Relationship Between Clarke’s Angle and Radiological Severity of Knee Osteoarthritis: A Cross-Sectional Study
DOI:
https://doi.org/10.36452/jkdoktmeditek.v31i3.3694Keywords:
Clarke’s angle, flatfoot, Kellgren-Lawrence, knee osteoarthritis, non-communicable diseasesAbstract
Introduction: Knee osteoarthritis (OA) is a degenerative joint disease causing disability, especially in older adults. Flatfoot, marked by reduced medial arch height, alters lower limb biomechanics and may influence knee OA severity. Objective: To evaluate the association between foot arch, measured by Clarke’s angle, and knee OA severity based on the Kellgren-Lawrence (K-L) grading to provide clinical insight for guiding management decisions. Methods: A cross-sectional study of 57 knee OA patients at Siloam Karawaci Hospital was conducted. Clarke’s angle was measured using ink footprints, and K-L grading assessed radiological severity. Statistical tests included Kolmogorov-Smirnov, one-way ANOVA, and Kruskal-Wallis, with p < 0.05 considered significant. Results: Most participants were female (77.2%) with a mean age of 65.85 ± 9.69 years. OA severity was mostly mild to moderate (K-L 2 and 3). Flatfoot prevalence was 47.4%, and lower Clarke’s angles were significantly associated with higher K-L grades (p = 0.029). No significant differences in age or BMI were found across severity groups, though BMI trended higher with severity. Conclusion: Lower Clarke’s angle correlates with increased knee OA severity. Flatfoot may contribute to or result from OA progression. Further research is needed to clarify causation and inform management strategies.
References
Alshami AM. Knee Osteoarthritis Related Pain : A Narrative Review of Diagnosis and Treatment. International Journal of Health Sciences. 2014 [cited 2025 March 19];8(1): 85–104. Available from: https://doi.org/10.12816/0006075.
Long H, Liu Q, Yin H, Wang K, Diao N, Zhang Y, et al. Prevalence Trends of Site‐Specific Osteoarthritis From 1990 to 2019: Findings From the Global Burden of Disease Study 2019. Arthritis & Rheumatology. 2022 [cited 2025 March 20];74(7): 1172–1183. Available from: https://doi.org/10.1002/art.42089.
Courties A, Kouki I, Soliman N, Mathieu S, Sellam J. Osteoarthritis year in review 2024: Epidemiology and therapy. Osteoarthritis and Cartilage. 2024 [cited 2025 March 19];32(11): 1397–1404. Available from: https://doi.org/10.1016/j.joca.2024.07.014.
Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. The Lancet. 2020[cited 2025 March 19];396(10267): 2006–2017. Available from: https://doi.org/10.1016/S0140-6736(20)32340-0.
Almeheyawi RN, Bricca A, Riskowski JL, Barn R, Steultjens M. Foot characteristics and mechanics in individuals with knee osteoarthritis: systematic review and meta‐analysis. Journal of Foot and Ankle Research. 2021 [cited 2025 March 19];14(1). Available from: https://doi.org/10.1186/s13047-021-00462-y.
Guler H, Karazincir S, Turhanoglu AD, Sahin G, Balci A, Ozer C. Effect of Coexisting Foot Deformity on Disability in Women with Knee Osteoarthritis. Journal of the American Podiatric Medical Association. 2009 [cited 2025 March 19];99(1): 23–27. Available from: https://doi.org/10.7547/0980023.
Michaudet C, Edenfield KM, Nicolette GW, Carek PJ. Foot and Ankle Conditions: Pes Planus. FP essentials. 2018 [cited 2025 March 21];465: 18—23. Available from: http://europepmc.org/abstract/MED/29381041
Hegazy F, Aboelnasr E, Abuzaid M, Kim IJ, Salem Y. Comparing Validity and Diagnostic Accuracy of Clarke’s Angle and Foot Posture Index-6 to Determine Flexible Flatfoot in Adolescents: A Cross-Sectional Investigation. Journal of Multidisciplinary Healthcare. 2021 [cited 2025 March 19]; 14: 2705–2717. Available from: https://doi.org/10.2147/JMDH.S317439.
Pauk J, Ihnatouski M, Najafi B. Assessing Plantar Pressure Distribution in Children with Flatfoot Arch. Journal of the American Podiatric Medical Association. 2014 [cited 2025 March 19];104(6): 622–632. Available from: https://doi.org/10.7547/8750-7315-104.6.622.
