By Philip Bresnahan, DPM, FACFAS
We have recognized flatfoot deformity — and its many synonyms including valgus foot deformity, pes planovalgus or talipes valgus — as a condition requiring observation or treatment for many years. However, controversies exist on several fronts. If the condition does not cause pain, as is frequently the case in a child or in less than severe cases, should you even consider treatment?1 Next, what type of treatment is the best choice for those affected? Also, how effective is treatment at controlling the nature of the deformity? Finally, what is the cost of not treating the condition?
First, my simple definition of what constitutes a flatfoot deformity is a foot that has “moved out” from underneath the weightbearing axis of a single limb of the body in the stance phase of gait. In other words, the foot, which primarily consists of the calcaneus, navicular and cuboid bones, has moved out from underneath the talus and eccentrically loads our body weight on the sustentaculum tali in stance and forces the foot into eversion. The functional end result is that the bones of the foot “unlock” from their stable structural alignment and provide little skeletal support for the body weight above.
A majority (if not all) of these cases begin at birth with a degree of calcaneovalgus deformity, which physicians may not have recognized and which went untreated. As that child takes the first step, the foot is “pre-determined” to land in a rearfoot valgus attitude, establishing the flatfoot condition from early on that gets progressively worse with ambulation over time. Harris and Beath felt there was an inherited malformation of the sustentaculum tali that led to this foot type.2 Gould described an angle that developed in the sustentaculum tali that affected the function of the posterior tibial tendon.3
Many of these cases that we identify in childhood do not cause pain or appear to affect a child’s ability to ambulate. I feel this is common in children 5 to 7 years of age and younger for a few reasons. First, while many younger children are often active, they are not participating in the numerous organized sports that require a great deal of running. Second, these children have not developed a lot of body mass so there is still a lesser load on the feet.
A Closer Look At Treatment Goals
Physicians must adopt a philosophy of care that if they recognize a deformity, they are obligated to attempt a reasonable and effective treatment plan. Whether a particular case is designated mild, moderate or severe, painful or asymptomatic, they should institute a treatment plan.
What is the “functional” goal of treatment? The objective is to attempt to restore the alignment of the foot underneath the talus during the weightbearing phase of gait so the bony skeleton of the foot can lock into a stable propulsive mechanism.
There are several treatment options available to the practitioner. The simplest form of treatment is some type of orthotic control. These days, everything that a person sees in a store is called an “orthotic.” For purposes of this discussion, I will refer to any off-the-shelf device as an arch support. A device that is constructed based on a mold or image of the foot with prescribed alterations/adjustments to modify the device is a prescription orthosis.
The objective of an external device is to brace the bone structure of the foot and act as a modified weightbearing surface for the foot to mold, which realigns the position of the bones of the feet into a more stable position. An off-the-shelf device may be effective with minimal cost to the patient and should be the first treatment option. There are many prefabricated devices available from orthotic manufacturers that have better rearfoot control than most of the store bought inserts at a minimally greater cost.
I advise my patients (or their parents) that prescription orthoses offer a few advantages over prefabricated devices. The obvious advantage is that the device should be a perfect mold of the foot that it is trying to adjust. Secondly, each foot is different and off-the-shelf devices are the same for both feet so these devices are unlikely to provide ideal control. Realistically, I try to use prefabricated orthotic devices throughout a child’s years of rapid foot growth to minimize cost.
Controversy exists in the orthopedic and podiatric communities. Staheli wrote that the use of orthoses or shoe modifications to treat children with physiologic flatfoot is not only ineffective but uncomfortable and embarrassing for the child, and is associated with lower self-esteem in adult life.4 Our own profession espouses that “most flexible flatfeet are physiologic, asymptomatic and require no treatment” in a clinical practice guideline.5
Conversely, as early as 1970, Giannestras noted, “Many of the therapeutic regimens, both conservative and surgical, would be unnecessary if the flatfoot deformity was recognized at birth and definitive treatment was immediately instituted. Just as early recognition and treatment are recommended for clubfeet, so too should the flatfoot be easily recognized and corrective measures promptly instituted. It behooves us to spread the gospel, so to speak, to the pediatricians, the generalists and the obstetricians and to educate them to be conscious of these ever present foot problems. With prompt recognition of the calcaneovalgus foot and … with the institution of conservative corrective measures, a large number of these feet can be made normal. The past thinking that correction of this deformity is spontaneous as the infant grows is fallacious.”6
More recently, in the National Health Survey of 1990, Shibuya reported data that suggests the prevention or treatment of flat feet may reduce the incidence of calluses, bunion, hammertoe and arthritis.7 The author also noted that treatment may have a role in the improvement of the overall health of an individual. In addition, a review of the literature at the time showed generally positive outcomes with the use of orthotics in a variety of measures.8
Debating The Surgical Treatment Of Asymptomatic Flatfoot In Kids
Does surgery have a place in the treatment of an asymptomatic flatfoot deformity? Again, the severity of the condition and the expectation that conservative treatment may or may not successfully address that condition should be the factors that lead a discussion about the risks and benefits of surgical treatment with a patient.
