scoliosis is a 3-dimensional vertebral transformation , accompanied by rotation and lateral 
 deviation of each vertebra1 .
scoliosis 
 most often develops in childhood ( at around 10  years of age ) becoming apparent in 
 adolescence , and is reported to deteriorate rapidly2 .
an especially fast progression of scoliosis is shown during the 
 adolescent period , when growth is the most active before it is completed , which has worsened 
 in recent years due to a lack of physical activity and due to the prolonged use of 
 smartphones and pcs in awkward postures3 . in cases of scoliosis that escape detection , patients complain of decreased social activity 
 and backache , primarily due to changes in body shape , which are often accompanied by 
 breathing difficulties . in extreme cases ,
the possibility of death due to a decline in 
 cardiac and pulmonary function and respiratory failure increases , and surgery is inevitably 
 necessary4 , 5 .
thus , early detection is paramount , because the prognosis of 
 undetected scoliosis is poor6 .
the main 
 methods used to diagnose scoliosis at clinical sites are cobb s angle , risser sign , 
 vertebral stability and rotation of vertebrae ( perdriolle or nash - moe method)7 .
most of these methods use expensive 
 magnetic resonance imaging ( mri ) equipment . in view of the characteristics of scoliosis
, 
 patients do not complain of limitations to physical movement or discomfort at early stages , 
 and only receive a diagnosis at clinical sites after vertebral arrangement progression 
 becomes serious .
many studies have found that examination at an early age ( 11 or 12  years ) 
 is appropriate because early screenings for scoliosis enable treatment to be given at a 
 critical point in time8 .
although there are many diagnostic methods that use high - priced cutting - edge equipment , 
 active treatment following quick early detection at schools or other youth facilities is the 
 most efficient evaluation method and means of enabling treatment9 .
in addition to examination methods that use harmful 
 radiation , location comparisons of the shoulders , chest , waist , and pelvis by ocular 
 inspection ; pulmonary function tests ; and measurements using a scoliometer along with 
 forward bending , are also reliable measurement methods10 .
this study carried out a correlation analysis based on quick predictive methods with the 
 naked eye , such as the calcaneal valgus angle , the calcaneal angle and adam s forward 
 bending test , in front - line facilities such as schools , then checked those methods 
 preciseness and reliability in order to present the most effective evaluation method .
the 
 purpose of this study was to detect adolescent scoliosis early , to prevent unnecessary 
 surgeries and aid proper treatment .
this study targeted adolescents who received diagnoses of idiopathic scoliosis with 10 or 
 more of cobb s angle on whole spine ap x - ray examination from rehabilitation medicine 
 specialists . after
potential subjects were informed of the objectives and procedures of the 
 experiment , those who understood the purpose of the study , and agreed to actively 
 participate in the work were enrolled in the study .
this study received approval from the 
 institutional review board ( irb ) of clinical test at gwangju oriental hospital of dongshin 
 university on september 9 , 2013 ( irb no : dsgoh-017 ) .
this study selected those subjects who 
 had no experience with conservative treatment for scoliosis in the past , those who had no 
 other problems in terms of orthopedics , and those with no history of cardiac problems and/or 
 pulmonary disease .
the participants physical properties are shown in table 1table 1.physical characteristics of subjectsitem classageheightweightbmifemale ( n=96)15.22.4160.75.547.96.018.51.9male ( n=22)16.52.4174.97.364.310.220.92.4total ( n=118)15.52.4163.48.050.99.518.92.2bmi : body mass index . for the adam s forward - bending test
, participants placed their feet together , allowing 
 their arms to hang naturally , and bent their upper bodies forward 90 from the standing 
 position .
