ORIGINAL ARTICLES

The Relationship Between Arch Height and Arch Flexibility

A Proposed Arch Flexibility Classification System for the Description of
Multidimensional Foot Structure
Rebecca Avrin Zifchock, PhD*
Christal Theriot, BS†
Howard J. Hillstrom, PhD‡
Jinsup Song, PhD§
Michael Neary, DPMjj

Background: The correlation between arch structure and injury may be related to the
fact that foot structure influences foot function. Foot structure is often defined by arch
height, although arch flexibility may be just as important to form a more complete
description. We propose an arch flexibility classification system, analogous to arch
height classification, and then use the classification system to examine the relationship
between arch flexibility and arch height.
Methods: Arch height index was calculated in 1,124 incoming military cadets, of whom 1,056
had usable data. By measuring arch height during both sitting and standing, a measurement of
arch flexibility could also be calculated. These values were used to create five arch flexibility
categories: very stiff, stiff, neutral, flexible, and very flexible. The distribution of arch flexibility
types among arch height categories was statistically compared.
Results: The goodness of fit test showed a disproportionate number of each arch
flexibility type in each of the arch height categories (P , .01). The largest proportion of
cavus feet was very stiff and the smallest proportion was very flexible. Conversely, the
largest proportion of planus feet was very flexible and the smallest proportion was very
stiff.
Conclusions: The results of this research support the common belief that cavus feet
tend to be very stiff and planus feet tend to be very flexible. (J Am Podiatr Med Assoc
107(2): 119-123, 2017)

Foot and ankle injuries are the number one
performance-inhibiting injury for soldiers.1 Wallace
et al1 found that ankle and foot injuries are a major
cause of active-duty Army soldiers’ time lost from
training and combat operations. Previous literature
suggests that there is a relationship between foot
structure and injury patterns. In a population of
*Department of Civil and Mechanical Engineering, United
States Military Academy, West Point, NY.
†United States Military Academy, West Point, NY.
‡Motion Analysis Laboratory, Hospital for Special Surgery,
New York, NY.
§Temple University School of Podiatric Medicine, Phila-
delphia, PA.
jjUnited States Military Academy, Keller Hospital, West
Point, NY.
Corresponding author: Rebecca Avrin Zifchock, PhD,
Department of Civil and Mechanical Engineering, United
States Military Academy, 752 Thayer Rd, West Point, NY
10996. (E-mail: becky_avrin@hotmail.com)
cadets from the United States Military Academy
(West Point, New York), Levy et al2 established a
significant relationship between pes planus and the
number of injuries sustained in a 4-year period. An
interesting deviation from the findings was that
women, who tended to have smaller feet and a
lesser degree of pes planus, sustained more injuries
than men. Williams et al3 examined injury history in
runners with pes cavus or pes planus and showed
that arch structure is associated with different
injury patterns in runners. Runners with pes cavus
reported greater incidences of ankle, bony, and
lateral injuries. Runners with pes planus reported
greater incidences of knee, soft-tissue, and medial
injuries.
The correlation between arch structure and injury
may be related to the fact that foot structure
influences foot function. Mootanah et al4 catego-