In the case of a child, there is the quandary that a discussion about surgery is with the parents, who are not directly affected by the condition but have to make the decision to proceed with a surgical procedure for their child.
There are numerous surgical procedures advocated for the correction of the flatfoot deformity. They range from soft tissue procedures including tendon and ligament plications and advancements to implantable materials designed to internally realign the bony relationships and osteotomies that realign the bone structure. Certainly, there is a percentage of these flat feet for which most would agree surgery is an appropriate method of treatment after failed conservative care.
I believe the best approach is to consider the least invasive procedures, especially in a child. In the majority of pediatric flatfoot cases, the bones are normal but the relationship between the bones is disturbed. I would consider a sinus tarsi implant procedure, which has the potential to internally realign the bone structure of the foot with minimal risk and have good outcomes in comparison to osteotomies that reposition the bones of the foot.9 Giannini stated that uncorrected severe deformity becomes progressively symptomatic in adolescence, requiring more invasive measures.10
What Is The Cost Of No Treatment?
When one considers doing nothing to treat an asymptomatic flatfoot deformity, does the patient pay a cost down the road?
A large study of almost 2,000 participants in the Framingham Foot and Osteoarthritis Study found a statistically significant increase in medial knee pain (1.3 times) and medial knee joint cartilage damage (1.4 times) in those with planus foot morphology.11 Also, there was a linear correlation for pain and cartilage damage with the degree of “flat-footedness.” While this is an association and not a cause and effect study, and one could argue that other factors caused the arthritis, it is difficult to disregard that correlation. The cost of knee and hip arthritis, for that matter, is huge. There were 750,000 hip and knee replacements in 2005 and the cost to Medicare in 2006 was $5 billion. It has been estimated that these procedures would cost Medicare $50 billion by 2030.12 Certainly, some of these procedures were due to other causes such as obesity and not related to a flatfoot deformity, but the numbers are staggering.
Also keep in mind that while the foot may seem to be asymptomatic, the sequelae of the valgus foot deformity and other symptoms may be related to the flatfoot deformity. For example, calcaneal apophysitis is frequently associated with the valgus foot position due to the inefficient overuse of the gastrocnemius-soleus muscle complex on an unstable foot structure. Shin splints, colloquially referred to as “growing pains,” are also likely related to a compartment-like syndrome in which the leg muscles are working harder than they should be required to propel the body forward. In other words, normal growth should not hurt.
What is the final outcome? The physician must evaluate the nature of the deformity and whether the instituted treatment plan has improved or should improve the quality of a patient’s life as one would assess any other condition and with the care you would provide if treating a member of your own family. If you feel the condition will follow a course of natural progression, do not identify it as a deformity from the outset. If we find it acceptable to treat mild blurry vision and early tooth decay, for example, before they become worse or painful, we should treat the asymptomatic flatfoot deformity similarly before it gets worse or creates a secondary condition. We should not sell our profession short by accepting an abnormality, albeit a common one, as something for which we “ration” treatment to only the worst or symptomatic cases.13
Dr. Bresnahan is an Assistant Professor at the Temple University School of Podiatric Medicine. He is a Past President of the American College of Foot and Ankle Pediatrics. He is in private practice in Souderton, Pa.
1. 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.
2. Harris RI, Beath T. Hypermobile flatfoot with short tendo Achilles. J Bone Joint Surg Am. 1948;30(1):116-138.
3. Gould N, Moreland M, Alvarez R, et al. Development of the child’s arch. Foot Ankle. 1989;9(5):241-245.
4. Staheli L. Planovalgus foot deformity. Current status. J Am Podiatr Med Assoc. 1999; 89(2):94-99.
5. Harris E, Vanore JV, Thomas JL, Kravitz SR, Mendelson SA, Mendicino RW, Silvani SH, Gassen SC. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg. 2004; 43(6):341-73.
