Pediatric flatfoot is a controversial topic on many levels. The decisions on when, how and if treatment is warranted are very much debatable. I have treated several children with pediatric flatfoot and I have learned a lot over the past 20 years from this experience. I would like to share some practical insights that will hopefully facilitate better outcomes if you currently treat or decide to treat this patient group.
For children under the age of 4, unless a pathologic condition exists such as a vertical talus or calcaneal valgus, I do not treat pediatric flatfoot. I recommend a good supportive gym shoe and monitor the foot every six months. In my opinion, the arch is still developing at this point and I think of these feet as “fat and flat.” After 4, the arch starts to develop and the baby fat starts to disappear from the foot.
If the child has a flatfoot after the age of 4 and this is evident both on the clinical and radiologic exam, I believe it is beneficial to treat it at that point.
Does the foot need to be painful to be treated? To me, it really depends on the severity of the condition. I have no hard and fast set boundaries on what requires treatment. It is a judgment call and there is nobody out there better to make that call than a well-trained podiatrist with experience in pediatrics. In the presence of symptoms, even the staunchest opponent to treatment would have to relent and agree to some form of conservative treatment. This conservative treatment regimen is what I would like to cover in this blog.
Essential Insights On The Diagnostic Workup
Most all of the pediatric flatfoot patients you will see will have gastrocnemius equinus. I think most of the population has equinus and that equinus is the “root of all foot evils.” My exam consists of a standard podiatric history and physical exam with standard foot radiographs. When it comes the physical exam, I do a complete equinus exam with the knee flexed and extended, and the midtarsal joint locked. This is very important and often neglected in the exam, which subsequently yields inaccurate results. I like to evaluate the forefoot to rearfoot position. In the younger patient, this is usually supinatus, which becomes a fixed forefoot varus as the child gets older. I also evaluate subtalar joint and midtarsal joint range of motion.
In regard to the weightbearing exam, I evaluate the medial arch, resting calcaneal heel position and check for reducibility with a Hubscher maneuver and trunk test. I also like to evaluate posterior tibial tendon function with double and single limb heel rises. During the gait exam, I look for early heel off, increased midstance pronation and a lack of resupination at toe-off. Radiographically, I evaluate the standard angles on the lateral and AP views. I am not one to actually measure each and every angle. It is more of an overview of all the angles together that I am evaluating.
Pertinent Treatment Pearls
At this point, it is very important to discuss your findings and treatment recommendations with the parents. I try to educate them as much as possible. Therefore, the treatment plan will make more sense to them and they are more likely to agree and follow my recommendations. I go into significant detail in layman’s terminology on what equinus is and how it is an external deforming force on the foot. I also discuss the pediatric flatfoot condition and what may happen if it is neglected.
The main point of this blog is that when treating this condition, you must treat the equinus first. Why? If you do not treat the equinus, you have a pronating force through the midfoot with a rigid arch support pushing up into the midfoot. This is crucial to the outcome and success of the orthotic.
I like to start treatment with night splints. For smaller children, it can be difficult to find a night splint to fit their foot. You may have to use a controlled ankle motion (CAM) walker instead or fabricate your own night splint.
I check the child after one month. If dorsiflexion is greater than 90 degrees with the knee extended, then we can move forward with orthoses. If dorsiflexion is not greater than 90 degrees with the knee extended, then children use the night splint for another month and I reevaluate them at that time.
Once children have achieve adequate stretching, if they participate in athletics, I like to put them on what I call “maintenance therapy” with the night splint. Playing sports will have a tendency to recontract the Achilles tendon so I have patients use the night splint once a week to maintain their stretch. It is a good idea to have the patient use the night splint the same night each week so it becomes a habit. I also recommend using the night splint during the week to avoid overnight stays outside of the parent’s home and skipping the night splint use for the week.
Once there is adequate stretching, you can proceed with orthotic therapy. I use a heel stabilizer (usually type C) for patients who are 4 to 6 or 7 years old. Then for patients who are 6 to 8 or 9 years old, I utilize a Whitman-Roberts type of device. If the child participates in athletics, I choose a sports type of orthoses with no forefoot posting. If the forefoot is posted to the cast, this transforms a supinatus into a fixed forefoot varus. Once children are 8 or 9 years of age, I treat them as adults orthotic-wise.
Remember, when you are treating the pediatric flatfoot, treat the equinus first and then follow with external support. Your outcomes will improve but most importantly your patient will be better off for it.