Journal of the American Podiatric Medical Association  Vol 107  No 2  March/April 2017 119
rized foot type based on arch height (planus, rectus,
and cavus), malleolar valgus index, arch height
index (AHI), and arch flexibility and foot function
based on center of pressure excursion index, peak
plantar pressure, maximum force, and gait pattern
parameters. The researchers observed a significant
relationship between several measures of foot
structure and foot function.
In addition to arch height, there is evidence to
suggest that arch flexibility may be a meaningful
descriptor of the relationship between foot struc-
ture and foot function. In their recent study of high-
arched runners, Williams et al5 found varying levels
of arch flexibility, which led to differing lower-
extremity movement patterns and loading. There is
substantial literature that uses methods of classifi-
cation to describe individuals’ arches as rectus,
cavus, or planus. Yet, despite the potential implica-
tions for including arch flexibility as a measure of
foot structure, there is not a similar categorization
method to describe arch flexibility. Classification
methods are useful for researchers to draw com-
parisons between groups. They can also be useful
for clinicians who are making decisions regarding
best practice treatment options. Therefore, the first
purpose of this study was to propose a classification
scheme for arch flexibility based on a large foot
structure data set.
Although recent literature, such as the study by
Willams et al,3 suggests that arch height does not
necessarily predict arch flexibility, it is often
assumed that high arches tend to be stiffer and
low arches tend to be more flexible.6 A clearer
understanding of the strength of the relationship
between these two structural measures can support
the development of appropriate clinical treatment of
foot abnormalities. It may also better describe the
spectrum of foot structure so as to strengthen the
predictability of foot function by structure. There-
fore, the second purpose of this study was to use
the classification scheme proposed herein to assess
the relationship of arch flexibility with arch height.
Based on the assumption that high arches are stiffer
and low arches are more flexible, a relationship
between arch flexibility and arch height categories
was expected.
Materials and Methods
Volunteers were drawn from a pool of 1,200
incoming military cadets, of whom 1,124 agreed to
participate in this study. All of the procedures were
reviewed and approved by the Keller Army Hospital
institutional review board, and all of the partici-
120 March/April 2017  Vol 107  No 2  Journal of the American Podiatric Medical Association
pants gave informed consent before participation in
the study. Erroneous data were eliminated from the
data set before analysis, including individuals who
had duplicate information, missing information (ie,
weight, foot structure measurements), or negative
values for the change in arch height from sitting to
standing. The negative value would suggest that
arch height in the standing position would be
greater than arch height in the sitting position,
which is not possible owing to the natural splaying
of the foot with body weight loading.
After the removal of erroneous data, 1,056
individuals (882 men and 174 women) were includ-
ed in the study (mean 6 SD: age, 18.4 6 1.4 years;
height, 1.76 6 0.80 m; and weight, 76.1 6 12.7 kg).
Arch height index was measured using the arch
height index measurement, the validity and reliabil-
ity of which has been previously established by
Butler et al.7 Figure 1 depicts the apparatus for the
right foot; a mirrored apparatus was used to
measure the left foot as well. Arch height index
(AHI) was calculated according to the following
formula8:
DorsalHeight50% Total Foot Length
AHI ¼
TruncatedFootLength
where dorsal height is measured at 50% of the total
foot length and truncated foot length is the distance
from the posterior heel to the first metatarsal head,
measured along the medial border of the foot.
Arch flexibility was defined as the change in arch
height (distance from the dorsal surface to the
ground) from sitting to standing due to the change
in load borne by the arch during these activities. The
change in load was based on an assumed change in
body weight from sitting to standing. The standing
condition assumes the weight on the foot to be 50% of
Figure 1. The arch height index measurement
system was used to measure the arch height at
half of the total foot length to calculate arch
flexibility.
the body weight on each foot, and the sitting
condition assumes the weight on the foot to be 10%
of the body weight.9 Therefore, there was an assumed
40% change in load from standing to sitting.
The final equation used to calculate arch flexibil-
ity4 was:
AHsitting  AHstanding
Arch height flexibility ¼ 3100 ½m=kN
0:4 3 BW
where AH is arch height from the floor to the dorsal
surface of the foot at half the total foot length and
BW is body weight.
Because data were collected from both the left and
right sides, the AHI and arch height flexibility data
were first compared between sides using a paired t
test to determine whether the analysis from one side
could be generalized to the other side. The data were
then used to create a classification scheme for arch
height flexibility. Visualization of the compiled AHI
data showed that the mean 6 SD would not
represent the skewness of the data (Fig. 2).
Therefore, quintiles were used to classify five arch
height flexibility categories: very stiff, stiff, neutral
flexible, and very flexible.
The distribution of arch flexibility types was also
compared among arch height categories. This was
accomplished by identifying the number of individ-
uals with each AHF type in each arch height
category. The arch height flexibility type was based
on the classification system proposed herein, and
the arch height category was based on previous
Figure 2. Distribution of left and right foot arch flexibility measurements was skewed toward stiffer feet.
Therefore, quintiles, as opposed to mean 6 SD, were used to classify arch flexibility types.
Journal of the American Podiatric Medical Association  Vol 107  No 2  March/April 2017
clinically based cutoff values for cavus, rectus, and
planus proposed by Hillstrom et al.10 The distribu-
tion was compared using a v2 goodness of fit test.
Results
The arch height flexibility was not significantly
different between the left and right feet (P ¼ .21).
Therefore, the right side was used to represent the
participants’ feet overall. The classification scheme
based on quintiles is shown in Table 1. The median
arch height flexibility value was 14.75 mm/kN. Sixty-
eight feet were classified as cavus, 225 as rectus,
and 763 as planus. The goodness of fit test
suggested that among arch height categories there
was a significantly disproportionate number of feet
that were classified in each of the arch height
flexibility categories (P , .01). As shown in Figure
3, the largest proportion of cavus feet was very stiff
and the smallest proportion was very flexible. This
was also true of the feet in the rectus arch height
category, although a large portion of rectus feet also
demonstrated neutral arch flexibility. Conversely,
the largest proportion of planus feet was very
flexible and the smallest proportion was very stiff.
Note that the planus group demonstrated an
obvious stepwise increase in the proportion of
individuals in each category from very stiff to very
flexible. However, the distribution of arch height
121
Table 1. Proposed Cutoff Values for Arch Flexibility Categories and the Distribution of 1,056 Feet by Arch Flexibility (AHF)
and Arch Height Categories
Arch Height Category (No.)
Arch Flexibility Category Quintile (%) Cutoff Value (mm/kN) Cavus Rectus Planus

