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Background Thong style flip-flops are a popular form of footwear for children. Health professionals relate the wearing of thongs to foot pathology and deformity despite the lack of quantitative evidence to support or refute the benefits or disadvantages of children wearing thongs. The purpose of this study was to compare the effect of thong footwear on children’s barefoot three dimensional foot kinematics during walking and jogging. Methods Thirteen healthy children (age 10.3 ± 1.6 SD years) were recruited from the metropolitan area of Sydney Australia following a national press release. Kinematic data were recorded at 200 Hz using a 14 camera motion analysis system (Cortex, Motion Analysis Corporation, Santa Rosa, USA) and simultaneous ground reaction force were measured using a force platform (Model 9281B, Kistler, Winterthur, Switzerland). A three-segment foot model was used to describe three dimensional ankle, midfoot and one dimensional hallux kinematics during the stance sub-phases of contact, midstance and propulsion. Results Thongs resulted in increased ankle dorsiflexion during contact (by 10.9°, p; = 0.005 walk and by 8.1°, p; = 0.005 jog); increased midfoot plantarflexion during midstance (by 5.0°, p; = 0.037 jog) and propulsion (by 6.7°, p; = 0.044 walk and by 5.4°, p;= 0.020 jog); increased midfoot inversion during contact (by 3.8°, p;= 0.042 jog) and reduced hallux dorsiflexion during walking 10% prior to heel strike (by 6.5°, p; = 0.005) at heel strike (by 4.9°, p; = 0.031) and 10% post toe-off (by 10.7°, p; = 0.001). Conclusions Ankle dorsiflexion during the contact phase of walking and jogging, combined with reduced hallux dorsiflexion during walking, suggests a mechanism to retain the thong during weight acceptance. Greater midfoot plantarflexion throughout midstance while walking and throughout midstance and propulsion while jogging may indicate a gripping action to sustain the thong during stance. While these compensations exist, the overall findings suggest that foot motion whilst wearing thongs may be more replicable of barefoot motion than originally thought.
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Effect of thong style flip-flops on childrens
barefoot walking and jogging kinematics
Chard et al.
Chard et al. Journal of Foot and Ankle Research 2013, 6:8
http://www.jfootankleres.com/content/6/1/8
R E S E A R C H Open Access
Effect of thong style flip-flops on childrens
barefoot walking and jogging kinematics
Angus Chard
1*
, Andrew Greene
1,2
, Adrienne Hunt
1
, Benedicte Vanwanseele
1,3
and Richard Smith
1
Abstract
Background: Thong style flip-flops are a popular form of footwear for children. Health professionals relate the
wearing of thongs to foot pathology and deformity despite the lack of quantitative evidence to support or refute
the benefits or disadvantages of children wearing thongs. The purpose of this study was to compare the effect of
thong footwear on childrens barefoot three dimensional foot kinematics during walking and jogging.
Methods: Thirteen healthy children (age 10.3 ± 1.6 SD years) were recruited from the metropolitan area of Sydney
Australia following a national press release. Kinematic data were recorded at 200 Hz using a 14 camera motion
analysis system (Cortex, Motion Analysis Corporation, Santa Rosa, USA) and simultaneous ground reaction force
were measured using a force platform (Model 9281B, Kistler, Winterthur, Switzerland). A three-segment foot model
was used to describe three dimensional ankle, midfoot and one dimensional hallux kinematics during the stance
sub-phases of contact, midstance and propulsion.
Results: Thongs resulted in increased ankle dorsiflexion during contact (by 10.9°, p; = 0.005 walk and by 8.1°,
p; = 0.005 jog); increased midfoot plantarflexion during midstance (by 5.0°, p; = 0.037 jog) and propulsion (by 6.7°,
p; = 0.044 walk and by 5.4°, p;= 0.020 jog); increased midfoot inversion during contact (by 3.8°, p;= 0.042 jog)
and reduced hallux dorsiflexion during walking 10% prior to heel strike (by 6.5°, p; = 0.005) at heel strike (by 4.9°,
p; = 0.031) and 10% post toe-off (by 10.7°, p; = 0.001).
Conclusions: Ankle dorsiflexion during the contact phase of walking and jogging, combined with reduced hallux
dorsiflexion during walking, suggests a mechanism to retain the thong during weight acceptance. Greater midfoot
plantarflexion throughout midstance while walking and throughout midstance and propulsion while jogging may
indicate a gripping action to sustain the thong during stance. While these compensations exist, the overall findings
suggest that foot motion whilst wearing thongs may be more replicable of barefoot motion than originally
thought.
Background
Thongs (also known as flip-flops) are a common foot-
wear choice for Australian children [1]. They are typic-
ally constructed from a rubber template which is loosely
secured to the foot by a single V-shaped rubber strap
extending from between the first web space to the base
of the first and fifth metatarsals. Footwear is regarded as
necessary apparel for foot comfort and protection. Due
to their flexible and unrestrictive nature, thongs may be
preferable to other childrens footwear types, all of which
have been shown to alter natural foot function [2], since
the ideal footwear for a childs developing feet is believed
to be that which allows natural motion of the foot [3,4].