6. Giannestras NJ. Recognition and treatment of flatfeet in infancy. Clin Orthop Relat Res. 1970; 70:10-29.
7. Shibuya MS, Jupiter DC, Ciliberti LJ, et al. Characteristics of adult flatfoot in the United States. J Foot Ankle Surg. 2010; 49(4):363-368.
8. Landorf KB, Keenan AM. Efficacy of foot orthoses. What does the literature tell us? J Am Podiatr Med Assoc. 2000; 90(3):149-58.
9. Bresnahan P, Chariton P, Vedpathak A. Extraosseous talotarsal stabilization using HyProCure: preliminary outcomes of a prospective case series. J Foot Ankle Surg. 2013; 52(2):195-202.
10. Giannini S. Kenneth A. Johnson Memorial Lecture. Operative treatment of the flatfoot: why and how. Foot Ankle Int. 1998; 19(1):52-8.
11. Gross KD, Felson DT, Niu J, et al. Association of flat feet with knee pain and cartilage damage in older adults. Arthritis Care Res. 2011; 63(7):937-44.
12. Wilson N, Schneller ES, Montgomery K, Bozic KJ. Hip and knee implants: current trends and policy considerations. Health Aff (Millwood). 2008;27(6):1587-98.
13. Bresnahan P. Letter to the editor: the flat-footed child: to treat or not to treat — what is the clinician to do? J Am Podiatr Med Assoc. 2009; 99(2):178.
By Edwin Harris, DPM, FACFAS
The question is: should we treat a condition simply because that is what we have always done?
The term asymptomatic pediatric flatfoot needs clarification since it is a part of a spectrum of conditions traditionally grouped together. There is no universally acceptable definition for flatfoot.1 Symptomatic or not, pediatric flatfoot is not a single entity and is not a single anatomical lesion. Pediatric flatfoot has undergone reclassification for better understanding and development of achievable treatment options.2 I will not consider rigid pronation deformities, pronation with tarsal coalition, iatrogenic flatfoot and other variations in this discussion — although they may be asymptomatic — because they are by definition pathological deformities requiring appropriate treatment.3
The cases in question are the asymptomatic physiologic and non-physiologic flexible deformities within the physiologic range of normal and outside the normal range respectively. Non-physiologic does not equate with pathologic. Both are likely to be asymptomatic and they make up most of the cases that present in community practice.3 This has led a number of investigators to question whether they are actually normal anatomical variants.4,5 The spectrum of normal variation is very broad and it can be difficult to separate them from the pathological.6 Simply put, flexible flatfoot becomes a medical issue when symptoms develop.7 Confusing the issue, we can call into question the validity and reliability of many diagnostic techniques we use to measure and qualify the flatfoot.8 Even inclusion criteria for studies are vague and open to criticism.9
We must balance intervention for any orthopedic pathology between the scientific and the art components of medical practice. Justifying management demands meeting a number of criteria.
First, the condition must be a real problem and not a customarily perceived or theoretical issue. Second, its natural history, if unaltered, must have an undesirable long-term consequence. Third, this undesirable outcome resulting from treatment failure must be likely to occur and not just be a theoretical possibility. Fourth, treatment options must be proven to alter the natural history in a positive way. Fifth, the risk-benefit ratio should be such that treatment does not produce an effect worse than the potential consequence if the problem remains untreated. Sixth, since there often are several treatment options available, we must weigh and tailor them for the specific pathology, recognizing that no single treatment is effective for every problem and that treatment options are not interchangeable. Seventh, treatments must be cost-effective.
A Closer Look At Biomechanical Considerations
Paraphrasing Albert Einstein, “Everything changes except our thinking.” Much of our biomechanical theory as we know it today developed almost 50 years ago based largely on principles developed 20 years earlier. When first introduced, biomechanical theory was designed largely for the adult population with very little practical application for children. Children are not short adults. Their variations of the pronation syndromes are unique to their ages and have an entirely different natural history, changing with age in comparison to their adult counterparts who for the most part are either stable or worsening. Couple this with new insights from the last few years and the whole subject needs rethinking and new treatment paradigms.
