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  • Meeting abstract
  • Open Access

1000 Norms Project: understanding foot and ankle health, disease and normality

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Journal of Foot and Ankle Research20147 (Suppl 1) :A6

  • Published:


  • Health Surveillance
  • Plantar Pressure
  • Reference Dataset
  • Measure Development
  • Ankle Instability
A primary goal of healthcare is to understand the boundaries of health and normality and identify when abnormalities are harmful. Diagnosis of disease or impairment is often made by comparing results from clinical measures with healthy reference values. At present there is a great need for comprehensive lower limb reference data representing the healthy population. The 1000 Norms Project is currently recruiting to provide reference values for a set of widely-used clinical and biomechanical measures of the foot and ankle. A volunteer sample of 1000 healthy individuals between the ages of 3 and 100 years is participating in the Project. Measures of plantar pressure, gait, ankle range of motion, foot and ankle muscle strength, foot posture and ankle instability are included in the comprehensive battery of items (Table 1).
Table 1

Foot and ankle items assessed in the 1000 Norms Project


Item Description

Measurement variables

Plantar pressure

Collection of plantar pressure during gait using two-step protocol and Emed pressure platform (Novel)

Peak pressure, mean pressure and pressure-time integral at different regions of the foot

Ankle range of motion

Active ankle plantarflexion measured using goniometry

Passive ankle dorsiflexion measured using weight-bearing lunge test

Plantarflexion angle in degrees

Dorsiflexion angle in degrees

Ankle strength

Plantarflexion strength assessed using fixed dynamometry

Dorsiflexion strength assessed using handheld dynamometry

Results from three trials presented as raw data in Newtons and also normalised to body weight

Toe flexor strength

Paper Grip Test assessing strength of hallux and four lesser toes

Pass/fail score recorded for ability to grip paper under toes


Spatio-temporal aspects of gait measured using Zeno walkway (Protokinetics)

Step time, step length and width, gait velocity and foot progression angle

Foot posture

Foot Posture Index consisting of six assessments relating to foot posture

Foot posture graded on a 15-point scale from -12 (varus) to +12 (valgus)

Ankle instability

Cumberland Ankle Instability Tool (Adult and Youth versions) consisting of 9 items pertaining to self-perception of ankle stability

Overall score out of 30 where higher scores indicate greater instability

The 1000 Norms Project reliability study was completed in November 2013. Inter-rater reliability was found to be excellent (ICC>.75) for all foot and ankle measures (Table 2). Recruitment and data collection will take place over the next two years. The release of the final database to the international community via a secure, free online network is anticipated to occur in March 2016. The 1000 Norms Project will provide a substantial contribution to our understanding of the range of normal foot and ankle function in healthy individuals. The reference dataset will be a useful tool for disease diagnosis and management, health surveillance and future outcome measure development for clinical trials of rehabilitative, surgical and pharmacological interventions.
Table 2

Inter-rater reliability of foot and ankle items assessed in the 1000 Norms Project


ICC (95% CI)


SEM % mean

Ankle plantarflexion ROM

.885 (.538-.971)



Ankle dorsiflexion lunge test

.875 (.498-.969)



Dorsiflexion strength

.958 (.831-.990)



Plantarflexion strength

.973 (.892-.993)



Foot Posture Index Left Total Score

.978 (.916-.994)



Foot Posture Index Right Total Score

.958 (.820-.990)



Note: ROM, range of motion; ICC, Intraclass Correlation Coefficient (95% Confidence Interval); SEM, Standard Error of Measurement; SEM % mean, Standard Error of Measurement expressed as a percentage of the mean

Authors’ Affiliations

Arthritis and Musculoskeletal Research Group, Faculty of Health Sciences, The University of Sydney, Australia
Institute for Neurosciences and Muscle Research, The Children’s Hospital at Westmead, Australia


© Baldwin et al; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.