Pediatric Flatfoot: When Do You Treat It?
In recent years, there has been much discussion over what criteria should prompt the treatment of pediatric flatfoot and when one should not treat it. This author discusses the consequences of pediatric flatfoot, the pathomechanics of the condition and recommendations for when one should treat it.
Perhaps the most controversial current topic in pediatric foot care is the debate over how to decide when treatment is warranted for pediatric flatfoot. The controversy rages most loudly when the flat foot in question is without classic symptoms such as pain.
It is easier to get agreement that a child with a symptomatic flatfoot should receive treatment. No one thinks a child in pain should be left untreated, especially given the myriad of options we have to relieve that pain. In that subgroup, the controversy is often over what type of treatment — off-the-shelf devices or custom orthoses — the child should receive.
The greater challenge for today’s practitioner is having the ability to discern when treatment is necessary for children with painless flatfoot. Bear in mind that a painless flat foot does not imply an asymptomatic flat foot. Children often express their symptoms without reporting any pain. They may be lazy, frequently ask to be carried, prefer sedentary activities or have trouble keeping up with their peers.
Only the clinician who probes these issues with the parents will uncover subtle manifestations of the flat, poorly supportive foot that are already contributing to changes in activity level and functional ability. The first step in identifying flat feet that require treatment is to uncover the subtle changes in activity level and performance that may well be caused or aggravated by foot misalignment and dysfunction. After one has instituted treatment, parents often report a significant change in children’s activity levels, which is often to the great satisfaction of the parent. The children themselves are happier, healthier and more active as well.
A Closer Look At The Consequences Of Pediatric Flatfoot
Numerous authors have written about the myriad of ways the subtle manifestations of flatfoot may present in children. In Clinical Orthopedics and Related Research, Meredy, Dolan and Luskin noted the characteristic “exaggerated out-toe gait” and reports of pain in the anterior and posterior muscle groups of the leg.1 Kirby and Green state that “mechanical instability of the foot during weightbearing activities may be a substantial source of growing pains in children.”2
Researchers have often noted in the literature that pediatric flatfoot is a precursor to a painful problem with the foot in adulthood and authors endorse the concept that one should vigorously treat the condition in childhood. In a seminal paper on the pediatric flatfoot, Rose and colleagues say “the aim of treatment is the prevention of latent disability.”3
Rose and co-authors highlight one of the most important aspects of caring for pediatric flatfoot. Adult deformities of the rearfoot and forefoot, deformities that are often of a mechanical nature, may be the result of chronic instability aggravated by body weight and age over time. The precursors to these common adult pathologies often occur in childhood. Accordingly, timely diagnosis and management in childhood are essential to healthier foot function in adulthood.