In support of this view are reports that, compared to ha-
bitually shod children, habitually unshod children have
stronger and healthier feet with less incidence of toe de-
formity [3].
Despite the possible advantage of thongs compared to
other footwear options for children, there is no evidence
that they are beneficial. Indeed, there are concerns that
thongs may be harmful. In a recent survey of 272 par-
ents of children, thongs were implicated by the parents
as contributing to 15% of forefoot and 22% of rearfoot
complaints [1]. Prolonged use of thongs has been linked
to heel pain [5] and shin-splints [6]. However, there ex-
ists no empirical evidence to explain the mechanisms for
* Correspondence: bcha8278@uni.sydney.edu.au
1
Discipline of Exercise and Sport Science, Faculty of Health Science, The
University of Sydney, Sydney, NSW 2006, Australia
Full list of author information is available at the end of the article
JOURNAL OF FOOT
AND ANKLE RESEARCH
© 2013 Chard et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Chard et al. Journal of Foot and Ankle Research 2013, 6:8
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specific pathologies, and no analysis of the effect of
thong wearing on foot function in children. From studies
of adults, thongs have been found to result in increas-
ed ankle plantarflexion at heel contact, compared to
sneakers [7] and decreased plantar pressure at the
rearfoot, forefoot and hallux, compared with barefoot
[8]. Whilst the implications of these findings are unclear,
the cushioning effect of a thong indicated by the de-
creased pressure challenges the commonly held belief of
the need to claw the toes in order to maintain inter-
action between the barefoot and the thong. Other patho-
logical mechanisms that are concerning because of their
associations with symptoms in adults and may poten-
tially occur in children who wear thongs include; that of
plantar fasciitis with flattening of the longitudinal arch
[9]; and foot pronation and reduced hallux dorsiflexion
[10]; and medial tibial stress syndrome also known as
shin-splints with excessive foot pronation [11] and
rearfoot eversion [12]. However, there have been no
studies of the effects on foot function in children to sup-
port or refute any concerns or harm in wearing thongs.
To our knowledge, no quantitative evidence to support
or refute the benefits or disadvantages of children wear-
ing thongs has been reported in the literature. The aim
of this paper is to compare the kinematic effects of wear-
ing thongs on childrens feet with a barefoot control
condition during walking and jogging using three di-
mensional motion analyses. It is hypothesised that, com-
pared to barefoot, wearing thongs will see reduced
hallux motion, greater midfoot dorsiflexion and ankle
eversion.
Methods
Participants
Study participants were thirteen children (8 girls and 5
boys) between 8 and 13 years of age (mean age 10.3 ±
1.6 SD years) from the metropolitan area of Sydney
Australia who volunteered in response to publicly
displayed posters, press release and fourteen radio in-
terviews. Power analysis using data from a previous
footwear study [13] indicated that twelve participants
would be necessary to achieve a significant difference
with alpha set at 0.05 and power set at 0.8 with the ef-
fect size 0.62. This number is similar to Leardini et als
[14] protocol for measuring multi segment foot mo-
tion, which found meaningful differences with ten
participants.
Inclusion criteria stipulated healthy children free of
known foot deformity, and not requiring medical con-
sultation for foot or leg pathology in the preceding
six months, Beighton Score less than 5/9 to exclude
hypermobile children [15] and a foot posture index (FPI)
within 2 SD of normal to exclude excessively pronated
and supinated foot types [16]. The University of Sydney
Human Ethics Committee granted ethics approval for
this study and a parent/carer of each participant gave
written consent together with the childs informed verbal
assent prior to participation.
Model, segment and joint angle definitions
Shank and rearfoot segments were defined using 3, 12
mm diameter, non-collinear reflective markers per seg-
ment (Figure 1). Motion of the shank was determined
using markers placed on areas of minimal soft tissue
movement at the proximal, distal and lateral shank. Mo-
tion of the rearfoot was determined using a detachable
wand triad marker previously shown to be valid and reli-
able [17]. It consisted of an array of three markers
mounted onto a rigid shaft that attached to the calca-
neus via a flexible metal stirrup. The stirrup provided a
large contact area around the calcaneus and was secured
using double sided adhesive tape and strapping tape.
Motion of the forefoot was determined with markers lo-
cated at the navicular, first and fifth metatarsal heads.
The first metatarsal segment was defined by the line
from the navicular to first metatarsal head and the
hallux segment by the line from the first metatarsal head
to the marker located dorsal to first distal phalanx.
The two joints of the rearfoot (talocrural and subtalar)
were considered as a single universal joint with its centre
located at the midpoint between the markers on the
Figure 1 Images of the foot and leg with markers used for the
definition of segments and their embedded axes.