Cheng CK, Zhang M, Nie M dan, Qi X zheng, Ke S, Li J wei, et al. The association between the flat feet and the symptoms of knee osteoarthritis. 2022 [cited 2025 March 18]. Available from: https://doi.org/10.21203/rs.3.rs-1240420/v1.
Zhang M, Nie MD, Qi XZ, Ke S, Li JW, Shui YY, et al. A Strong Correlation Between the Severity of Flatfoot and Symptoms of Knee Osteoarthritis in 95 Patients. Frontiers in Surgery. 2022 [cited 2025 March 19];9. Available from: https://doi.org/10.3389/fsurg.2022.936720.
Iijima H, Ohi H, Isho T, Aoyama T, Fukutani N, Kaneda E, et al. Association of bilateral flat feet with knee pain and disability in patients with knee osteoarthritis: A cross‐sectional study. Journal of Orthopaedic Research. 2017 [cited 2025 March 21];35(11): 2490–2498. Available from: https://doi.org/10.1002/jor.23565.
Hakukawa S, Kaneda K, Yamada Y, Harato K, Sasaki R, Oki S, et al. The Association Between Progression of Flat Foot and Knee Deformity in Patient with Knee Osteoarthritis -A Study with Three-Dimentional Upright Computed Tomography-. Osteoarthritis and Cartilage. 2022 [cited 2025 March 20];30: S286–S287. Available from: https://doi.org/10.1016/j.joca.2022.02.384.
Patil V, Shah M, Krishnani K, Jhala N. The Impact of Pes Planus on Knee Function and Its Association with Medial Compartment Knee Osteoarthritis. Journal of Orthopaedic Case Reports. 2024 [cited 2025 March 21];14(10): 275–281. Available from: https://doi.org/10.13107/jocr.2024.v14.i10.4888.
Kohn MD, Sassoon AA, Fernando ND. Classifications in Brief: Kellgren-Lawrence Classification of Osteoarthritis. Clinical Orthopaedics & Related Research. 2016 [cited 2025 March 23];474(8): 1886–1893. Available from: https://doi.org/10.1007/s11999-016-4732-4.
Steinmetz JD, Culbreth GT, Haile LM, Rafferty Q, Lo J, Fukutaki KG, et al. Global, regional, and national burden of osteoarthritis, 1990–2020 and projections to 2050: a systematic analysis for the Global Burden of Disease Study 2021. The Lancet Rheumatology. 2023 [cited 2025 March 23];5(9): e508–e522. Available from: https://doi.org/10.1016/S2665-9913(23)00163-7.
Sikander T, Raza MH, Ullah A, Khurshid A, Zafar A, Haider MA, et al. Association Between Occurrence of Knee Osteoarthritis and Physical Activity in Older Adults. Journal of Health and Rehabilitation Research. 2024 [cited 2025 March 21];4(1): 764–768. Available from: https://doi.org/10.61919/jhrr.v4i1.408.
Yoldas B, Akdemir E, Anil B, Korkmaz E, Kumru D, Yilmaz C, et al. Pain, quality of life, proprioception and physical function in patient with knee osteoarthritis: Comparison of different grades. Medicine Science | International Medical Journal. 2024 [cited 2025 March 22];13(2): 406. Available from: https://doi.org/10.5455/medscience.2024.04.037.
Butarbutar JCP, Basuki P, Sungono V, Riantho A, Fidiasrianto K. Burden of osteoarthritis in Indonesia: A Global Burden of Disease (GBD) study 2019. Narra J. 2024 [cited 2025 March 24];4(2). Available from: https://doi.org/10.52225/narra.v4i2.884.
Fahdizhar E, Nugraheni Sulistiawaty N, Zaim Chilmi M. Clinical Profile Of Knee Osteoarthritis In The Medical Rehabilitation Outpatient Installation Of Dr. Soetomo General Hospital Surabaya. International Journal of Research Publications. 2021 [cited 2025 March 22];91(1). Available from: https://doi.org/10.47119/IJRP1009111220212586.
Kim I, Kim HA, Seo YI, Song YW, Jeong JY, Kim DH. The Prevalence of Knee Osteoarthritis in Elderly Community Residents in Korea. Journal of Korean Medical Science. 2010 [cited 2025 March 23];25(2): 293. Available from: https://doi.org/10.3346/jkms.2010.25.2.293.
Bakılan F, Özgen M. The Characteristics of Radiographic Knee Osteoarthritis According to Age and Gender at a University Hospital. Osmangazi Tıp Dergisi. 2021 [cited 2025 March 21];43(2): 164–170. Available from: https://doi.org/10.20515/otd.776910.
Geng R, Li J, Yu C, Zhang C, Chen F, Chen J, et al. Knee osteoarthritis: Current status and research progress in treatment (Review). Experimental and Therapeutic Medicine. 2023 [cited 2025 March 25];26(4): 481. Available from: https://doi.org/10.3892/etm.2023.12180.
Primorac D, Molnar V, Rod E, Jeleč Ž, Čukelj F, Matišić V, et al. Knee Osteoarthritis: A Review of Pathogenesis and State-Of-The-Art Non-Operative Therapeutic Considerations. Genes. 2020 [cited 2025 March 24];11(8): 854. Available from: https://doi.org/10.3390/genes11080854.
Allen KD, Thoma LM, Golightly YM. Epidemiology of osteoarthritis. Osteoarthritis and Cartilage. 2022 [cited 2025 March 23];30(2): 184–195. Available from: https://doi.org/10.1016/j.joca.2021.04.020.
Vina ER, Kwoh CK. Epidemiology of osteoarthritis: literature update. Current Opinion in Rheumatology. 2018 [cited 2025 March 25];30(2): 160–167. Available from: https://doi.org/10.1097/BOR.0000000000000479.
Klets O, Mononen ME, Liukkonen MK, Nevalainen MT, Nieminen MT, Saarakkala S, et al. Estimation of the Effect of Body Weight on the Development of Osteoarthritis Based on Cumulative Stresses in Cartilage: Data from the Osteoarthritis Initiative. Annals of Biomedical Engineering. 2018 [cited 2025 March 24];46(2): 334–344. Available from: https://doi.org/10.1007/s10439-017-1974-6.
Liu Z, Xie W, Li H, Liu X, Lu Y, Lu B, et al. Novel perspectives on leptin in osteoarthritis: Focus on aging. Genes & Diseases. 2024 [cited 2025 March 24];11(6): 101159. Available from: https://doi.org/10.1016/j.gendis.2023.101159.
Wang T, He C. Pro-inflammatory cytokines: The link between obesity and osteoarthritis. Cytokine & Growth Factor Reviews. 2018 [cited 2025 March 24];44: 38–50. Available from: https://doi.org/10.1016/j.cytogfr.2018.10.002.
Levinger P, Menz HB, Fotoohabadi MR, Feller JA, Bartlett JR, Bergman NR. Foot posture in people with medial compartment knee osteoarthritis. Journal of Foot and Ankle Research. 2010 [cited 2025 March 19];3(1). Available from: https://doi.org/10.1186/1757-1146-3-29.
Reilly K, Barker K, Shamley D, Newman M, Oskrochi GR, Sandall S. The role of foot and ankle assessment of patients with lower limb osteoarthritis. Physiotherapy. 2009 [cited 2025 March 19];95(3): 164–169. Available from: https://doi.org/10.1016/j.physio.2009.04.003.
Abourazzak FE, Kadi N, Azzouzi H, Lazrak F, Najdi A, Nejjari C, Harzy TJ. A Positive Association Between Foot Posture Index and Medial Compartment Knee Osteoarthritis in Moroccan People. The Open Rheumatology Journal. 2014 [cited 2025 March 24];8(1): 96–99. Available from: https://doi.org/10.2174/1874312901408010096.
Akaltun MS, Koçyiğit BF. Assessment of foot posture and related factors in patients with knee osteoarthritis. Archives of Rheumatology. 2021 [cited 2025 March 23];36(2): 267–273. Available from: https://doi.org/10.46497/ArchRheumatol.2021.8354.
Yue Y, Lam WK, Jiang L, Liu Z, Ma R, Zheng Y. The effect of arch-support insole on knee kinematics and kinetics during a stop-jump maneuver. Prosthetics & Orthotics International. 2022 [cited 2025 March 23];46(4): 368–373. Available from: https://doi.org/10.1097/PXR.0000000000000103.
