pain is common complaint among individuals engaging in standing for long periods, such as teachers, due to the constant mechanical load placed on the entire lower extremity and spine for prolonged periods of time. Any deviations/alterations in any one component of the lower kinematic chain can cause secondary alignment changes in the higher components leading to structural and functional deviations and finally causing pain and disability. This leads to loss of working days, low productivity and also poor quality of life.

A study on 56 subjects in the age group of 18-40 years for evaluating pelvic tilting associated with flat foot revealed that the presence of bilateral or unilateral flat foot causes anterior pelvic tilting and lateral pelvic tilting, respectively, which is more significant in the sagittal plane.[14] Similar correlation between pronated foot and changes in lumbar spine curvature was also noted in our study population.

Pronation of the foot causes an increased anterior pelvic tilt as demonstrated in a study on bilaterally induced hyperpronation of the foot using medially tilted wedges causing an increase of the anterior pelvic tilt and calcaneal eversion inclination in healthy subjects.[1] A similar trend was seen in this study with 75% of the teachers with pronated foot reported having low back pain.

Nonneutral postures can occur due to changes in the foot alignment secondarily causing spinal curvature alterations which, in the long run, could lead to the presence of low back pain and functional disability as reported by Smith A et al.[15] due to the changes in mechanical loading on the spine.

Alteration of the medial longitudinal arch leads to changes in lumbar curvature, where women with collapsed arch were commonly found to have an increased lumbar curvature and lumbar arch leading to low back pain.[16] The plantar arch position was not evaluated in our study, but it was noted that the presence of pronated foot was greater in female teachers who also demonstrated an increased lumbar lordosis and the presence of low back pain.

Standing for long hours to teach can cause micro-trauma to the feet, alteration at the subtalar joint and calcaneum. The teachers in our study, mainly secondary school and preuniversity teachers, showed foot posture deviations and associated changes in the lumbar spine along with pain. This could probably be due to longer duration and a greater number of teaching hours engaged by them as compared to other categories included in the study. Female teachers demonstrated more changes in the lumbar spine as compared to the male which could be because the female teachers in our sample engaged a greater number of classes.

The results of this study indicate that assessment of foot posture is important and necessary in an individual with the complaint of low back pain, especially in professions requiring standing for long hours. This component should be looked into to provide better management of the pain in the long run.

Generalization of results with respect to category and gender of teachers was not possible due to unequal distribution. The teachers from schools and colleges were not available at a single point of time, as they were either engaged in class or on leave, which is a limitation of the study. Entire lower extremity kinematic chain analysis to study the influence of each component on the spine and use of objective methods of lumbar lordosis measurement like radiographs may be used for better quantification.

  Conclusion Top

Foot posture changes lead to changes in the lumbar spine curvature in teachers. Lumbar curvature changes are associated with low back pain. Foot posture assessment should be included as a necessary component in the evaluation of an individual presenting with low back pain and a related occupational history of prolonged standing.


The authors would to thank the participants for their participation and the statistician for data analysis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Khamis S, Yizhar Z. Effect of feet hyper pronation on pelvic alignment in a standing position. Gait Posture 2007;25:127-34.  Back to cited text no. 1
Cote KP, Brunet ME, Gansneder BM, Shultz SJ. Effects of pronated and supinated foot postures on static and dynamic postural stability. J Athl Train 2005;40:41-6.  Back to cited text no. 2
Duval K, Lam T, Sanderson D. The mechanical relationship between the rearfoot, pelvis and low-back. Gait Posture 2010;32:637-40.  Back to cited text no. 3
Clement DB, Taunton JE, Smart GW, McNicol KL. A survey of overuse running injuries. Phys Sportsmed 1981;9:47-58.  Back to cited text no. 4
Schepsis AA, Leach RE, Gorzyca J. Plantar fasciitis. Etiology, treatment, surgical results, and review of the literature. Clin Orthop Relat Res 1991; (266):185-96.  Back to cited text no. 5
Dananberg HJ, Guiliano M. Chronic low-back pain and its response to custom-made foot orthoses. J Am Podiatr Med Assoc 1999;89:109-17.  Back to cited text no. 6
Eldesoky MT, Abutaleb EE. Influence of bilateral and unilateral flatfoot on pelvic alignment. Int J Innov Res Sci Eng Technol 2015;9:641-5.  Back to cited text no. 7
Redmond AC. Foot Posture in Neuromuscular Disease: Development and Evaluation of a Novel Method for Quantifying Changes in Foot Posture Using Charcot-Marine-Tooth Disease as a Clinical Model. University of Sydney; [dissertation on the Internet]. University of Sydney; 2004 [cited 2018 Nov 22]. Available from: https://eprints.whiterose.ac.uk/4808/12/redmonda1.pdf.  Back to cited text no. 8
Tománková K, Přidalová M, Gába A. The impact of obesity on foot morphology in women aged 48 years or older. Acta Gymnica 2015;45:69-75.  Back to cited text no. 9
Azadinia F, Kamyab M, Behtash H, Ganjavian MS, Javaheri MR. The validity and reliability of non-invasive methods of measuring kyphosis. Clin Spine Surg 2014;27:E212-8.  Back to cited text no. 10
Lin RM, Jou IM, Yu CY. Lumbar lordosis: Normal adults. J Formos Med Assoc 1992;91:329-33.  Back to cited text no. 11
Fairbank JC, Couper J, Davies JB, O'Brien JP. The Oswestry low back pain disability questionnaire. Physiotherapy 1980;66:271-3.  Back to cited text no. 12
Manniche C, Asmussen K, Lauritsen B, Vinterberg H, Kreiner S, Jordan A. Low Back Pain Rating scale: Validation of a tool for assessment of low back pain. Pain 1994;57:317-26.  Back to cited text no. 13
Abdel-Raoof N, Kamel D, Tantawy S. Influence of second-degree flatfoot on spinal and pelvic mechanics in young females. Int J Ther Rehabil 2013;20:428-34.  Back to cited text no. 14
Smith A, O'Sullivan P, Straker L. Classification of sagittal thoraco-lumbo-pelvic alignment of the adolescent spine in standing and its relationship to low back pain. Spine (Phila Pa 1976) 2008;33:2101-7.  Back to cited text no. 15
Borges Cdos S, Fernandes LF, Bertoncello D. Relationship between lumbar changes and modifications in the plantar arch in women with low back pain. Acta Ortop Bras 2013;21:135-8.  Back to cited text no. 16


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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