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medial and lateral malleolus. The forefoot segment X
and Y axes had their origin in line with the navicular
marker and the Z axis in line with the rearfoot joint
centre. The axis system origin for the shank segment
was midway between the medial and lateral femoral con-
dyles. All segment X axes were initially aligned with the
laboratory -Z axis (down), segment Y axis pointing an-
teriorly (X axis of laboratory) and the segment Z axis
pointing to the right of the participant (-Y axis of the la-
boratory). For the shank segment the X axis was subse-
quently aligned with the rearfoot joint centre.
The three degrees of freedom ankle joint angle was de-
scribed using the joint coordinate system according to
International Society of Biomechanics (ISB) recommen-
dations [18]. The midfoot angle describing the angular
relationship between the forefoot and the rearfoot used
a similar joint coordinate system as that for the ankle.
That is, the midfoot plantarflexion/dorsiflexion axis was
the Z-axis of the rearfoot, the midfoot abduction/adduc-
tion axis was the X-axis of the forefoot and the inver-
sion/eversion axis of the midfoot was the cross product
between the Z-axis of the rearfoot and the X-axis of the
forefoot.
Experimental approach
Study participant characteristics were recorded (Table 1)
and reflective markers applied prior to a standardised
foot reference position being recorded. Participants
practised walking and jogging along the seven metre
walkway at a self-selected pace while visually attending
to a distant line bisecting the lab to maintain direction
and avoid targeting of the force plate. Participants then
conducted five walking trials and five jogging trials in a
straight line while barefoot, or while wearing simple,
non-contoured thongs (Figure 2). The test order of bare-
foot and a thong condition was randomised between
participants.
Equipment
Video data were recorded at 200 Hz using a 14 camera
motion analysis system (Cortex Version 1.1, Motion
Analysis Corporation, Santa Rosa, USA). The initial
right foot ground reaction force was measured using a
force platform (Model 9281B, Kistler, Winterthur,
Switzerland). Calibration of all fourteen cameras was
completed prior to each session of data collection.
Residual error for the motion analysis system, re-
presenting the accuracy with which the system could
reconstruct marker location within the captured vol-
ume, was <0.5mm across all testing sessions.
Data processing
All trials were truncated at 20% prior to heel-strike of
the right foot and at 20% after the right foot toe-off and
time normalised to the right footsstancephase.Inac-
cordance with previous literature, the kinematic data
were smoothed at 5 Hz [19] for walking and 20 Hz [20]
for jogging. Relative angles were calculated using
KinTrak software (University of Calgary, Canada). The
timing of heel contact and toe-off events was es-
tablished from the vertical ground reaction force. For
each participant and condition the mean of five trials
was calculated. The ensemble mean and 95% confidence
intervals across participants were computed. The confi-
dence intervals were used to determine whether dif-
ferences were significant between conditions for the
continuous data.
Four events were used to define the three stance sub-
phases: foot contact (heel contact to foot flat), mid-
stance (foot flat to heel rise) and propulsion (heel rise to
toe off). Foot flat and heel rise events were defined
within stance phase using the minimum of the poster-
iorly directed and the zero-crossing of the anterior-
posterior ground reaction force respectively.
Statistical analysis
For the primary discrete variable of the footwear condi-
tion thong to barefoot, a two by five nested repeated
Table 1 Study participant characteristics (n = 13)
Variable Mean or count Range
Gender, male:female 5:8 NA
Age, years (SD) 10.3(1.6) 8 - 13
Height, m (SD) 1.4 (0.1) 1.2 - 1.6
Body mass, kg (SD) 34.0 (8.2) 21.6 - 47.8
Beighton Score (SD) 2.7 (1.6) 0-4
Foot Posture Index, score (SD) 6 (0.1) 2 - 9
Dominant leg, right (%) 12 (92) NA
Thong size 35/36 31/32 39/40
Figure 2 Example simple non-contoured thongs.
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measures analysis of variance was used (SPSS Version
19, IBM SPS Inc, USA). Bonferoni adjustments to condi-
tion and gait were applied to test significant differences
between footwear conditions and gaits walking and jog-
ging over five trials. The threshold of p< 0.05 was set to
determine the significance of range of motion value and
mean difference.
Results
Participants
Mean age, height, mass, Beighton Score, FPI, dominant
leg and thong size for the participants are presented in
Table 1. On average, during walking in barefoot and
thong conditions, foot-flat occurred at 13 and 14 percent
of stance and heel-rise at 54 and 53 percent of stance re-
spectively
.
During jogging, barefoot and in thong condi-
tions, foot-flat occurred at 20 and 22 percent of stance
and heel-rise at 44 and 44 percent of stance respectively
.
Participant barefoot and thong ankle, midfoot and hallux
range of motion (ROM) and walking and jogging vel-
ocity are shown in Table 2.
Kinematics
Walking
At heel strike the ankle was 10.4°, (p; = 0.010, 95% CI
[2.02, 18.73]) more dorsiflexed in the thong condition
when compared to barefoot (Figure 3) and remained
more dorsiflexed by 10.9°, (p; = 0.005, 95% CI [4.04,
17.75]) throughout the contact phase (Figure 3). Over
the entire stance phase, the ankle averaged greater dorsi-
flexion in the thong condition, although this difference
was not significantly different at 5.3°, (p; = 0.122, 95% CI
[1.66, 12.32]). Ankle frontal and transverse plane mo-
tion in the thong condition closely followed that of bare-
foot throughout the stance phase.
