Gait Analysis In Pediatric Patients With Flatfoot

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Louis J. DeCaro, DPM

   Identification of a significant forefoot varus in young children is important. However, we are not necessarily treating it but just monitoring the condition. The general rule of forefoot varus is that the child loses about 2 degrees of forefoot varus every year up until about the age of 6. At birth, if you were able to measure it, 12 to 15 degrees of forefoot varus is average with derotation of the varus ideally completed by the age of 6 or 7. Compensation for a forefoot varus requires calcaneal eversion beyond vertical. Forefoot varus conditions are very destructive at an early age and result in severe hyperpronation. Any residual forefoot varus after the age of 7 or 8 may need specific orthotic correction/posting, either intrinsic or extrinsic.

   In regard to rearfoot alignment, normal development begins with a typical 1-year-old child having about 6 degrees of calcaneal eversion. Calcaneal eversion should resolve by approximately 1 degree every year up until about the age of 7. A 2-year-old should have about 5 degrees of eversion, a 3-year-old has 4 degrees, etc. By the age of 6 or 7, the child should have a fairly neutral foot alignment with the calcaneus close to vertical. Any calcaneal alignment deviating by 4 degrees or more from vertical at this age may be a significant problem and one should treat it.

   Muscle strength and function can be compromised based on foot type. Hypermobile flat feet are perpetually mobile adaptors and are typically unable to lock the midtarsal joint in a timely fashion to prepare for the propulsive phase of gait. This unstable foundation makes it very challenging to develop lower extremity stability and, in turn, core trunk strength. Just imagine walking barefoot in the soft sand of a beach all day. It takes a lot of work and is rather exhausting.

   We also need to keep in mind the genetic component of foot types. We can inherit our underlying foot structure much like we may inherit our eye and hair color among other things. When treating pediatric patients, question the parents about their feet, siblings’ feet, grandparents’ feet, etc. It should be of no surprise to see patterns quickly develop. This always leads to more referrals.

   Postural assessment above the foot is no less important than the actual foot assessment. We would be doing a disservice to our patients if we did not pay close attention to the upper kinetic chain. We need to understand the difference between structural and functional asymmetries, functional versus structural leg length discrepancies, and recognizing how the foot type can affect a patient’s center of gravity. As we all know, there are many factors to consider when assessing leg length such as pelvic obliquities/torsions, scoliosis, foot disparities, etc. I am a firm believer that as much as 80 percent of limb length disparities are functional, not structural.

   Dispensing a heel lift should take careful consideration, particularly if a foot disparity is present. Equalizing the feet from left to right with foot orthoses as well as physical therapy to address muscle imbalances will often reduce or correct most “apparent” limb length disparities. When I do dispense a heel lift with foot orthoses, I usually provide it as a detached heel lift so patients may easily remove it from shoes.

A Protocol For First-Time Evaluation Of The Pediatric Patient

Accordingly, when evaluating a patient for the first time, there are several factors one needs to examine. First, I obtain an extensive patient history. I find out about the patient’s medical history, family history, chief podiatric complaints, interests/activities and his or her overall well-being.

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