examiners used visual evaluations , with their eyes at levels equal to those of the 
 participants backs , and measured asymmetrical thoracic rotation angles ( atra ) and 
 asymmetrical lumbar rotation angles ( alra ) at the rib hump and lumbar hump using a 
 scoliometer ( usa ) ( table 2table 2.the mean and standard deviation of scoliosis related variablesitem classatraalralllcvarcvafemale ( n=96)7.13.46.94.041.66.67.93.87.43.9male ( n=22)6.52.95.23.841.67.56.73.76.94.5total ( n=118)7.03.36.64.041.66.77.73.87.34.0atra : asymmetry thoracic rotation angle (  ) ; alra : asymmetry lumbar rotation angle 
 (  ) ; ll : lumbar lordosis (  ) ; lcva : left calcaneal valgus angle (  ) ; rcva : right 
 calcaneal valgus angle ( ))11 . atra : asymmetry thoracic rotation angle (  ) ; alra : asymmetry lumbar rotation angle 
 (  ) ; ll : lumbar lordosis (  ) ; lcva : left calcaneal valgus angle (  ) ; rcva : right 
 calcaneal valgus angle (  ) participants were instructed to stand straight in order to view lumbar lordosis angles from 
 the sagittal plane , bending the upper limbs forward by 90 , and keeping the eyes forward . 

lumbar lordosis angles were 
 used to calculate crossed angles by drawing each line on the upper end - plate of the first 
 lumbar vertebra and the upper end - plate of the first sacral vertebra , giving the calculated 
 angle of the size of the curvature as shown in fig . 

total lumbar lordosis ( ll ) measurement for the analysis of the calcaneal valgus angles , this study performed a plumb line 
 test13 , as shown in fig .
2.calcaneal valgus angle measurement ( a : left calcaneal valgus angle [  ] , b : right 
 calcaneal valgus angle [  ] ) , using the body balance index system , steps , korea .
this study measured 
 the angle between the mid - calcaneal axis and the mid - talar axis .
calcaneal valgus angle measurement ( a : left calcaneal valgus angle [  ] , b : right 
 calcaneal valgus angle [  ] ) this study computed the mean and standard deviation of the factors related with scoliosis , 
 and extracted variables with correlation at significance level  of 0.05 .
this set the 
 degree of scoliosis as a dependent variable to predict thoracic and lumbar scoliosis using 
 ankle angles and physique factors , and set height , weight , and left and right calcaneal 
 ankle angles as independent variables , and then performed a multiple regression analysis to 
 find meaningful explanatory variables .
variables were extracted at a significance level (  ) 
 of 0.05 by applying a stepwise method , and then the regression equation was calculated .
tables 3table 3.summary of stepwise regression procedure for dependent variable atrasteppartial r2model r2c(p)bmi0.130.134.48lcva0.040.171.32bmi : body mass index ; lcva : left calcaneal valgus angle (  ) ; 
 * * * p<0.0001 ( f=16.11 ) , * p < 0.05 ( f=5.24 ) and 4table 4.multiple regression analysis for predicting atravariableparameter estimatestandard errortype ii ssintercept14.192.72245.88bmi0.450.13106.79lcva0.180.0847.51atra = 14.190.45228  bmi + 0.17  lcvabmi : body mass index ; atra : asymmetry thoracic rotation angle (  ) ; lcva : left 
 calcaneal valgus angle (  ) ; * * * p < 0.0001 ( f=27.13 ) , * *
p 
 < 0.001 ( f=11.78 ) , * p < 0.05 ( f=5.24 ) show the results of variable extraction and regression equations using a 
 stepwise method of multiple regression analysis in order to predict thoracic scoliosis 
 through height , weight , bmi , and left and right calcaneal valgus angles .
bmi : body mass index ; lcva : left calcaneal valgus angle (  ) ; 
 * * * p<0.0001 ( f=16.11 ) , * p < 0.05 ( f=5.24 ) bmi : body mass index ; atra : asymmetry thoracic rotation angle (  ) ; lcva : left 
 calcaneal valgus angle (  ) ; * * * p < 0.0001 ( f=27.13 ) , * * p 
 < 0.001 ( f=11.78 ) , * p < 0.05 ( f=5.24 ) as shown in table 3 , the variables that could 
 predict only thoracic scoliosis were selected by applying the stepwise method ; thereby , bmi 
 and left calcaneal valgus angles were selected .
bmi and left calcaneal valgus angles 
 explained 17% of atra , and were statistically significant variables ( p<0.05 ) . to estimate atra as shown in table 4 , this study set bmi and left calcaneal valgus angles as independent variables , 
 and thoracic scoliosis angles as dependent variables , and constructed a regression equation . 

