Pediatric Flatfoot: When Do You Treat It?
When it comes to flatfoot and gait, the propulsive child approaching 3 years of age demonstrates characteristic findings when an excessively pronated foot is present. Typical findings include a marked abducted angle of gait (which may be reduced when superstructural in-toe is contributing to the deformity). It is also common to see late midstance and propulsive phase pronation of the subtalar and midtarsal joints. This is characteristically marked by continued eversion of the calcaneus after heel lift. Shortened stride length with poor quality propulsion, medial roll of the hallux and lifting are often visible as well.
Formulating A Philosophy Of Treatment
In the youngest children, the absence of symptomatology is an unreliable indicator of optimal foot function. The use of prefabricated or off-the-shelf devices may be appropriate in mild, uncomplicated cases. However, the pediatric acquired pes plano valgus foot with underlying biomechanical etiologies often requires a custom orthosis with subtle, patient-specific modifications to a negative cast technique, positive cast modification, shell design, posting and other sophisticated techniques to optimize correction for the individual foot.
In a letter to the editor in the Journal of the American Podiatric Medical Association (JAPMA), Bresnahan stated that “when we espouse the observation of a mild deformity in a child’s foot, this ‘benign neglect’ is no more than a failure to take action.”5 He goes on to say that our duty as physicians is to determine if what we are seeing is “normal vs. abnormal” … by our method of examination. Bresnahan also notes that once we determine that the patient’s condition is abnormal, we should then determine which treatment plan would benefit the patient most.
In a letter to the editor in the same issue of JAPMA, D’Amico points out that Wolff’s law of bone and Davis’ law of soft tissue support early intervention in the pediatric flatfoot to encourage remodeling of the foot to a more normal alignment.6 He states that “growth and development can be used to effectively influence alignment and function in a positive manner.” Confirming the earlier views of Rose and colleagues, D’Amico states that “excessive pronation at any age, but especially in the developing foot, is a poor postural position that sets the stage for future deformity and dysfunction.” (This is Rose’s “latent disability.”)
In her article “The Flat-Footed Child – To Treat Or Not To Treat, What Is The Clinician To Do?” Evans states that “if the designated clinical outcome measures show improvement … the treatment is clinically supported.”7
The astute clinician establishes clear goals and benefits for the prescribed orthoses. With follow-up care, the clinician monitors through subjective reporting and objective measures that the “designated clinical outcomes” are showing improvement. The skilled podiatrist approaches the pediatric flatfoot with top-level training to identify the clinical deformity and applies powerful tools to improve the structural and functional position of the child’s foot. Clearly identifiable measures for the treatment one prescribes will enable the practitioner to track and monitor success.
Recommendations For When To Treat Pediatric Flatfoot
The following guidelines should prove useful in determining when a child with a flatfoot/pes plano valgus should undergo treatment.
• Symptoms (frequent changes in activity level and function before pain develops) of any kind that are attributable to abnormal foot posture
• A non-physiologic flatfoot at any age
• Abnormal weightbearing position of the foot based on the child’s age with associated signs of abnormal foot posture such as midfoot abduction, talar deviation and frontal plane hallux deviation
• The presence of comorbidities linked to pedal compensations
• Changes in dynamic function in gait associated with flatfoot