Cho Y, Ko Y, Lee W. Relationships among foot position, lower limb alignment, and knee adduction moment in patients with degenerative knee osteoarthritis. Journal of Physical Therapy Science. 2015 [cited 2025 March 19];27(1): 265–268. Available from: https://doi.org/10.1589/jpts.27.265.
Flemister AS, Neville CG, Houck J. The Relationship Between Ankle, Hindfoot, and Forefoot Position and Posterior Tibial Muscle Excursion. Foot & Ankle International. 2007 [cited 2025 March 21];28(4): 448–455. Available from: https://doi.org/10.3113/FAI.2007.0448.
Tan JM, Crossley KM, Munteanu SE, Collins NJ, Hart HF, Donnar JW, et al. Associations of foot and ankle characteristics with knee symptoms and function in individuals with patellofemoral osteoarthritis. Journal of Foot and Ankle Research. 2020 [cited 2025 March 21];13(1). Available from: https://doi.org/10.1186/s13047-020-00426-8.
Powers CM, Witvrouw E, Davis IS, Crossley KM. Evidence-based framework for a pathomechanical model of patellofemoral pain: 2017 patellofemoral pain consensus statement from the 4th International Patellofemoral Pain Research Retreat, Manchester, UK: part 3. British Journal of Sports Medicine. 2017 [cited 2025 March 19];51(24): 1713–1723. Available from: https://doi.org/10.1136/bjsports-2017-098717.
Kumar Jha D, Unprasert P, Chuckpaiwong B. The Prevalence and Correlation of Foot Deformity in Primary Osteoarthritis of the Knee. 2021 Dec. 21 [cited 2025 April 10];45(3-4):9-12. Available from: http://thailand.digitaljournals.org/index.php/JRCOST
McWilliams DF, Doherty S, Maciewicz RA, Muir KR, Zhang W, Doherty M. Self‐reported knee and foot alignments in early adult life and risk of osteoarthritis. Arthritis Care & Research. 2010 [cited 2025 March 19];62(4): 489–495. Available from: https://doi.org/10.1002/acr.20169.
Sharma L, Song J, Dunlop D, Felson D, Lewis CE, Segal N, et al. Varus and valgus alignment and incident and progressive knee osteoarthritis. Annals of the Rheumatic Diseases. 2010 [cited 2025 March 19];69(11): 1940–1945. Available from: https://doi.org/10.1136/ard.2010.129742.
Yu L, Wang Y, Yang J, Wang J, Zhang Y. Effects of orthopedic insoles on patients with knee osteoarthritis: A meta-analysis and systematic review. Journal of Rehabilitation Medicine. 2021 [cited 2025 March 19];53(5): jrm00191. Available from: https://doi.org/10.2340/16501977-2836.
Zhang B, Yu X, Liang L, Zhu L, Dong X, Xiong Y, et al. Is the Wedged Insole an Effective Treatment Option When Compared with a Flat (Placebo) Insole: A Systematic Review and Meta‐Analysis. Evidence-Based Complementary and Alternative Medicine. 2018 [cited 2025 April 18];2018(1). Available from: https://doi.org/10.1155/2018/8654107.
Hunt MA, Takacs J, Krowchuk NM, Hatfield GL, Hinman RS, Chang R. Clinical changes using lateral wedges with and without arch support in people with medial knee osteoarthritis and flat feet: a randomized crossover study. Osteoarthritis and Cartilage. 2017 [cited 2025 March 19];25: S406. Available from: https://doi.org/10.1016/j.joca.2017.02.701.
Rogoschin J, Preiser T, Hansen L, Potthast W, Komnik I. Kinetic effects of unicompartmental unloader braces in medial knee osteoarthritis: A longitudinal study of joint load during level, stair, and slope walking. Journal of Biomechanics. 2025 [cited 2025 April 19];184: 112593. Available from: https://doi.org/10.1016/j.jbiomech.2025.112593.
Parween R, Shriram D, Mohan RE, Lee YHD, Subburaj K. Methods for evaluating effects of unloader knee braces on joint health: a review. Biomedical Engineering Letters. 2019 [cited 2025 March 19];9(2): 153–168. Available from: https://doi.org/10.1007/s13534-019-00094-z.
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