0198-0211/90/1004-0211$02.00/0 FOOT& ANKLE Copyright 0 1990 by the American Orthopaedic Foot and Ankle Society, Inc.
Foot Growth in Children Age One to Five Years Nathaniel Gould,* t M.D., Morey Moreland,* M.D., Saul Trevino, * M.D., Richard Alvarez, M.D., James Fenwick,* Ph.D., and Nguyen Bach, B.S.
*
Burlington, Vermont
ABSTRACT As part of the protocol on the Development of the Child’s Arch,’ foot growth studies were monitored prospectively in 107 children from 1 year of age till 5 years of age. Under 15 months of age, growth necessitated a 112 size-footwear change in less than 2 months; from 15 months to 2 years of age, 112 size increase occurred every 2 to 3 months; from 2 to 3 years of age, 112 size change every 3 to 4 months; and from 3 to 5 years of age, 112 size change every 4 months. Although foot growth in boys and girls is parallel, boys’ feet tend to average one size longer and one size wider. Width growth remained proportional to length growth throughout the study.
youngest children approximately every 3 months, or more often if the youngster had obvious complaints. MATERIAL AND METHODS
An experienced shoe fitter employed a Ritz Stick to obtain foot measurements, which were taken during the afternoon. Information on 107 children who had made a minimum of three visits was collected and available for computerization. Although the initial group of children numbered 125, dropouts lowered the final number to 107. Polynomial regression was used to model the relationship between age and growth rate. To determine if the sexes differed in length or width, our analysis of covariance was used adjusting for age differences. Figure 1 is an illustration of the third order model that provides the best fit with an F value of 6.67 and tail probability of 0.001. It represents the curve of growth of all the children, male and female. It is not possible to follow the growth rate by using age alone, since children’s feet grow in spurts and these spurts do not occur at the same age in all children. Therefore this model accounts for only 24.4% of the variability in growth rate. To further assess the distribution of growth rate, cutpoints in age (Table 1) have been selected using the regression model. To be useful to pediatricians, other practitioners, and parents of small children, these cutpoints were chosen to correspond with the number of months needed for the foot to grow 1/2 shoe size. For example, if the rate of growth is 0.167 sizes/month, 3 months are needed to grow 1/2 shoe size. Age was broken down into five discrete categories of approximately 1 year each starting with younger than 15.5 months.
FOOT GROWTH IN CHILDREN AGE 1 TO 5 YEARS
As a segment of the protocol on a larger prospective 4 year study on the development of the child’s arch (age 1 to 5 years of age)l shoe sizing was monitored in 107 children with a minimum of three and a maximum of eleven visits to the shoe fitter. The children, at the onset of the study, ranged in age from 11 to 15 months. The earliest visit to the shoe fitter was therefore at 11 months of age and the latest at 79 months of age. No significant definitive studies on foot growth have been recorded in the literature till 1983 when Wenger et al. published a report in Foot & Ankle on “Foot Growth Rate in Children Age One to Six year^."^ Prior to this, the usual determinants for changes in shoe sizing have followed the experience and “guessology” of the shoe store itself, or obvious manifestations of foot-shoe problems such as pressure and redness of the feet (especially the toes), pain complaints, or limping. The latter are still the best criteria. In our protocol, visits to the shoe fitter were recommended for the
t
*
Department of Orthopaedic Surgery and Rehabilitation, University of Vermont College of Medicine. To whom all reprint requests should be addressed at: University of Vermont College of Medicine Given Building Burlington, Vermont 05405. Departmentof Biometry, University of Vermont College of Medicine.
RESULTS
Table 1 provides a clear picture of the variability in growth rate for young children. The majority (54.1“/o) of 21 1
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212
Foot & Ankle/Vol. 10, No. 4/February, 7 990
GOULD ET AL.
early toddlers (less than 15.5 months) grow more than 1/2 size in 2 months. The next two age groups have a wide distribution in growth rate and 59% of the children over 34.3 months grow slower than 0.125 sizes/month, and in these more than 4 months are depicted for a change of 1/2 shoe size. The growth pattern is shown in Figure 1. Figure 2 shows the relationship between size and age for boys and girls separately. There is a statistically significant difference between the size of shoes worn by boys and girls of the same age (F = 32.62, P .c 0.001), the boys' feet being longer. The width of children's feet (Fig. 3) is relatively constant over the entire range of ages studied (F = 2.43, P < 0.047). The only statistically significant difference occurs between the youngest age group of less than 18 months and the middle age group of 30 to 42 months. On the average, the younger group is 0.4 units wider than the middle age group on a 1-7 scale where 1 = A and 7 = EEE. The majority of all children's feet are width D (33.5%) or E (37.5%). Thus D and E widths occur in 71O/O of the children. Boys' feet on the average are wider than girls' feet (Fig. 3) at all ages (F = 48.29, P < 0.001).
