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Reliability and Agreement of a Dual-Method Radiographic Standard vs. Clinical Goniometry for Shank-Forefoot

Sergi Carrelero-Camp1, Miki Dalmau-Pastor2,3, Vanessa Oliva-Garballo1

  • 1Departmental Section of Podiatry, Department of Clinical Sciences, School of Medicine and Health Sciences, University of Barcelona, 08907 Barcelona, Spain.

Diagnostics (Basel, Switzerland)
|March 14, 2026
PubMed
Summary

Marker-based radiography offers a reliable standard for assessing forefoot varus, a common foot alignment issue. Standardized goniometry is suitable for routine clinical use, while radiography is best for research.

Keywords:
forefoot varusgoniometryradiographyreference standardsreproducibility of resultsshank-forefoot alignment

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Area of Science:

  • Orthopedics and Biomechanics
  • Radiographic Imaging
  • Clinical Measurement Reliability

Background:

  • Forefoot varus prevalence estimates vary significantly due to the absence of a gold standard diagnostic method.
  • Existing clinical assessment techniques for forefoot varus are limited by subjective positioning and variability in anatomical landmark identification.
  • Establishing a reliable radiographic reference is crucial for accurate diagnosis and consistent measurement of forefoot varus.

Purpose of the Study:

  • To establish a reliable radiographic reference standard for measuring forefoot varus using a dual-method radiographic approach.
  • To compare the reliability and agreement of marker-based radiography with standardized goniometry.
  • To determine the clinical utility of goniometry versus radiography for forefoot varus assessment.

Main Methods:

  • Seventy lower limbs from 35 participants were evaluated following the Guidelines for Reporting Reliability and Agreement Studies (GRRAS).
  • Three blinded investigators assessed reliability through inter-rater (30-minute interval) and intra-rater (≥30-day washout) sessions.
  • Dual radiographic techniques (metallic nail vs. radiopaque markers) were compared against standardized goniometry, with statistical analysis including ICC, SEM, MDC95, and Bland-Altman plots (p < 0.005).

Main Results:

  • The study found a high prevalence of forefoot varus (97.1%, ≥0°), with a mean measurement of 15.53 ± 7.35°.
  • Goniometry demonstrated excellent inter-rater reliability (ICC = 0.987), and marker-based radiography showed excellent intra-rater reliability (ICC = 0.906).
  • Strong agreement was observed between goniometry and marker-based radiography (ICC = 0.898), with no significant differences based on sex or laterality.

Conclusions:

  • Marker-based radiography serves as a validated, highly reliable reference standard for forefoot varus measurement.
  • Standardized clinical goniometry is reliable and shows strong agreement with radiographic findings, making it suitable for routine clinical assessment (changes > 1.4° indicate true structural change).
  • Radiographic assessment should be reserved for research purposes or definitive structural confirmation, given its established reliability and agreement with clinical methods.