Gait Analysis In Pediatric Patients With Flatfoot

Author(s): 
Louis J. DeCaro, DPM

Analyzing biomechanics and gait can paint a more accurate picture of pediatric patients with flatfoot and enhance treatment. Accordingly, this author offers salient diagnostic insights to inform one’s biomechanical exam and gait assessment in this patient population.

The identification and successful treatment of the pediatric flatfoot at an early age is of utmost importance in 21st century podopediatrics. My personal podiatric mantra is “prevention begets correction.” A majority of the patients in my private practice — and I expect in yours as well — are seeking treatment not only for “foot problems” but for associated ankle, knee, hip and back pain/dysfunction. It is for this reason that I spend a considerable amount of time with each patient educating him or her about their feet and the foot’s influence on the entire kinetic chain.

   Let’s take some time to review not only the essentials of age-specific treatments of podopediatric flat feet but the numerous varieties of flat feet that exist in our pediatric patient population.

   Identification of a patient’s “foot type,” coupled with successful orthotic intervention, can mitigate or eliminate many orthopedic conditions that would otherwise affect patients throughout their lives. It is important to keep in mind that children are often asymptomatic despite poor foot mechanics. However, this does not mean that the dysfunction should go untreated. Pain should not be the sole indicator of intervention with children. It is paramount that we understand the impact of poor foot biomechanics and proper growth and development.

A Closer Look At The Major Flatfoot Types

I can attest to the fact that there are six major foot types (six variations of “normal”) that occur in the general population (see http://www.decaropodiatry.com/ ). Two of these six are typically defined as “flat feet,” the “bread and butter” of a podiatrist’s practice. These two foot types are referred to as the “D and F” foot types. Let us begin with a review of these two common varieties of flat feet and their impact on the kinetic chain.

   The D foot type, or what we politely refer to as the “Fred Flintstone” foot, is the wide, splayed flatfoot variety. It is the result of a compensated rearfoot varus in which the subtalar joint allows the heel to evert/pronate to a vertical alignment that facilitates unlocking of the midtarsal joint. The hypermobility of this foot type leads to numerous conditions of the foot (think of this foot as a “loose bag of bones”).

   As the heel everts, the midtarsal joints unlock, leading to peroneal insufficiency and first ray instability. Propulsion then transfers to the second and third metatarsals with associated reversal of the transverse metatarsal arch. The loss of the first ray inclination angle results in an impaired windlass mechanism and may lead to hallux limitus/rigidus. Continuing “up the chain,” the rearfoot pronation leads to excessive internal tibial rotation and knee flexion.

   Typical conditions that can arise from this foot type are plantar fasciitis, callusing beneath the second and third metatarsal heads, hallux limitus, metatarsalgia and patellofemoral pain. The gait cycle is dominated by hypermobility as the foot typically remains unlocked through most of the stance phase and often fails to become that rigid lever in the propulsive phase of gait. This hypermobility leads to muscular overuse, fatigue, low endurance and poor core trunk strength.

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