. . o . ~ . 7 - .
-
- ,
,
, , ,,,,
-
DISCUSSION
The information presented in Table 1 provides a clear picture of the variability in growth. For most of the early toddlers (< 15.5 months) a change in shoes is needed every 2 months or less. This time period covers the first two or three pairs of shoes. In the next 18 months (ages 16-34 months) children should be checked for size change at 3 month intervals. Growth rate during this age interval is extremely variable with children needing 2 to 3, 3 to 4, or > 4 months to grow to a 1/2 size larger. At age 34 months (or approximately 3 years) the growth rate slows down and a 1/2 size shoe change occurs every 4 months or longer. Our study included a somewhat larger number of children in the younger age groups than Wenger et al., 1983.3 However, the growth rates reported here are consistent with theirs. They reported shifts from 2 to 3, 3 to 4, and > 4 months between shoe size change at 17, 29, and 47 months, respectively. The proportionate width of childrens feet changes very little over the first 5 years. Perhaps the most important finding in this study is the difference between boys and girls shoe sizes. On the average boys feet
-._
--.-7T7-v-.
Age (montk)
Fig. 1.
Curve of growth of all children
TABLE 1 Number of Children in Each Age Group and Specific Rate of Growth
Age (in months) 45.5
15.5 to 23.5
23.5 to 34.3
20
14
0
3
2-3 months per I/z size change. (0.167 < rate 0.25)
6
43
20
7
3-4 months per l/z size change. (0.125 < rate c 0.167)
8
25
33
22
Greater than 4 months per M size change (rate 5 0.125)
3
25
43
46
37
107
96
78
~~~~~
Total
>34.3
~
Less than 2 months per I/z size change. (rate > 0.25 sizes/months)
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Foot & Ankle/Vol. 10, No. 4/February, 1990
FOOT GROWTH IN CHILDREN
are longer than girls and are width E compared to width D for girls feet. Most of the footwear in this early age group is manufactured and imported from other countries. In the youngest age groups, shoes and sneakers are manufactured in one width size only, medium or D width. In order to adequately fit a youngster who requires a greater width, it is necessary to use the next size length. This creates a toe-stubbing effect and has been shown to cause unsatisfactory gait patterns and more frequent falls, especially on rugs.’ From this study slightly over 1/3 of the children fit into the D width category, mostly girls. If the manufactered width were changed to E, then approximately 3/4 of the children would be accommodated. The slightly wider than necessary shoe fitting creates little or no problems especially if the lacing of the shoe is snugly applied. CONCLUSIONS
Boys’ feet, in general, were one size longer and one size wider than girls’ feet, but their growth during the
213
5 year time period of this study paralleled growth of the girls feet. Children younger than 15 months of age required 1/2 size change every 5 to 6 weeks. Children between 15 months and 2 years of age, averaged 1/2 size change every 2 months. From 2 years to 3 years of age, children averaged 1/2 size change every 3 months, and from 3 years to 5 years of age, a 1/2 size change every 4 months was needed. The width of childrens feet, relative to length, remained proportionally unchanged in the time period of this study. It is recommended that manufacturers make children’s footwear in E width rather than D width, since nearly 3/4 of the children would then be accommodated in their proper length size, as compared to 1/3 of the children who are accomodated by the D width. ACKNOWLEDGMENTS
This study was carried out by annual grants from Memorial Research Fund of the Prescription Footwear Association. All footwear was provided gratis by the Sabel Shoe Company, Philadelphia, courtesy of Sidney Pols, President. Special thanks to Richard Munsell, shoe coordinator and fitter, and also to Bonnie Tucker, secretary.
REFERENCES 1. Gould, N., Moreland, M., Alvarez, R., Trevino, S., and Fenwick, J.: The development of the toddler arch. Foot Ankle, 9(5):241, 1989. 2. Gould, N.: Shoes versus sneakers in toddler ambulation. Foot Ankle, 6(2):105, 1985. 3. Wenger, D., Maul, din D., Morgan, D., Sobol, M., Pennebaker M., and Thale, R.: Foot growth rate in children age one to six years. Foot Ankle, 3(4):207,1983.