Asymptomatic pediatric physiologic pronation deformities are defined as those in toddlers and children who evert 10 to 12 degrees during early stance phase and do not effectively resupinate in terminal stance. Resting calcaneal stance position is about 10 degrees and represents the maximal heel eversion. We can best define asymptomatic pediatric non-physiologic pronation as those in the same age group who evert more than 15 degrees during early stance and do not effectively resupinate. Resting calcaneal stance position is the total amount of heel eversion. If these children later hyperpronate past the physiologic range of motion, they invariably have clinical symptoms and are not part of this discussion.
Other orthopedic conditions are factors. Tibia varum and genu valgum influence the position of the calcaneus in stance in relation to the ground outside of issues in the rearfoot complex. Primary ankle valgus deformity, although unusual in young children, can produce apparent excessive pronation when the real anatomical lesion is supramalleolar. Equinus deformity and obesity complicate the issue.
The idea that all pronation is exactly alike in all patients is fallacious. There are anatomical differences in the anatomy of the talus and calcaneus as well as variations in the talocalcaneonavicular joint complex. These produce deformities that tend to dominate on (but are not necessarily exclusive to) one of the anatomical planes.10-12 Not only do these deformities differ in the clinical picture but they also differ in treatment if one decides to intervene.
The natural history of pediatric flatfoot still does not have a full definition. There are data suggesting that pronation deformity is very common in toddlers and young children, but gradually improves over most of the first decade of life.1,6,13-15 This still remains highly debatable and quality studies meeting the standards of evidence-based analyses are still largely unavailable.
Do adverse long-term events occur? The findings of Harris and Beath in their study of Canadian recruits suggest that the only morbidity in their cohort was in the individuals with rigid flatfoot but not the ones with flexible flatfoot.16 Studies have also called into question long-term morbidity and function.6,17 However, one study of 377 children between 2 and 6 years of age suggested that those with flexible flatfoot performed physical tasks poorly and walked slower than those without flexible flatfoot.18 More data and additional well designed and controlled prospective studies are needed.
How Effective Is Orthotic Therapy?
Treatment options for asymptomatic pediatric flatfoot include observation, orthoses and surgical intervention. With appropriate monitoring, observation is quite acceptable. Children can have exams for the development of clinical symptoms, worsening of the problem and the emergence of ligamentous laxity. One can treat the child if any of these occur.
The preventative benefits of orthotic therapy in this group of patients remain totally unproven.5 It is extremely difficult to develop such a study and the pitfalls are well known. One attempt analyzed 129 children assigned to four groups that included a control population and groups treated with heel cups, molded orthoses and corrective shoes.19 The study ran for three years and concluded that there was no difference between the treated and the control groups. Others found little evidence of the benefit of orthoses in the management of pediatric flexible flatfoot.20 One study concluded that all of the apparently normal toddlers in their study had pes planus but developed arches regardless of footwear worn.21 Of interest, development was faster up to age 3 when they wore arch supportive footwear.
Surgical intervention is also controversial. Early intervention may be unnecessary if the natural history of pediatric flatfoot in general points to spontaneous improvement of the worrisome findings. Since the anatomical lesions of asymptomatic pronated children are different, no single orthotic or surgical procedure will manage every case. Some may respond to a sinus tarsi implant but others may require much more extensive surgery that may not become necessary until years later.
To summarize, asymptomatic flatfoot is not a single pathology. Referring to the article of Harris and colleagues, the semirigid, rigid and remaining variations of the flatfoot picture are symptomatic and not a part of this discussion.2 We are more interested in children between the toddler years and the preteen years. The first part of the decision-making process is to determine whether it is truly a pathological condition that has a negative natural history resulting in long-term harm if untreated. To date, there is insufficient evidence-based medicine to determine which, if any, of these children will fall into this picture.
Proposed treatment must be physiologically goal-oriented, realistically achievable and produce a positive response resulting from the treatment. Treatment must modify the natural history in a positive way, be proven effective and offer little or no risk or morbidity. Compounding the issue, the parents may want to do something because they perceive their child’s feet as severely deformed. Parents may have worn orthotics themselves and they feel that their normal feet are the direct result of that therapy.
Excluding all of the clearly pathological forms of pronated feet from the discussion, one must decide on the management of asymptomatic flexible flatfoot.
