Foot & Ankle International - June 2017 - 693

Miller et al
the variety of pathologies seen in a typical foot and ankle
practice, our study was underpowered to determine if any
specific diagnosis would lead to inappropriate amounts of
weight bearing. One might surmise, for example, that acute
injuries and fractures would predispose patients to apply
less weight as compared to less severe or more chronic conditions. Third, there is no current evidence to suggest the
recommended amount of weight that patients should bear in
order to adequately evaluate all foot and ankle pathology.
For the purpose of this study, our cut-offs were chosen arbitrarily based on the authors' consensus.
Given that a significant portion of the gait cycle is in single leg stance, a question raised is whether a normal weightbearing radiograph should be obtained with 100% body
weight. Although the answer to this is beyond the scope of
this study and practical considerations exist regarding patient
safety, complete weightbearing may further elucidate pathology and deformity, which previously may have been underestimated. Furthermore, this question drives to the heart of
the issue, whether weight-bearing radiographs provide full
and accurate clinical information. How much weight is
required to adequately evaluate pathology is unknown. We
are unaware of any current studies that have addressed the
question of how radiographic parameters change with incremental weight bearing. It is unknown whether radiographic
parameters such as the Meary and intermetatarsal angles
would continue to change when body weight approaches
100% and perhaps we are underestimating deformity.
Because standing radiographs may be used for decisions as
broad as deciding between operative and nonoperative treatment or as exacting as determining the amount of bony
resection required when performing an osteotomy, inadequate weight bearing and assessment of deformity may
explain some of the "undercorrections" we all have and see.
In conclusion, the current investigation highlights the
variability of weight applied and improvements seen with
prompting. However, more significant implications are raised
regarding the assumptions made regarding weight-bearing
radiographs. Although the instruction to obtain a standing or
nonstanding radiograph is dichotomous and binary, the resultant radiographic image and relative alignment of bony structures is influenced by the continuous variable of how much
weight is actually applied. In other words, the amount of
deformity or malalignment seen is influenced by the weight
that the patient applies. Without an understanding of how
much weight is required to accurately measure the true
malalignment of foot and ankle pathology, we may be inappropriately diagnosing and treating conditions of the foot and
ankle. Considering this concept, future studies should be considered to determine how radiographic parameters change
with incremental weight bearing in order to define the minimum, and potentially a maximum, acceptable amount of
weight bearing for various foot and ankle pathologies.

693
Authors' Note
This research was performed at the Beth Israel Deaconess Medical
Center, Harvard Medical School, Boston, Massachusetts.

Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Each author certifies that he has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/
licensing arrangements, etc) that might pose a conflict of interest
in connection with the submitted article.

Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.

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