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Foot Growth in Children Age One to Five Years Nathaniel Gould,* t M.D., Morey Moreland,* M.D., Saul Trevino, * M.D., Richard Alvarez, M.D., James Fenwick,* Ph.D., and Nguyen Bach, B.S.
*
Burlington, Vermont
ABSTRACT As part of the protocol on the Development of the Child’s Arch,’ foot growth studies were monitored prospectively in 107 children from 1 year of age till 5 years of age. Under 15 months of age, growth necessitated a 112 size-footwear change in less than 2 months; from 15 months to 2 years of age, 112 size increase occurred every 2 to 3 months; from 2 to 3 years of age, 112 size change every 3 to 4 months; and from 3 to 5 years of age, 112 size change every 4 months. Although foot growth in boys and girls is parallel, boys’ feet tend to average one size longer and one size wider. Width growth remained proportional to length growth throughout the study.
youngest children approximately every 3 months, or more often if the youngster had obvious complaints. MATERIAL AND METHODS
An experienced shoe fitter employed a Ritz Stick to obtain foot measurements, which were taken during the afternoon. Information on 107 children who had made a minimum of three visits was collected and available for computerization. Although the initial group of children numbered 125, dropouts lowered the final number to 107. Polynomial regression was used to model the relationship between age and growth rate. To determine if the sexes differed in length or width, our analysis of covariance was used adjusting for age differences. Figure 1 is an illustration of the third order model that provides the best fit with an F value of 6.67 and tail probability of 0.001. It represents the curve of growth of all the children, male and female. It is not possible to follow the growth rate by using age alone, since children’s feet grow in spurts and these spurts do not occur at the same age in all children. Therefore this model accounts for only 24.4% of the variability in growth rate. To further assess the distribution of growth rate, cutpoints in age (Table 1) have been selected using the regression model. To be useful to pediatricians, other practitioners, and parents of small children, these cutpoints were chosen to correspond with the number of months needed for the foot to grow 1/2 shoe size. For example, if the rate of growth is 0.167 sizes/month, 3 months are needed to grow 1/2 shoe size. Age was broken down into five discrete categories of approximately 1 year each starting with younger than 15.5 months.
FOOT GROWTH IN CHILDREN AGE 1 TO 5 YEARS
As a segment of the protocol on a larger prospective 4 year study on the development of the child’s arch (age 1 to 5 years of age)l shoe sizing was monitored in 107 children with a minimum of three and a maximum of eleven visits to the shoe fitter. The children, at the onset of the study, ranged in age from 11 to 15 months. The earliest visit to the shoe fitter was therefore at 11 months of age and the latest at 79 months of age. No significant definitive studies on foot growth have been recorded in the literature till 1983 when Wenger et al. published a report in Foot & Ankle on “Foot Growth Rate in Children Age One to Six year^."^ Prior to this, the usual determinants for changes in shoe sizing have followed the experience and “guessology” of the shoe store itself, or obvious manifestations of foot-shoe problems such as pressure and redness of the feet (especially the toes), pain complaints, or limping. The latter are still the best criteria. In our protocol, visits to the shoe fitter were recommended for the
t
*
Department of Orthopaedic Surgery and Rehabilitation, University of Vermont College of Medicine. To whom all reprint requests should be addressed at: University of Vermont College of Medicine Given Building Burlington, Vermont 05405. Departmentof Biometry, University of Vermont College of Medicine.
RESULTS
Table 1 provides a clear picture of the variability in growth rate for young children. The majority (54.1“/o) of 21 1
Downloaded from fai.sagepub.com by guest on January 17, 2015
212
Foot & Ankle/Vol. 10, No. 4/February, 7 990
GOULD ET AL.
early toddlers (less than 15.5 months) grow more than 1/2 size in 2 months. The next two age groups have a wide distribution in growth rate and 59% of the children over 34.3 months grow slower than 0.125 sizes/month, and in these more than 4 months are depicted for a change of 1/2 shoe size. The growth pattern is shown in Figure 1. Figure 2 shows the relationship between size and age for boys and girls separately. There is a statistically significant difference between the size of shoes worn by boys and girls of the same age (F = 32.62, P .c 0.001), the boys' feet being longer. The width of children's feet (Fig. 3) is relatively constant over the entire range of ages studied (F = 2.43, P < 0.047). The only statistically significant difference occurs between the youngest age group of less than 18 months and the middle age group of 30 to 42 months. On the average, the younger group is 0.4 units wider than the middle age group on a 1-7 scale where 1 = A and 7 = EEE. The majority of all children's feet are width D (33.5%) or E (37.5%). Thus D and E widths occur in 71O/O of the children. Boys' feet on the average are wider than girls' feet (Fig. 3) at all ages (F = 48.29, P < 0.001).