In the absence of symptoms, one can defer treatment of toddlers and children under the age of 3 for several reasons. First, the natural history in the absence of any modifying factors is for some degree of spontaneous correction. The aforementioned published studies indicate that spontaneous correction may continue up to the age of 8. Second, the use of orthoses in children 3 years and younger is problematic because of the difficulties in fabricating good fitting and functioning devices. Lever arms are so short and subcutaneous fat is so abundant that it limits the ability to produce a functioning device. Third, growth in this age group is so great that replacement of orthoses due to increased size will become financially impractical. Fourth, surgical intervention in the same age group is technically very difficult and could become mutilating. Fifth, there are no data suggesting that a period of careful observation will close any door to future treatment.
My recommendation is observation on a regularly scheduled basis and withholding treatment if asymptomatic. With regular reassessment, any negative deviation from spontaneous correction will become apparent over time and one can institute appropriate intervention. This can continue indefinitely as long as the children remain asymptomatic. In the event that minor subjective symptoms develop (such as plantar discomfort with sports and other activities, diffuse leg pain following activity), prefabricated orthoses are acceptable. It is unlikely that a custom orthosis designed to correct a static intrinsic foot misalignment would be necessary.
It is apparent that clinical management will continue to evolve over the ensuing years. It is also obvious that researchers must develop well-designed prospective studies to address the questions about the natural history of pediatric flatfoot, the effectiveness of treatment and the evolution of asymptomatic pediatric pronation into major adult foot pathology.
Dr. Harris is a Clinical Associate Professor in the Department of Orthopaedics and Rehabilitation at the Loyola Medical Center in Maywood, Ill. He is a Fellow of the American College of Foot and Ankle Surgeons.
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2. Harris EJ, Vanore JV, Thomas JL, et al. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg. 2004;43(6):341–73.
3. Sullivan JA. Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg. 1999; 7(1):44-53
4. Engelhardt P. [Long-term results in pediatric orthopedics.] Ther Umsch. 1995;52(7):444-448.
5. Staheli LT. Planovalgus foot deformity. Current status. J Am Podiatr Med Assoc. 1999;89(2):94–9.
6. Zollinger H, Exner GU. [The lax juvenile flexible flatfoot–disease or normal variant?] Ther Umsch. 1995;52(7):449–53
7. McCarthy DJ. The developmental anatomy of pes valgo planus. Clin Podiatr Med Surg 1989;6(3):491–509
8. Menz HB. Alternative techniques for the clinical assessment of foot pronation. J Am Podiatr Med Assoc. 1998;88(5):253–5.
9. Pfeiffer M, Kotz R, Ledl T, et al. Prevalence of flat foot in preschool-agedchildren. Pediatrics. 2006;118(2):634–39.
10. Blitz NM, Stabile RJ, Giorgini RJ, DiDominico LA. Flexible pediatric and adolescent pes planovalgus: conservative and surgical treatment options. Clin Podiatr Med Surg. 2010;27(1):59-77
11. Borrelli AH. Planar dominance. A major determinant in flatfoot stabilization. Clin Podiatr Med Surg. 1999;16(3):407-21.
12. Green DR, Carol A. Planal dominance. J Am Podiatry Assoc. 1984;74(2):98–103.
13. Cappello T, Song KM. Determining treatment of flatfeet in children. Curr Opin Pediatr. 1998;10(1):77–81.
14. Evans AM, Rome K. A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. Eur J Phys Rehabil Med. 2011;47(1):69-89
15. Staheli L, Chew DE, Corbett M. The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am. 1987; 69(2):426–8.
16. Harris RI, Beath T. Hypermobile flatfoot with short tendo Achilles. J Bone Joint Surg Am. 1948;30:116–40.
17. Tudor A, Ruzic L, Sestan B, Sirola L, Prpic T. Flat-footedness is not a disadvantage for athletic performance in children aged 11 to 15 years. Pediatrics. 2009;123(3):e386-92.
18. El O, Akcali O, Kosay C, et al. Flexible flatfoot and related factors in primary schoolchildren: a report of a screening study. Rheumatol Int. 2006;26(11):1050–3.
19. Wenger DR, Mauldin D, Speck G, et al. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am. 1989; 71(6):800–10.
20. Dare DM, Dodwell ER. Pediatric flatfoot: cause, epidemiology, assessment, and treatment. Curr Opin Pediatr. 2014;26(1):93-100.
21. Gould N, Moreland M, Alvarez R, Trevino S, Fenwick J. Development of the child’s arch. Foot Ankle. 1989;9(5):241-245.