The pattern of midfoot sagittal plane motion (Figure 4)
was similar between barefoot and thong conditions,
although the thong condition demonstrated a trend to-
wards increased plantarflexion throughout stance by
6.5°, (p; = 0.055, 95% CI [0.156, 13.3]) (Table 3). Al-
though not significant the following two observations
were noted. During the contact phase, when thongs
were worn, the midfoot was more plantarflexed by 5.4°
(p; = 0.090, 95% CI [1.00, 11.9]) than when barefoot.
During mid-stance, the midfoot was more plantarflexed
by 6.6°, (p; = 0.052, 95% CI [0.065, 13.3]) when thongs
were worn. The midfoot was more plantarflexed when
thongs were worn during the propulsive phase by 6.7°,
(p; = 0.044, 95% CI [0.205, 13.3]) (Table 3). Midfoot
frontal and transverse plane motion in the thong condi-
tion showed no difference to barefoot through the
stancephase(Table3).
Hallux sagittal plane position in the thong condition
was less dorsiflexed prior to heel strike at 10% of
stance by 6.5°, (p; = 0.005, 95% CI [3.76, 7.67]) at heel
strike by 4.9°, (p; = 0.031, 95% CI [3.68, 7.78]) and at
110% of stance by 10.7°, (p; = 0.001 95%CI [3.49, 17.93])
(Figure 5).
Jogging
Greater ankle dorsiflexion occurred in the thong condi-
tion at heel-strike by 10.2°, (p; = 0.003, 95% CI [2.25,
17.74]) and following toe-off at 110% of stance by 5.8°,
(p; = 0.016, 95%CI [4.69, 6.09]) (Figure 6). Over the en-
tire stance phase, ankle sagittal plane motion when
thongs were worn was similar in pattern to barefoot jog-
ging. This occurred despite a trend towards greater
dorsiflexion throughout stance when thongs were worn
4.4°, (p; = 0.070 95%CI [0.416, 9.23]) (Table 3). No dif-
ference was seen for ankle frontal plane or transverse
plane motions when thongs were worn (Table 3).
The midfoot was more plantarflexed during the thong
condition in the sagittal plane during midstance by 5.0°,
(p; = 0.037, 95% CI [0.37, 9.73]) and propulsion by 5.4°,
Table 2 Mean, pvalue and 95% confidence interval for the difference between the means for the joint range of
motion and velocity over the stance phase for barefoot and thong while walking and jogging
Walk Jog
Variable Barefoot Thong Barefoot Thong
Angle (°) SD Angle (°) SD p;<0.05 95% CI Angle (°) SD Angle (°) SD p;<0.05 95% CI
Ankle sagittal 22.4 5.4 20.7 7.9 0.386 2.39, 5.76 28.2 5.4 25.8 5.8 0.085 0.383, 5.18
Ankle frontal 11.6 2.5 11.1 2.1 0.580 1.59, 0.940 12.8 3.2 12.5 2.5 0.626 1.03, 1.64
Ankle transverse 12.1 3.6 12.6 4.3 0.688 2.78, 1.90 10.1 3.6 9.3 3.2 0.162 0.376, 2.01
Midfoot sagittal 21.8 6.1 21.2 6.1 0.701 2.69, 3.87 25.0 5.0 22.9 3.2 0.116 0.589, 4.69
Midfoot frontal 7.0 1.4 7.4 4.0 0.656 2.51, 1.64 6.7 3.2 6.0 2.2 0.452 1.34, 2.82
Midfoot transverse 7.5 3.2 8.4 3.2 0.099 1.90, 0.186 5.9 1.8 5.2 1.8 0.327 0.794, 2.20
Hallux sagittal 30.4 7.6 25.3 6.5 0.80 1.42, 5.29 25.0 7.6 22.3 6.1 0.170 1.30, 6.56
Mean velocity (ms
-2
) 1.4 0.2 1.4 0.2 0.079 1.24, 1.56 2.5 0.2 2.5 0.2 0.520 2.34, 2.66
* indicates a significant difference compared to barefoot when p < 0.05.
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(p; = 0.020, 95% CI [1.01, 9.84]) (Table 3) (Figure 7). The
midfoot mean plantarflexion angle was greater by 4.6°
(p; = 0.051, 95% CI [0.031, 9.17]) over the entire stance
phase when thongs were worn but not significantly so
(Table 3). The midfoot was more inverted during the
contact phase by 3.8°, (p; = 0.042, 95% CI [0.15, 7.40])
(Figure 8) (Table 3) and at toe-off by 4.6°, (p; = 0.008,
95% CI [3.44, 5.65]). Midfoot transverse plane motion in
the thong condition showed no difference to barefoot
throughout the stance phase (Table 3).
Hallux sagittal plane motion was unaffected by thongs
while jogging.
Discussion
The purpose of this study was to examine the effects of
wearing thongs on selected foot kinematics while chil-
dren were walking and jogging using the barefoot condi-
tion as a baseline. Children adapted to wearing thongs
with altered ankle kinematics during the contact phase
while walking and jogging and midfoot adaptations dur-
ing midstance while jogging. Hallux adaptations were
observed while walking prior to and during weight ac-
ceptance and after toe off. Overall ankle, midfoot and
hallux range of motion was unaffected while wearing
thongs compared to barefoot.
Self-selected barefoot walking velocity (Table 2) in the
present study is consistent with previous studies [21,22].
Thongs had a minimal effect on barefoot walking and
jogging velocities. Barefoot walking joint angle ROM
(Table 2), in the current study are consistent with previ-
ously reported literature for those papers that used the
relative angle of the shank to the rearfoot to describe sa-
gittal plane ankle ROM in children [22]. Since childrens
gait is considered to be mature by age four [23] and foot
mechanics mature by age five [24], comparisons can be
drawn between the current study and adult studies using
the same joint definition models. Consistencies were
identified between the current data and adult ankle ROM
in the sagittal [19,25,26], frontal [19,25] and transverse
planes [19,25] and the midfoot ROM in the sagittal
[19,25] and frontal planes [19].
Only small differences were seen when children wore
thongs compared to barefoot for the tested foot model.
The overall pattern and range of joint angle motion for
ankle, midfoot and hallux kinematics were comparable
between barefoot and thong conditions during both
walking and jogging (Table 2). Barefoot kinematics
were altered when thongs were worn throughout vari-
ous phases of the gait cycle, with these changes mainly
occurring in the sagittal plane (Table 3). Participants
wearing thongs exhibited more ankle dorsiflexion
throughout the contact phase while walking together
with midfoot inversion while jogging, more midfoot
plantarflexion during midstance while jogging, more
midfoot plantarflexion while walking and jogging dur-
ing the propulsive phase (Table 3) and hallux dorsiflex-
ion was reduced prior to and post stance phase while
walking (Figure 5).
Ankle and midfoot adaptations occurred during the
contact and midstance phases while wearing thongs
compared to barefoot. Significant ankle dorsiflexion dur-
ing walking (Figure 3) and jogging (Figure 6) combined
with midfoot inversion during jogging (Figure 8) prior to
and during the contact phase may be a compensatory
mechanism necessary to retain thongs on the foot. This
increased dorsiflexed and inverted position through
loading may have implications for the tibialis anterior
muscle, which has been shown through eccentric con-
traction to be a primary resistor of foot plantarflexion
and rearfoot eversion during the first 10% of the stance
phase [27]. Previously reported evidence of increased
foot plantarflexion seen when wearing thongs compared
to shod conditions [7] cannot be directly compared to
the current study given their use of a two dimensional
single segment foot model in which markers were placed
on the outer surface of participants pre-worn shoes, and
motion of the rearfoot segment were not measured.
Figure 4 Sagittal plane midfoot motion in walking gait. Mean
joint angles for barefoot (red) including 95% confidence intervals
(red shading) and thong (blue dashed) including 95% confidence
intervals (blue shading), including 20% before and 20% after stance
(y-axis), while walking. Events foot-flat and heel-rise represented by
the vertical red (barefoot) and blue (thong) dashed lines.
Figure 3 Sagittal plane ankle motion in walking gait. Mean joint
angles for barefoot (red) including 95% confidence intervals (red
shading) and thong (blue dashed) including 95% confidence
intervals (blue shading), including 20% before and 20% after stance
(y-axis), while walking. Events foot-flat and heel-rise represented by
the vertical red (barefoot) and blue (thong) dashed lines.
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An action to grip thongs may be present during
midstance and in particular during propulsion with
greater midfoot plantarflexion while walking (Figure 4)
and to a greater extent while jogging (Figure 7). The
midfoot was more plantarflexed during midstance phase
while walking and more plantarflexed during the propul-
sive phase of walking and jogging (Table 3).
Anecdotally, clinicians have believed it necessary to
claw ones toes to maintain thongs. This popular belief
has been found lacking with hallux plantar pressure
measures reduced when wearing thongs [8]. The present
study confirms this outcome during the stance phase
with hallux angular displacement remaining unchanged
(Table 2) between conditions while walking (Figure 5) or
jogging.