. . o . ~ . 7 - .
-
- ,
,
, , ,,,,
-
DISCUSSION
The information presented in Table 1 provides a clear picture of the variability in growth. For most of the early toddlers (< 15.5 months) a change in shoes is needed every 2 months or less. This time period covers the first two or three pairs of shoes. In the next 18 months (ages 16-34 months) children should be checked for size change at 3 month intervals. Growth rate during this age interval is extremely variable with children needing 2 to 3, 3 to 4, or > 4 months to grow to a 1/2 size larger. At age 34 months (or approximately 3 years) the growth rate slows down and a 1/2 size shoe change occurs every 4 months or longer. Our study included a somewhat larger number of children in the younger age groups than Wenger et al., 1983.3 However, the growth rates reported here are consistent with theirs. They reported shifts from 2 to 3, 3 to 4, and > 4 months between shoe size change at 17, 29, and 47 months, respectively. The proportionate width of childrens feet changes very little over the first 5 years. Perhaps the most important finding in this study is the difference between boys and girls shoe sizes. On the average boys feet
-._
--.-7T7-v-.
Age (montk)
Fig. 1.
Curve of growth of all children
TABLE 1 Number of Children in Each Age Group and Specific Rate of Growth
Age (in months) 45.5
15.5 to 23.5
23.5 to 34.3
20
14
0
3
2-3 months per I/z size change. (0.167 < rate 0.25)
6
43
20
7
3-4 months per l/z size change. (0.125 < rate c 0.167)
8
25
33
22
Greater than 4 months per M size change (rate 5 0.125)
3
25
43
46
37
107
96
78
~~~~~
Total
>34.3
~
Less than 2 months per I/z size change. (rate > 0.25 sizes/months)
Downloaded from fai.sagepub.com by guest on January 17, 2015
Foot & Ankle/Vol. 10, No. 4/February, 1990
FOOT GROWTH IN CHILDREN
are longer than girls and are width E compared to width D for girls feet. Most of the footwear in this early age group is manufactured and imported from other countries. In the youngest age groups, shoes and sneakers are manufactured in one width size only, medium or D width. In order to adequately fit a youngster who requires a greater width, it is necessary to use the next size length. This creates a toe-stubbing effect and has been shown to cause unsatisfactory gait patterns and more frequent falls, especially on rugs.’ From this study slightly over 1/3 of the children fit into the D width category, mostly girls. If the manufactered width were changed to E, then approximately 3/4 of the children would be accommodated. The slightly wider than necessary shoe fitting creates little or no problems especially if the lacing of the shoe is snugly applied. CONCLUSIONS
Boys’ feet, in general, were one size longer and one size wider than girls’ feet, but their growth during the
213
5 year time period of this study paralleled growth of the girls feet. Children younger than 15 months of age required 1/2 size change every 5 to 6 weeks. Children between 15 months and 2 years of age, averaged 1/2 size change every 2 months. From 2 years to 3 years of age, children averaged 1/2 size change every 3 months, and from 3 years to 5 years of age, a 1/2 size change every 4 months was needed. The width of childrens feet, relative to length, remained proportionally unchanged in the time period of this study. It is recommended that manufacturers make children’s footwear in E width rather than D width, since nearly 3/4 of the children would then be accommodated in their proper length size, as compared to 1/3 of the children who are accomodated by the D width. ACKNOWLEDGMENTS
This study was carried out by annual grants from Memorial Research Fund of the Prescription Footwear Association. All footwear was provided gratis by the Sabel Shoe Company, Philadelphia, courtesy of Sidney Pols, President. Special thanks to Richard Munsell, shoe coordinator and fitter, and also to Bonnie Tucker, secretary.
REFERENCES 1. Gould, N., Moreland, M., Alvarez, R., Trevino, S., and Fenwick, J.: The development of the toddler arch. Foot Ankle, 9(5):241, 1989. 2. Gould, N.: Shoes versus sneakers in toddler ambulation. Foot Ankle, 6(2):105, 1985. 3. Wenger, D., Maul, din D., Morgan, D., Sobol, M., Pennebaker M., and Thale, R.: Foot growth rate in children age one to six years. Foot Ankle, 3(4):207,1983.
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