the root mean square error ( rmse ) was 1.48 ; therefore , bmi and left calcaneal valgus angles 
 were effective variables to predict thoracic scoliosis ( p<0.05 ) .
tables 5table 5.summary of stepwise regression procedure for dependent variable alrasteppartial r2model r2c(p)ll**0.070.071.46bmi0.020.091.35bmi : body mass index ; ll : lumbar lordosis (  ) , * * p < 0.001 ( f=7.47 ) and 6table 6.multiple regression analysis for predicting alravariableparameter estimatestandard errortype ii ssintercept17.233.72324.68bmi0.270.1832.49ll0.130.0676.61alra = 17.230.2696 bmi0.13  llbmi : body mass index ; alra : asymmetry lumbar rotation angle (  ) ; ll : lumbar lordosis 
 (  ) , * * * p < 0.0001 ( f=21.48 ) , * p < 0.05 ( f=5.07 ) show the results of extraction of variables and the regression equation using 
 stepwise multiple regression analysis methods in order to predict the degree of lumbar 
 scoliosis through height , weight , bmi and left and right ankle valgus angles .
bmi : body mass index ; ll : lumbar lordosis (  ) , * * p < 0.001 ( f=7.47 ) bmi : body mass index ; alra : asymmetry lumbar rotation angle (  ) ; ll : lumbar lordosis 
 (  ) , * * * p < 0.0001 ( f=21.48 ) , * p < 0.05 ( f=5.07 ) as shown in table 5 , as the result of 
 extracting the variables that can predict lumbar scoliosis by applying stepwise multiple 
 regression analysis , lumbar lordosis and bmi were selected .
the two variables explained 9% 
 of alra , and were statistically significant variables ( p<0.05 ) .
bmi and lumbar lordosis were as independent variables , and alra was set as a dependent 
 variable to estimate alra , formulating the regression equation shown in table 6 .
the rmse of estimation was 1.68 , therefore , the y - intercept was not zero 
 ( p<0.0001 ) , and lumbar lordosis was an effective variable for predicting lumbar scoliosis 
 ( p<0.05 ) .
this study sought to identify degrees of scoliosis through the left and right calcaneal 
 valgus angles , which can be observed with the naked eye without radiation techniques , and by 
 using a scoliometer , with which measurements can easily be conducted . to enhance the 
 reliability of this study ,
correlations were analyzed with each variable by additionally 
 associating lumbar lordosis in the sagittal plane . ultimately , a negative correlation between lumbar lordosis ( ll ) and alra was revealed 
 ( r=0.266 ) .
compensation for this can be revealed through observing the degree of asymmetry 
 in the tuberosity of the calcaneus .
this is consistent with other studies14 which found that imbalances are revealed 
 in the sagittal plane .
compensation can be divided into two , namely , intraspinal 
 compensation and extraspinal compensation .
muscle 
 function changes occur , resulting in hip , lumbar and cervical pain , while proper standing 
 positions can not be maintained15 , 16 . the greatest degree of ll is found at the third lumbar vertebra , fourth lumber vertebra , or 
 at the disk between them .
lumbar segment lordosis starts between the first and second lumbar 
 vertebrae , and gradually increases in the lower section .
it was found that the greatest 
 degree of segment lordosis is found between the fourth and fifth lumbar vertebrae , and the 
 angle between the fifth and first lumbar vertebrae accounts for 60% of total lordosis12 .
the pelvic tilt is the angle made by the 
 line connecting the center of the sacral vertebral superior endplate and hip axis with the 
 central plumb line , and is a location indicator reflecting pelvic compensation mechanisms 
 when there are sagittal plane imbalances17 . from recent studies
, it was revealed that the shape of the pelvis 
 is important in in determining the curve of the sagittal plane17,18,19 .
vialle et al.19 revealed that some 
 correlation exists between pelvic incidence angles and ll in normal individuals .
this 
 assertion nearly matched the findings of this study , in that significant correlation exists 
 between lumbar lordosis angles and alra .
