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Posts Tagged ‘metatarsal arch’

It is often stated that the human foot has 3 arches; two longitudinal arches and the transverse arch (sometimes also referred to as the metatarsal arch).1 Whereas the presence of longitudinal arches are unanimously accepted, the transverse metatarsal arch of the foot is considered to be quite controversial.  Believe it or not its existence has been debated since last century.  But what is the transverse metatarsal arch?  And what does the research actually tell us about it?

The existence of a transverse arch at the metatarsal region would require the pressure to be greatest at the areas beneath the 1st and 5th metatarsal heads, and the area of the 2nd, 3rd and 4th metatarsal heads to be elevated relative to this.  This gives us the ‘tripod’ like weight distribution of the foot which was first described by Kapandji in 1970.2 However, the first descriptions of the transverse metatarsal arch date back as far as 100 years prior to Kapandji’s work3 and several papers published in Germany between 1882 and 1927 actually concluded that no transverse arch of the foot was usually present.4-7 Much of the research produced following Kapandji’s work concurs with these conclusions regarding the transverse metatarsal arch being a misnomer.

So if the presence of a transverse metatarsal arch has long been questioned, why have so many authors, and indeed medical professionals, subscribed to this theory for so long (and continue to do so) in spite of growing evidence against it?

The conception of the foot bearing its weight on three points must be quite attractive in order to persist (Jones, 1941)8

When a patient presents with diffuse pain across the forefoot, what should be performed is thorough examination of the region, identification of the anatomical structure which is involved, and then a management plan directed towards reducing the symptoms with the most appropriate treatment available.  However, all too often a clinician will diagnose ‘metatarsalgia’ (NOT a diagnosis, but we’ll save that for another blog) caused by ‘dropped metatarsals’ or ‘a fallen metatarsal arch’.  It’s very quick and very easy, and you can see how it doesn’t require too much thinking.  For these clinicians to accept that a transverse metatarsal arch does not exist would require them to change their entire clinical practice, and for many this sort of paradigm shift in thinking is too uncomfortable to accept, so instead they continue as they are.

So, 100 year old journal articles written in German aside, lets look at some of the more current research which has looked at the mythical transverse metatarsal arch.

In 1997, Daentzer et al.9 performed a study on 100 feet.  The age range of the participants in the study was between 10-72 years old.  None of the participants had any foot deformity or symptoms.  Ultrasonography was performed at the level of the metatarsal heads in both non weight bearing and weightbearing.  Barefoot plantar pressure measurements were recorded using a force plate.  Their findings/conclusions: Pressures are usually highest underneath the 2nd, 3rd and 4th metatarsal heads, there is no transverse metatarsal arch, and the forefoot is normally flat at the level of the metatarsal heads.

In 1999, Luger et al.10 performed a study on 720 feet (the largest study to my knowledge).  The age range of the participants in the study was 18-83 years old.  Interestingly they included individuals with a variety of foot symptoms and abnormalities as well as pain free individuals.  The all had static and dynamic barefoot pressure measurements taken.  Their findings/conclusions: Only 22 feet out of 720 (3%) had a dynamic metatarsal arch whilst walking, and this was only found in the feet classified as having deformity or pain.  Not only was a transverse metatarsal arch rarely seen, but they concluded that it actually indicated a possible pathological deformity (i.e it is an abnormality which may cause problems)

In 2003, Kanatli et al.11 performed a study on 32 feet.  The age range of the participants in the study was 20-30 years old.  All participants were pain free and had no foot deformities.  Barefoot plantar pressure measurements were taken whilst walking.  Their findings/conclusions: Significantly higher pressures were recorded beneath the 2nd and 3rd metatarsal heads, and the transverse metatarsal arch did not exist in normal subjects.

As you can see one of the common findings seen in the research discussed has been that higher pressures are not seen beneath the 1st and 5th metatarsal heads during gait.  Other authors have investigated this employing pressure measurement equipment and found that the pressures in the middle metatarsals are consistently greater than the 1st and 5th metatarsals.12,13 All of the research suggests that the tripod configuration of the foot is completely erroneous, and without this, it is obvious that it is not possible for there to be a transverse metatarsal arch.  Clinicians who continue to talk about the transverse arch, and offer treatments for its ‘collapse’ are either uninformed, bogged down in old habits or in denial.

References

  1. Williams, P.L. et al. (1995) Gray’s Anatomy. 38th Edition, Churchill Livingstone, New York.
  2. Kapandji, L.A. (1970) The Physiology of the Joints. E & S Livingstone, Edinburgh.
  3. Henle, J. (1871) Handbuch der Knochenlehre des Menschen. Vieweg, Braunschweig.
  4. Beely, F. (1882) Zur Mechanik des Stehens. Uber die Bedeutung des Fussgewolbes im Stehen. Arch klin Chir, 27: 457-471.
  5. Momburg, F.A. (1909) Die Stutzpunkte des Fusses beim Gehen und Stehen. Dtsch med Wschr, 4: 148-152.
  6. Frostell, G. (1925) Beitrag zur Kenntnis der vorderen Stutzpunkte des Fusses, sowie des Fusswinkels beim Stehen und Gehen. Z  Orthop Chir, 47: 3-54.
  7. Abramson, E. (1927) Zur Kenntnis der Mechanik des Mittelfusses. Skand Arch Physiol, 51: 175-234.
  8. Jones, R.L. (1941) The Human Foot. An experimental study of its mechanics, and the role of its muscles and ligaments in support of the arch. American Journal of Anatomy, 68: 1-39.
  9. Daentzer, D., Wulker, N., & Zimmermann, U. (1997) Observations concerning the transverse metatarsal arch. Foot and Ankle Surgery, 3: 15-20.
  10. Luger, E.J., Nissan, M., Karpf, A., Steinberg, E.L., & Dekel, S. (1999) Patterns of weight distribution under the metatarsal heads. The Journal of Bone & Joint Surgery (Br), 81: 199-202.
  11. Kanatli, U., Yetkin, H., & Bolukbasi, S. (2003) Evaluation of the transverse metatarsal arch of the foot with gait analysis. Arch Orthop Trauma Surg, 123: 148-150.
  12. Cavanagh, P.R., Rodgers, M.M., & Iiboshi, A. (1987) Pressure distribution under symptom-free feet during barefoot standing. Foot and Ankle, 7: 262-276.
  13. Hennig, E.M., & Milani, T.L. (1993) Die Dreipunktuntersttzung des Fusses. Eine Druckverteilungsanalyse bei statischer und dynamischer Belastung. Z Orthop, 131: 279-284.

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