The ongoing debate over when it is appropriate to treat a child with asymptomatic pes planovalgus rages on. It will be the topic of what promises to be an interesting and spirited forum at the upcoming Midwest Podiatry Conference in early March.
There are a variety of different opinions on this controversial topic and the perspective of the commentator seems to influence the viewpoint held. Academicians line up with a more purist view that the limited outcome evidence in the literature on the effect of intervening in this population precludes recommending a proactive, preventative philosophy. Clinicians cite years of anecdotal evidence of the benefit of such early interventions to improve position, posture and function. This supports the strongly held belief that a proactive, preventative philosophy forestalls a myriad of potential compensations and dysfunctions.
The epidemic of overweight children in this country adds to the complexity of this problem. Experts on both sides of the treatment spectrum agree that the presence of comorbidities or risk factors is often the tipping point in deciding when an intervention may be appropriate. One of the most significant of these factors is excess body weight increasingly reaching the level of obesity. It is important to mention that one must carefully evaluate children with acquired pes valgus for any and all comorbidities before deciding whether to recommend treatment.
A 2010 study by Pomerantz and colleagues quoted other studies stating that 30 percent of U.S. children ages 6 to 11 are overweight.1 In the study of 23,349 patients presenting to a pediatric emergency department, 16.5 percent qualified as obese. In this large cohort, the numbers are even more frightening in certain ethnic groups. The obesity rate is 20 percent among African-American children and 25 percent in Hispanic children in comparison to 14 percent in Caucasian children. The authors found that obese children are significantly more likely to sustain lower extremity injuries than upper extremity injuries and are more likely to sustain lower extremity injuries than non-obese children (1.7 times greater risk).
Paul Scherer, DPM, a Clinical Professor at the College of Podiatric Medicine at the Western University of Health Sciences, has authored a very thoughtful and thorough presentation titled “Pediatric Obesity And Its Relationship To Pediatric Hypermobile Flatfoot” that focuses our attention on the role that this societal trend is having on the child’s developing foot.2 He presented this lecture at the New York Clinical Conference last month.
Dr. Scherer provided an excellent review of the literature on the role of increasing body weight in pediatric flatfoot in his lecture. Epidemiologically, Garcia-Rodriquez and co-workers in 1999 reported an increased prevalence of flatfoot in overweight children.3 In 2001, Bordin and colleagues found an incidence of flatfoot of 24.3 percent in obese children and 16 percent in non-obese children.4 In 2008, Mauch and co-workers reported that flat feet were twice more likely in overweight children than children of normal weight.5 Most recently, in a 2009 study of Taiwanese children, Chen and colleagues found an incidence of flatfoot of 27 percent in those of normal weight, 31 percent in those who were overweight and 56 percent in those who were obese.6
In the area of gait analysis, Dowling and co-workers in 2001 reported that obese children have higher forefoot peak pressures than non-obese children.7 In 2006, Mickle and colleagues reported that obese children have higher pressure-time intervals than non-obese children.8
All offer compelling evidence that a child’s weight plays a significant role in foot structure and function.
We are not helping our children to stay thin as a society. In a study of over 1,000 sixth graders in southeastern Michigan published in the American Heart Journal in December 2010, students who regularly had the school lunch were 29 percent more likely to be obese than those who brought lunch from home.9 Further, the study found that spending two or more hours a day watching television or playing video games also increased the risk of obesity by 19 percent. So couch potatoes who eat poorly are racking up the pounds, further placing their vulnerable feet at risk.
In a way that crystallizes the essence of the issue, Dr. Scherer quotes Mauch and colleagues from their 2008 paper: “the verified change in foot morphology from childhood obesity may produce foot discomfort and … in turn might keep children from being active and … therefore reinforce the risk of obesity.”5
As practitioners charged with protecting and treating feet, we must remember that destruction comes in many forms. The child who has poor foot posture exacerbated by increasing weight is highly vulnerable to a vicious cycle of inactivity as a result of poor foot function, leading to reduced activity and further weight gain. Is that reason enough to reposition, stabilize and treat the child’s pronated foot and, in doing so, help the child to get off the couch?
1. Pomerantz WJ, Timm NL, Gittelman MA. Injury patterns in obese versus nonobese children presenting to a pediatric emergency department. Pediatrics. 2010; 125(4):681-5.
2. Scherer R. Pediatric obesity and its relationship to pediatric hypermobile flatfoot. Presented at the New York Podiatric Clinical Conference, Jan. 30, 2011.
3. Garcia-Rodriguez A, Martin-Jiminez F, Carnero-Varo M, et al. Flexible flat feet in children: a real problem? Pediatrics. 1999; 103(6):e84.
4. Bordin D, De Giorgi G, Mazzocco G, Rigon F. Flat foot and cavus foot, indexes of obesity and overweight in a population of primary school children. Minerva Pediatr. 2001; 53(1):7-13.
5. Mauch M, Grau S, Krauss I, et al. Foot morphology of normal, underweight and overweight children. Int J Obes (London). 2008; 32(7):1068-75.
6. Chen JP, Chung MJ, Wang MJ. Flatfoot prevalence and foot dimensions 0f 5- to 13-year-old children in Taiwan. Foot Ankle Int. 2009; 30(4):326-32.
7. Dowling AM, Steele JR, Baur LA. Does obesity influence foot structure and plantar pressure patterns in prepubescent children? Int J Obes Relat Metab Disord. 2001; 25(6):845-52.
8. Mickle KJ, Steele JR, Munro BJ. They feet of overweight and obese young children: are they flat or fat? Obesity (Silver Spring). 2006; 14(11):1949-53.
9. Eagle TF, Gurm R, Goldberg CS, et al. Health status and behavior among middle-school children in a Midwest community: what are the underpinnings of childhood obesity? Am Heart J. 2010; 160(6):1185-9.