this study revealed that the left calcaneal valgus angle has a correlation with atra 
 ( r=0.282 ) .
when the left ankle arch collapses causing flat feet , and both shoulders become imbalanced , 
 scoliosis appears to develop .
namely , imbalance from the feet affects the legs , pelvis and 
 vertebrae ; therefore , scoliosis is believed to be resultant . according to a preceding study , 
 when load is added to a specific lower limb , energy consumption increases
this energy 
 consumption increase was reported to increase more when it was added to the end of the lower 
 limb , rather than close to the trunk , despite the same weight20 .
scoliosis is a disease in which 3-dimensional transformation of 
 the vertebrae bend together to one side with vertebral rotation of one foot s load , arising 
 from an imbalance of the feet ; therefore , it was reported that a change of the angle 
 supporting the body weight , including shoes , can affect the prognosis of the disease21 .
the pelvic obliquity attributable to rotational malalignment 
 results in compensatory curves of the spine or the accentuation of any pre - existing curves . 

carole et al.23 , tested the reliability 
 of a quantitative clinical posture assessment tool among persons with idiopathic scoliosis . 

the dependability coefficients (  ) for posture indices are presented in the tibiocalcaneal 
 angles ( l and r ; =0.51 and 0.53 , respectively ) .
according to 3-dimensional analysis results , it was reported that functional shoes are 
 helpful to vertebrae , especially for lumbar muscular strength consolidation and vertebral 
 health , through the improvement of feet stability25 .
based on the results of this study and the many preceding studies , the progress of 
 scoliosis can be predicted to some degree , depending on visual checks of the sole arch 
 shape , tuberosity of the calcaneus , adam s forward bending test , and the use of a 
 scoliometer .
idiopathic scoliosis develops during adolescence and progresses rapidly26 , and therefore correction becomes 
 difficult if the treatment window passes .
therefore , it is important to diagnose scoliosis 
 early27 . if scoliosis is diagnosed in 
 its early stages through prompt examination and evaluation at schools or other facilities , 
 curvature progression and unnecessary surgeries can be prevented through conservative 
 treatment with walking aids and/or exercise , when curvatures are slight28 .
first , calcaneal valgus angles and asymmetrical 
 thoracic - lumbar rotation angles were only assessed in patients with adolescent scoliosis ; 
 there was no control group .
moreover , direct analysis of the correlations between cobb 
 angles and calcaneal valgus angles and asymmetrical thoracic - lumbar rotation angles was not 
 performed .
future 
 studies will be required to classify major curvatures in detail , and to analyze the 
 relationship between cobb angles , asymmetrical thoracic - lumbar rotation angles and calcaneal 
 valgus angles , the results of which may contribute to streamlined predictions and 
 evaluations of idiopathic scoliosis .
 [ purpose ] this study aimed to provide a predictable evaluation method for the progression 
 of scoliosis in adolescents based on quick and reliable measurements using the naked eye , 
 such as the calcaneal valgus angle of the foot , which can be performed at public 
 facilities such as schools . 
 [ subjects and methods ] idiopathic scoliosis patients with a 
 cobb s angle of 10 or more ( 96 females , 22 males ) were included in this study . to 
 identify relationships between factors , 
 pearson s product - moment correlation coefficient 
 was computed . 
 the degree of scoliosis was set as a dependent variable to predict thoracic 
 and lumbar scoliosis using ankle angle and physique factors . 
 height , weight , and left and 
 right calcaneal valgus angles were set as independent variables ; thereafter , multiple 
 regression analysis was performed . 
 this study extracted variables at a significance level 
 (  ) of 0.05 by applying a stepwise method , and calculated a regression equation . 
 [ results ] 
 negative correlation ( r=0.266 ) was shown between lumbar lordosis and asymmetrical lumbar 
 rotation angles . a correlation ( r=0.281 ) 
 was also demonstrated between left calcaneal 
 valgus angles and asymmetrical thoracic rotation angles . 
 [ conclusion ] prediction of 
 scoliosis progress was revealed to be possible through ocular inspection of the calcaneus 
 and adams forward bending test and the use of a scoliometer . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION