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Is It Unethical To Prescribe Orthoses For Children With Asymptomatic Flatfoot Deformity?

The question of whether we should treat children with significant flatfoot deformity and especially those flatfooted children without subjective complaints (i.e. asymptomatic) with foot orthoses is one of the most controversial subjects within the international podiatric and orthopedic communities. Over the three decades that I have been lecturing on flatfoot deformity in children and its treatment, I am still amazed at how this subject can spark emotion on both sides of the treatment versus non-treatment debate.

As an example of the wild controversy that can occur on this subject, I was invited to speak on pediatric flatfoot deformity at a seminar in Rome in 2010 in a large auditorium full of podiatrists, orthopedic surgeons and orthotists. In the question/answer period that followed my lecture, individuals from different medical disciplines in the audience started loudly debating the subject back and forth as to whether we should treat flatfooted children with foot orthoses. While the translators in their booth at the back of the lecture hall were frantically trying to keep up with the rapidly shouted dialogue from one side of the auditorium to another, in the end, I commended everyone involved for their passion on this very important subject.

The question of whether flatfooted children should receive treatment with foot orthoses has also been a subject of interest within the podiatric medical literature. Two Australian podiatrists wrote one of the most controversial articles ever written on the subject in 1998.1 In their paper, the authors concluded that “one may be forced to conclude that this course of action [treating asymptomatic flatfooted children with custom foot orthoses] may well be in breach of medical ethics; that is, the practitioner may be acting or practicing in an unethical manner.”

Is it truly unethical for us to treat children with significant flatfoot deformity with custom foot orthoses if they have no subjective complaints? My answer to this question is based largely on my education and clinical experience during my student years and a Biomechanics Fellowship at the California College of Podiatric Medicine, where I had the good fortune of learning from some of the best minds in pediatric foot and lower extremity biomechanics: John Weed, DPM, and Ronald Valmassy, DPM.  

These respected professors instructed me and many of my podiatric colleagues about the importance of listening to what our pediatric patients were telling us. They also emphasized asking the parents how their children performed in activities with their friends, whether they asked to be carried on long walking trips, whether they felt their children tripped or appeared clumsy during walking or running, and whether they had any complaints in their feet, legs, knees, hips or back during long walks or after running sports. They also taught the importance of fully examining the feet and lower extremities of the flatfooted child, watching him or her walk and run, and also asking about any adult family members who suffered from painful conditions due to flatfoot deformity.

Then after consideration of these many factors, the podiatric clinician could make the best decision as to whether an in-shoe arch support or custom foot orthoses would be beneficial at improving the symptoms, and/or improving the gait function of the flatfooted child while at the same time not causing him or her harm.

Faced with this controversy, what should podiatrists do when a parent brings in a child with a significant flatfoot deformity who does not currently complain of any symptoms? What do we do with a child who has obvious gait pathology, cannot keep up with other children during sports activities and has a mother and father who have painful flatfoot deformity?  

Should the treating podiatrist say, “Sorry, Mrs. Smith, the evidence-based medical guidelines that we follow for our treatment decisions indicate there is insufficient high-quality, long-term research studies for me to recommend treating your flatfooted child with custom foot orthoses”?

Alternately, should the treating podiatrist say, “Yes, Mrs. Smith, I believe we should treat your flatfooted child with specially-designed custom foot orthoses that will decrease the pathologic forces acting within your child’s foot and should improve gait function so we can not only improve (his or her) ability to participate in walking and sports activities, but also hopefully prevent further progression of the flatfoot deformity into adulthood”?

Which of these two podiatrists seems the most “medically ethical” to you?

Dr. Kirby is an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif. He is in private practice in Sacramento, Calif.

1. McDonald M, Kidd R. Mechanical intervention in children: some ethical considerations. Australasian J Pod Med. 1998; 32(1):7-12.

Kevin A. Kirby, DPM



The answer ought to be simple. Why aren't there high quality studies demonstrating efficacy or lack there of one way or the other, and even breaking it down by various categories, such as when treatment is begun (and ended) and type of devices used, e.g., each kind of custom-made device prescribed according to one podiatric biomechanical theory or another vs off-the-shelf vs custom-made but non-podiatric? Foot orthoses have been around many, many years. With many practitioners as well as many parents (since they usually have to pay for these things) believing asymptomatic feet should not be treated and there not being any reports that I know of of deaths caused by untreated (or treated, for that matter) asymptomatic flat foot, it should be fairly easy to undertake such studies without concern for ethical considerations. The lack of such studies after all these years suggest that those who financially profit from orthoses, i.e,, fabricating labs and prescribing doctors, suggest that they would rather not know the answer

Dr. Kirby, thank you for presenting an ongoing question which has peplexed the podiatric practitioner for years and which has been met with sometimes strong opposition from our physician friends. Having practiced for thirty five plus years and trained on both coasts, I would have to take a strong position of treating the flatfoot deformity as early as possible. I have always believed that placing the developing foot into a suitable correct functional position during development is our inherent responsibility. We thus permit the normal ontogeny to take place with correct pressures and phasic timing of motion through each joint relationship. Identifying a familial history of similar pathology or biomechanical abnormality should be a significant signal to evaluate more thoroughly. Identifying a parental limb length inequality, torsional abnormality or spinal pathology which results in compensatory foot function or vice versa should be a standard part of suspected childhood evaluations. I would never hesitate to ask the parents to visit for a brief evaluation to rule out such pathology. Having the wonderful opportunity to have spent time with the likes of John Weed DPM, Tom Sgarlato DPM, Justin Wernick, DPM and Sheldon Langer, DPM has instilled in me to not hesitate to control abnormal forces being applied through a developing foot. It is indeed rewarding to follow a young child into adulthood where you were able to successfully help develop a normal functioning foot when the parental foot was not. Glenn Ocker, DPM, MS, MEd, FACFS, FACFOM
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