Reduced hallux dorsiflexion immediately prior-to and
at heel strike while walking may indicate an action to
grip and lever the thong to make contact with the heel
in preparation for weight acceptance at heel strike
(Figure 5). This adaptation may disrupt tensioning of the
plantaraponeurosis with preload, thought to be import-
ant for midfoot stability in preparation for load accept-
ance [28] and increase demand of other midfoot
stabilising structures including plantar intrinsic foot
muscles [29,30]. Reduced hallux dorsiflexion seen at 110%
of stance following toe-off while walking (Figure 5) has
Table 3 Mean, pvalue and 95% confidence interval for the difference between the angle means over the stance phase
for barefoot and thong while walking and jogging
WALK JOG
Phase Joint Plane Barefoot Thong p;<0.05 95% CI Barefoot Thong p;<0.05 95% CI
Contact Ankle Sagittal 1.1(8.3) 12.0(12.2) 0.005* 17.8, -4.04 13.0(7.6) 21.1(10.4) 0.005* 13.2, -2.98
Frontal 7.5(3.6) 10.0(5.8) 0.694 3.23, 2.25, 4.7(4.3) 3.6(4.7) 0.31 3.30, 1.14
Transverse 1.6(4.7) 1.7(3.2) 0.957 3.15, 3.00 3.6(5.0) 1.4(5.8) 0.194 1.30, 5.77
Midfoot Sagittal 3.8(6.5) 9.2(12.2) 0.090 1.00, 11.9 3.5(6.5) 6.6(11.9) 0.203 1.92, 8.13
Frontal 2.0 (2.9) 0.6 (5.0) 0.181 0.750, 3.55 1.2(3.6) 2.6(6.5 0.042* 0.15, 7.40
Transverse 3.6(3.6) 1.0(4.0) 0.441 5.21, 2.42 0.8(4.3) 2.2(4.3) 0.075 6.30, 0.35
Hallux Sagittal 6.2(4.3) 3.7(5.4) 0.203 1.57, 6.65 4.3(4.7) 3.3(6.5) 0.694 4.41, 6.41
Midstance Ankle Sagittal 7.6(5.8) 12.6(10.4) 0.124 11.44, 1.56 20.3(5.4) 24.4(9.0) 0.099 9.02, 0.88
Frontal 3.8(3.6) 4.2(4.7) 0.672 1.47, 2.20 0.3(4.7) 1.0(4.7) 0.492 2.94, 1.50
Transverse 4.1(4.3) 2.5(4.0) 0.315 1.74, 4.96 6.4(5.8) 3.4(5.8) 0.069 0.28, 6.40
Midfoot Sagittal 0.8(6.1) 7.4(12.6) 0.052 0.065, 13.3 2.9(7.2) 2.2(12.6) 0.037* 0.370, 9.73
Frontal 3.6 (1.8) 2.2 (5.0) 0.231 1.02, 3.83 2.0(4.3) 0.5(6.1) 0.140 0.908, 5.71
Transverse 0.5(3.2) 1.9(4.7) 0.421 5.21, 2.33 0.1(4.7) 2.8(4.0) 0.085 5.82, 0.435
Hallux Sagittal 1.1(2.9) 1.2(4.7) 0.926 2.99, 2.74 0.3(3.2) 0.4(4.7) 0.664 4.26, 2.81
Propulsive Ankle Sagittal 12.4(8.3) 16.4(11.5) 0.282 3.74, 11.8 18.0(6.5) 21.0(10.4) 0.242 8.12, 2.27
Frontal 6.8(5.0) 6.8(5.0) 0.552 1.44, 2.56 3.6(4.3) 3.0(4.7) 0.536 2.68, 1.47
Transverse 0.1(5.4) 1.3(4.3) 0.383 1.97, 4.78 3.6(5.8) 0.8(6.1) 0.098 0.591, 6.09
Midfoot Sagittal 3.4(7.2) 10.1(12.6) 0.044* 0.205, 13.3 2.1(7.9) 7.5(11.9) 0.020* 9.84, -1.01
Frontal 2.5(1.8) 1.9(4.7) 0.645 2.07, 3.18 1.8(4.0) 0.3(5.4) 0.153 0.908, 5.13
Transverse 0.7(3.2) 0.5(4.7) 0.524 5.00, 2.69 0.7(4.3) 1.7(3.6) 0.107 5.37, 0.594
Hallux Sagittal 7.0(4.3) 6.0(6.8) 0.675 3.89, 5.81 7.6(5.4) 5.4(4.3) 0.249 1.77, 6.30
Stance Ankle Sagittal 9.1(6.8) 14.4(8.3) 0.122 12.32, 1.66 17.6(6.1) 22.0(9.7) 0.070 9.23, 0.416
Frontal 5.5(4.0) 5.8(5.0) 0.775 1.68, 2.19 2.8(4.3) 2.0(4.3) 0.426 2.86, 1.29
Transverse 1.9(4.7) 0.7(4.0) 0.444 2.11, 4.52 4.3(5.8) 1.7(5.8) 0.120 0.798, 6.06
Midfoot Sagittal 2.5(6.5) 9.0 (13.0) 0.055 0.156, 13.3 1.1(7.2) 5.6(11.9) 0.051 0.31, 9.17
Frontal 2.8(2.2) 1.7(4.7) 0.362 1.37, 3.48 1.7(4.0) 0.9(5.8) 0.102 0.596, 5.78
Transverse 0.2(3.2) 1.2(4.3) 0.435 5.20, 2.39 0.5(3.6) 2.2(4.0) 0.084 5.65, 0.409
Hallux Sagittal 1.1(2.9) 1.2(4.3) 0.926 2.99, 2.74 4.9(4.3) 3.5(3.2) 0.384 2.08, 5.08
* indicates a significant difference compared to barefoot when p < 0.05.