Very stiff 0–20 AHF , 9.91 22 56 133

Stiff .20–40 9.91  AHF , 13.54 17 51 142
Neutral .40–60 13.54  AHF , 16.00 8 52 153
Flexible .60–80 16.00  AHF , 20.54 15 32 164
Very flexible .80–100 AHF  20.54 6 34 171
Total 68 225 763

flexibility categories in cavus and rectus feet is less clearer distribution of arch flexibility types in those
defined. arch height categories.
Nevertheless, despite the skew toward planus
feet enrolled in the study, the results supported the
Discussion
hypothesis: there was a significantly different
The purpose of this study was to expand our distribution of arch flexibility types among arch
understanding of arch flexibility as a measure of foot height types. Specifically, planus feet were more
structure. Although still measured statically, arch likely to be very flexible and cavus and rectus feet
flexibility accounts for dynamic foot changes. Based were more likely to be stiffer. This relationship was
on a large data set, we proposed a five-category most evident for the two extreme arch flexibility
categories (very stiff and very flexible). For planus
classification scheme for arch flexibility. This infor-
arches, there was a commensurate stepwise in-
mation is useful for clinically defining an individual’s
crease in the number of feet that fell into the stiff,
foot structure, and it will assist in future studies that
neutral, and flexible categories. The clear distribu-
seek to develop categorical analyses between foot
tion of these data may be due to the large number of
types. Categorical analyses have been performed for
individuals in this subcohort (n ¼ 763). The
decades based on arch height11,12; however, new
distribution in the cavus and rectus categories,
emphasis4,5 of the importance of arch flexibility in
specifically in the intermediate categories (stiff,
describing foot structure supports the need for a neutral, and flexible), was less obvious.
similar classification scheme based on this measure. The results of the present research support the
It is important to note some limitations associat-
ed with this study. First, arch flexibility is calculated
based on the assumption that the individuals were
evenly loading their body weight on each of their
feet as they were being measured. The participants
were prompted to stand evenly on both feet, but this
was not quantitatively monitored during data
collection. In addition, the study was conducted
on a population of healthy men and women aged 18
to 25 years. Therefore, the arch flexibility classifi-
cation scheme described in this study was based on
this demographic feature. Future studies should be
performed to determine whether the classification
scheme can be applied to children, older adults, or a
pathologic population. It is likely that additional, or
modified, classification schemes may be necessary.
Finally, there were more than ten times as many
planus as cavus feet and more than three times as Figure 3. Distribution of feet in the appropriate arch
many planus as rectus feet in the cohort. Future height and arch flexibility categories. The distribu-
studies should include additional cavus and rectus tion of arch flexibility types was significantly different
feet in the cohort to determine whether there is a among arch height types (P , .01).

122 March/April 2017  Vol 107  No 2  Journal of the American Podiatric Medical Association
common belief that cavus feet tend to be very stiff
and planus feet tend to be very flexible.6 This finding
is useful where generalizations of foot structure are
warranted. However, the results of this study also
demonstrate that there was a distribution of arch
flexibility types among the arch height types. For
example, although 22 of the 68 cavus feet were very
stiff, another 15 of the 68 cavus feet were flexible. In
fact, this study demonstrates that at least two foot
classification methods are useful to fully describe
foot structure.
This study proposes a five-category arch flexibil-
ity classification system. The results suggest that a
multidimensional description of foot structure
requires classification of both arch height and arch
flexibility. In addition to addressing the relationship
between arch height and flexibility, the five-category
classification of arch flexibility combined with the
three-category classification of arch height proposes
a two-dimensional matrix of 15 possible foot types
that more completely describe foot structure. This
provides the framework for a normative database
that will be useful for future studies relating foot
structure to injury and performance.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
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