Cath Lab Digest

Should You Treat Asymptomatic Pediatric Flatfoot?

By Brian McCurdy, Senior Editor

   When encountering a child with asymptomatic flatfoot, it is important to decide whether you should treat the condition or see if the flatfoot will improve on its own. A recent article in the Journal of the American Podiatric Medical Association (JAPMA) examines the effects of orthoses for this condition and provides a framework for treatment.

   After reviewing studies on the use of orthoses to treat pediatric flatfoot, the authors of the JAPMA article presented three recommendations for the treatment of children with flatfoot.

   First, when it comes to symptomatic pediatric flatfoot, the authors emphasize the use of footwear, stretching or (usually generic) orthoses. Second, the JAPMA article also advocates monitoring and providing simple treatment for patients with a typical asymptomatic flatfoot that displays non-developmental foot morphological structures for the child’s age. Third, the authors suggest discharging those patients who have a “typical flexible flatfoot that is normally transient and developmental.” Rather than discharging such patients, Russell Volpe, DPM, suggests offering advice to and observing patients as it may require continued oversight to determine that a child has a typical flatfoot that needs no intervention.

Can Orthoses Have An Impact?

   Dr. Volpe cites numerous advantages to treating flatfoot with orthoses. He says the devices correct the position of the child’s flat or pronated foot to a more neutral position. Dr. Volpe says starting orthoses at a young age, when the foot is pliable and cartilaginous, may over time improve the developing foot’s structure. Furthermore, he notes that orthoses may be advantageous in improving a child’s function in regard to gait, sports and other daily activities.

    “Often, young children may not yet have pain or other symptoms, but they may be avoiding certain activities or favoring other more sedentary ones as a result of their pronated or flatfoot position/function,” explains Dr. Volpe, a Professor in the Department of Orthopedics and Pediatrics at the New York College of Podiatric Medicine.

   The primary disadvantage of using orthoses at an early age is the possibility that a child with a mild deformity is being “overtreated” and has a foot position/deformity that will improve with age “physiologically” even without treatment, according to Dr. Volpe. He notes that the JAPMA article offers “sensible and evidence-based guidance” to avoid overtreating those whose flat feet may not need treatment.

Other Pertinent Considerations

   Ron Raducanu, DPM, does not see any disadvantages to using orthoses if they are indicated for patients with pediatric flatfoot. The real question, he notes, is whether the devices address the patient’s comfort. Dr. Raducanu advises discontinuing insoles if they are causing patients pain, since more evaluation may be necessary for a more accurate diagnosis and treatment plan.

   In regard to children with asymptomatic flatfoot, Dr. Raducanu would base the decision on the presenting deformity.

    “We know that some deformities have a clear progression to further deformity and arthritic changes within the foot and ankle, so anything we can do to limit the deformity’s effect is advisable,” says Dr. Raducanu, the President of the American College of Foot and Ankle Pediatrics.

   He says one example of this is a flatfoot secondary to a tarsal coalition. However, one will often see associated symptoms with these cases, according to Dr. Raducanu, who is in private practice in Virginia Beach, Va.

   Dr. Volpe agrees with the JAPMA article authors about the importance of differentiating between physiological and non-physiological flatfoot. However, in his clinical experience, he says the vast majority of children with flat or pronated feet, even if they are not overtly symptomatic, do have history findings, subjective features or objective measures that warrant appropriate treatment.