Mean joint angles for ankle and midfoot sagittal, frontal and transverse planes and hallux sagittal plan during stance. Positive value indicates dorsiflexion, eversion
and abduction; negative values indicate plantarflexion, inversion and adduction.
Chard et al. Journal of Foot and Ankle Research 2013, 6:8 Page 6 of 8
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implications for hallux clawing during the swing phase of
the gait cycle reducing ground clearance, known to be re-
lated to trips and falls [31] and thought to be a protective
antalgic response of the symptomatic foot [10].
There were a number of limitations to the current study.
Firstly, the inclusion criterion was restrictive. This limits
the extent to which the findings can be generalized, and
cannot be applied to those children with excessively flat or
highly arched feet. Further research is required to substan-
tiate the current findings. Our study considered the in-
fluence of thongs on childrens kinematics in the
immediate time after the thongs were put on and
prior wear of thongs was not controlled for. Children
were not separated into groups of habitual or infre-
quent wearers of thongs which may have an effect on
condition familiarity and the individual methods to
secure the thong. Future studies should include side-
stepping tasks and should examine the inverse dy-
namics during prolonged wearing of thongs to better
understand pathological implications of the processes
necessary to maintain thongs and their effect.
Conclusions
Thongs had a minimal effect on walking and jogging at
self-selected speed. The adaptations seen in this study
may be necessary to maintain contact between the thong
and the foot. In particular, increased contact phase ankle
dorsiflexion, during walking and jogging with reduced hal-
lux dorsiflexion during walking suggests a need to retain
the thong during weight acceptance. Greater midfoot
plantarflexion during midstance while jogging and propul-
sion while walking and jogging suggests a gripping action
to retain the thong during stance. Reduced hallux dorsi-
flexion after toe-off during walking indicates a gripping ac-
tion may be necessary during early swing. These
adaptations may result in muscle overuse syndromes for
rearfoot dorsiflexors and midfoot plantarflexors with
prolonged thong wear, however further evidence is re-
quired to explore these areas. While differences were sta-
tistically significant, clinical importance is yet to be
determined and so, overall, foot motion whilst wearing
thongs may be more replicable of barefoot motion than
originally thought.
Figure 8 Frontal plane midfoot motion in jogging gait. Mean
joint angles for barefoot (red) including 95% confidence intervals
(red shading) and thong (blue dashed) including 95% confidence
intervals (blue shading), including 20% before and 20% after stance
(y-axis), while jogging. Events foot-flat and heel-rise represented by
the vertical red (barefoot) and blue (thong) dashed lines.
Figure 6 Sagittal plane ankle motion in jogging gait. Mean joint
angles for barefoot (red) including 95% confidence intervals (red
shading) and thong (blue dashed) including 95% confidence
intervals (blue shading), including 20% before and 20% after stance
(y-axis), while jogging. Events foot-flat and heel-rise represented by
the vertical red (barefoot) and blue (thong) dashed lines.
Figure 7 Sagittal plane midfoot motion in jogging gait. Mean
joint angles for barefoot (red) including 95% confidence intervals
(red shading) and thong (blue dashed) including 95% confidence
intervals (blue shading), including 20% before and 20% after stance
(y-axis), while jogging. Events foot-flat and heel-rise represented by
the vertical red (barefoot) and blue (thong) dashed lines.
Figure 5 Sagittal plane hallux motion in walking gait. Mean
joint angles for barefoot (red) including 95% confidence intervals
(red shading) and thong (blue dashed) including 95% confidence
intervals (blue shading), including 20% before and 20% after stance
(y-axis), while walking. Events foot-flat and heel-rise represented by
the vertical red (barefoot) and blue (thong) dashed lines.
Chard et al. Journal of Foot and Ankle Research 2013, 6:8 Page 7 of 8
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Competing interests
The authors declare no competing interests.
Authorscontributions
AC carried out participant recruitment, data collection and analysis, statistical
analysis, interpretation of results and manuscript draft. AG assisted data
collection, statistical interpretation and editing the manuscript. AH and BV
assisted in editing the manuscript. RS conceived the study, constructed the
methodology, procedure for statistical analysis and interpretation and study
overall coordination and helped to edit the manuscript. All authors read and
approved the final manuscript.
Acknowledgements
I would like to acknowledge Caleb Wegener for his guidance throughout
the research process and Raymond Patton for his technical expertise with
the biomechanics lab.
Author details
1
Discipline of Exercise and Sport Science, Faculty of Health Science, The
University of Sydney, Sydney, NSW 2006, Australia.
2
Postgraduate Medical
Institute, Faculty of Health, Social Care and Education, Anglia Ruskin
University, Chelmsford, UK.
3
Human Biomechanics Research Group,
Department of Kinesiology, KU Leuven, Belgium/ Health, Innovation &
Technology, Fontys University of Applied Sciences, Eindhoven, Netherlands.
