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.
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.
One should neutralize pathomechanical forces acting on the child’s foot from the earliest weightbearing in order to allow normal development of bone and soft tissue without undue stress and establish optimum foot function in stance and gait. The functional requirement of a stable platform once the child has begun to stand and for the stance phase of gait is compromised in the flat foot. Later, once the child has achieved propulsive gait, the ability of the foot to convert to a rigid lever is also altered in the flat foot.
A careful musculoskeletal exam including gait analysis will allow the clinician to build on information obtained in the history to identify the superstructural and pedal comorbidities that lead to compensation in the already challenged toddler foot. Experts agree that a positive family history of a consequential flat foot, evidence of a compensated, acquired flatfoot through skilled biomechanical evaluation and compromised gait function all elevate the index of suspicion in a pediatric flat foot and strongly suggest that one should consider treatment.
The presence of comorbidities in the biomechanical exam in the form of deviations from the normal for the child’s age marks these feet as “at risk” and provide a clear rationale for the astute clinician to act and to intervene on the child’s behalf. Unless and until these comorbidities resolve and cease to exert an untoward effect on the malleable foot compensating at the base of support, the physician should institute treatment.
Common comorbidities contributing to pediatric acquired pes planovalgus include residual transverse plane torsional problems such as femoral and tibial torsion and metatarsus adductus. Soft tissue components such as excessive internal hip rotation and pseudo torsion at the knee may also lead to pedal compensation. Frontal plane malalignments such as rearfoot and forefoot varus, tibial and genu varum may precipitate compensation. Sagittal plane contributions include equinus and limitations of dorsiflexion necessary for smooth excursion of the leg over the planted foot in gait. These may occur at the level of the foot, the gastroc-soleus complex, the hamstring and the iliopsoas muscles.
Numerous joints in the foot with sagittal plane dominance — such as the midtarsal joint, first ray and metatarsophalangeal joints — facilitate compensation and may lead to acquired deformities of the foot.
Systemic ligamentous laxity, as a component of a syndrome such as Marfan’s syndrome or as a familial or individual body type predisposes the child’s foot to be the compensatory site for superstructural influences.
The weightbearing component of the lower extremity exam provides key information to identify the acquired pes plano valgus deformity and grade its severity. Decreased medial longitudinal arch height (navicular differential or drop) from off to on weightbearing is a useful screening tool. Significant drop with other changes such as medial and plantar prominence of the talus, abduction of the midfoot and frontal plane rotation of the hallux signal the presence of compensation and the abnormal foot position often associated with the onset of deformities.
Assessment of the relaxed calcaneal stance position (RCSP) to determine the degree of heel valgus on weightbearing is useful in grading severity. Systems such as the Valmassy formula can help the clinician to determine when heel valgus is excessive for a young child of a particular age.4 High heel valgus may indicate a frontal planal dominance to the deformity and, in some cases, may be associated with changes in the transverse plane such as medial talar deviation and midfoot abduction.
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.
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.
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
Following these guidelines should enable clinicians to recognize the at-risk pediatric foot and offer management recommendations to parents who are often eager to improve their child’s quality of life. Parents are also eager to embrace preventative measures that will increase the likelihood of their children growing ever more active and reaching maturity with feet prepared to serve an ever increasing average life expectancy. By following the principles outlined in this article, you can help them achieve these goals.
Dr. Volpe is a Professor in the Department of Orthopedics and Pediatrics at the New York College of Podiatric Medicine. He is in private practice in New York City and Farmingdale, N.Y.
1. Meredy C, Dolan C, Luskin R. Evaluation of the University of California Biomechanics Laboratory shoe insert in ‘flexible’ pes planus. Clin Orthop. 1972; (82):45-58.
2. Kirby K, Green D. Evaluation and nonoperative management of pes valgus. In DeValentine SJ (ed.): Foot and Ankle Disorders in Children, Churchill Livingstone, 1992, pp. 295-327.
3. Rose GK, Welton EA, Marshall T. The diagnosis of flat foot in the child. J Bone Joint Surg. 1985; (67-B):71-78.
4. Valmassy RL. Biomechanical evaluation of the child. Clin Podiatry. 1984; 1(3):563-79.
5. Bresnahan P. Letter to the editor. Journal Am Podiatr Med Assoc 2009; 99(2):178.
6. D’Amico JC. Letter to the editor. Journal Am Podiatr Med Assoc 2009; 99(3):267-8.
7. Evans AM. The flat-footed child – to treat or not to treat, what is the clinician to do? J Am Podiatr Med Assoc. 2008; 98(5):386-93.
Editor’s note: For further reading, see “Point-Counterpoint: Asymptomatic Flatfoot In Kids: Should You Treat It?” in the January 2010 issue of Podiatry Today or “When Pediatric Flatfoot Requires Surgical Correction” in the January 2010 issue.