Received: 7 August 2012 Accepted: 26 February 2013
Published: 5 March 2013
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doi:10.1186/1757-1146-6-8
Cite this article as: Chard et al.:Effect of thong style flip-flops on
childrens barefoot walking and jogging kinematics. Journal of Foot and
Ankle Research 2013 6:8.
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Chard et al. Journal of Foot and Ankle Research 2013, 6:8 Page 8 of 8
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The effect of footwear on the gait of children is poorly understood. This systematic review synthesises the evidence of the biomechanical effects of shoes on children during walking and running. Study inclusion criteria were: barefoot and shod conditions; healthy children aged ≤ 16 years; sample size of n > 1. Novelty footwear was excluded. Studies were located by online database-searching, hand-searching and contact with experts. Two authors selected studies and assessed study methodology using the Quality Index. Meta-analysis of continuous variables for homogeneous studies was undertaken using the inverse variance approach. Significance level was set at P < 0.05. Heterogeneity was measured by I2. Where I2 > 25%, a random-effects model analysis was used and where I2 < 25%, a fixed-effects model was used. Eleven studies were included. Sample size ranged from 4-898. Median Quality Index was 20/32 (range 11-27). Five studies randomised shoe order, six studies standardised footwear. Shod walking increased: velocity, step length, step time, base of support, double-support time, stance time, time to toe-off, sagittal tibia-rearfoot range of motion (ROM), sagittal tibia-foot ROM, ankle max-plantarflexion, Ankle ROM, foot lift to max-plantarflexion, 'subtalar' rotation ROM, knee sagittal ROM and tibialis anterior activity. Shod walking decreased: cadence, single-support time, ankle max-dorsiflexion, ankle at foot-lift, hallux ROM, arch length change, foot torsion, forefoot supination, forefoot width and midfoot ROM in all planes. Shod running decreased: long axis maximum tibial-acceleration, shock-wave transmission as a ratio of maximum tibial-acceleration, ankle plantarflexion at foot strike, knee angular velocity and tibial swing velocity. No variables increased during shod running. Shoes affect the gait of children. With shoes, children walk faster by taking longer steps with greater ankle and knee motion and increased tibialis anterior activity. Shoes reduce foot motion and increase the support phases of the gait cycle. During running, shoes reduce swing phase leg speed, attenuate some shock and encourage a rearfoot strike pattern. The long-term effect of these changes on growth and development are currently unknown. The impact of footwear on gait should be considered when assessing the paediatric patient and evaluating the effect of shoe or in-shoe interventions.
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Flip-flops are becoming a common footwear option. Casual observation has indicated that individuals wear flip-flops beyond their structural limit and have a different gait while wearing flip-flops versus shoes. This alteration in gait may cause the anecdotal foot and lower-limb discomfort associated with wearing flip-flops. To investigate the effect of sneakers versus thong-style flip-flops on gait kinematics and kinetics, 56 individuals (37 women and 19 men) were randomly assigned to a footwear order (flip-flops or sneakers first) and were asked to wear the assigned footwear on the day before and the day of testing. On each testing day, participants were videotaped as they walked at a self-selected pace across a force platform. A 2 (sex) x 2 (footwear) repeated-measures analysis of variance (P = .05) was used for statistical analysis. Significant interaction effects of footwear and sex were found for maximal anterior force, attack angle, and ankle angle during the swing phase. Footwear significantly affected stride length, ankle angle at the beginning of double support and during the swing phase, maximal braking impulse, and stance time. Flip-flops resulted in a shorter stride, a larger ankle angle at the beginning of double support and during the swing phase, a smaller braking impulse, and a shorter stance time compared with sneakers. The effects of footwear on gait kinetics and kinematics is extensive, but there is limited research on the effect of thong-style flip-flops on gait. These results suggest that flip-flops have an effect on several kinetic and kinematic variables compared with sneakers.
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The child's foot is clearly distinct from the adult foot in its functional anatomy and ability to cope with pressure. This requires special considerations in the development of a children's sport shoe. Medical and sport science databases were thoroughly searched for studies pertaining to the anatomy and biomechanics of children's feet during their development. With the data found, a list of requirements for the children's shoe was compiled. Small children should have a sports shoe, which is as flexible as their own foot. The small impact forces during their sports activities make extra cushioning superfluous. During school age the connective tissue gains stability. The growing amount of sports activities, much of which is performed on hard indoor surfaces, enhances the need for cushioning. At the same time there is a growing necessity for adequate mechanical stimuli to help the muscles and bones develop. The strength of the connective tissue and the flexibility of the joints reach adult levels by the age of 15. In small shoes, the displacement of proportions can lead to improper positioning of the flex zone and thereby causing harmful stress on the foot. Cushioning elements are often oversized. Considering the wide range of anatomy in the child's foot, it is advisable to produce children's shoes in different widths. The child's foot differs in anatomy and function from the adult foot. Children sport shoes should meet the child specific requirement.