Asymptomatic Flatfoot In Kids: Should You Treat It?

Yes. Ron Raducanu, DPM, FACFAS notes that orthotic treatment may help correct pediatric flatfoot and potentially prevent related biomechanical dilemmas as children move into adulthood.

   There continues to be quite a bit of controversy surrounding the treatment of pediatric flatfoot with custom orthotics. Given the continued emphasis on evidence-based medicine, this controversy is largely fueled by the lack of any empiric data to support the use of custom orthotics as a means to prevent future podiatric abnormalities or symptoms.

   The difficulty with relying on empiric data for this particular treatment modality is the lack of a standardized design to measure the modality in and of itself. In other words, how does one design a long-term study with a control group and a study group in this situation without compromising the test patients? There is no good justification to have a study where one child gets the treatment and the other does not just to “see what happens.”

   Unfortunately, this inherently brings into question the efficacy of the treatment itself. However, we must factor in the effect the treatment, or lack thereof, has on the patient.

   There is some data that suggests the torque surrounding the talus during a pronatory situation can affect the knee’s position as well as the position of the femoral head within the hip socket. There is also some data that suggests the treatment of the pediatric flatfoot with custom orthotics can permanently alter the mechanics of the child’s foot, thereby removing the need for custom orthotic support in the future. Unfortunately, the data for both of these theories are scant.

   Parents may bring in a pediatric patient for an evaluation of his or her feet. The child’s parents note they have been to other doctors and have been told that their young one’s problems are nothing to concern themselves with as the child will “grow out of it.” The parents say their child has been tripping a lot and is generally not able to keep up with the other children because of what they perceive to be a foot problem.

   After a thorough podopediatric history and physical, the podiatrist concludes that the patient does have a podiatric abnormality, confirming the parents’ concerns. However, since the patient is not complaining about pain or symptoms, is there a cause for concern or treatment?

   Of course there is a cause for concern. As educators and healers, our primary concern is the Hippocratic Oath. However, our patients need to feel at ease and confident in their doctor. Once again, there is no study that shows that a pediatric flatfoot left to its own devices will cause an eventual catastrophic podiatric situation.

   However, with what we know about biomechanics, it stands to reason that an abnormally positioned foot will eventually cause more harm than good.

   If one chooses to follow the “Do not worry. Your child will grow out of it” ideology, there is no separation by the parents between our profession and every other physician to whom they have taken their child. We have a tool to potentially aid in this child’s foot health so why not use it?

   One very daunting aspect of treating children is that they tend to be rather poor historians. Rarely can children under the age of 6 tell their parents that something “hurts.” Children generally need to be in substantial pain to be able to verbalize it.

   Indeed, trying to ascertain from children that their feet hurt during activity, particularly at a young age, is difficult. Once the child gets older, this becomes easier and easier, and can help to justify the use of an orthotic to support a potentially painful foot problem.

   Having a knowledgeable parent can be very helpful in evaluating the nature of the child’s pain. If a child limps at times, a parent can jog the patient’s memory as to how the patient felt during this episode. Any of these signs can also justify to the parent the need for an in-shoe device.

Other Considerations In Justifying Treatment

   Podiatric physicians can also use X-rays to help determine whether orthotic treatment is necessary. There has been some anecdotal data to suggest that taking X-rays to view the foot with and without an orthotic shows that the positions of the joints and their relationship to one another does improve when the patient wears an insole, even more so with the custom variety.

   As we continue to learn more on podopediatrics, it is very clear there are gaps in our knowledge as to the understanding of the use of orthotics. However, it stands to reason that the single thing we should strive to achieve is pain-free ambulation or, in the case of an asymptomatic deformity, better ambulation. If the patient has a gait abnormality and the insole might help, why not try it? Certainly, if the child has pain and an orthotic manages the pain, this is a win/win situation in every circumstance.

   Granted, there are gray areas with treatment with an insole. However, there are many situations when adult patients admit they have had a foot deformity since youth. They wish someone would have paid more attention and at least offered them a potential treatment option other than surgery.

   Now these adults are faced with a potentially life altering surgical procedure to relieve their pain, and they also have children or grandchildren who seem to have “the same feet as me.” This is another situation in which our profession can not only show its expertise but can also gain the patient’s confidence even more when making an offer to evaluate and help their loved ones.

In Conclusion

   If there is an available tool that has the potential to help, why not use it? One can always make the case to use something that can improve the quality of life of a patient, regardless of whether insurance covers the treatment.

   As a parent, the health and well-being of my children’s health are paramount. While some may question the evidence to support the use of custom orthotics to treat asymptomatic pediatric flatfoot, a patient’s positive experience with treatment is all that should be needed to counter even the most ardent argument against treatment.

Dr. Raducanu is board certified by the American Board of Podiatric Surgery and is a Fellow of the American College of Foot and Ankle Surgeons. He also serves as the President of the American College of Foot and Ankle Pediatrics. He is in private practice in Virginia Beach and Norfolk, Va.

No. Angela Margaret Evans, PhD, GradDipSocSc, DipAppSc(Pod) notes a lack of sufficient clinical evidence for treating asymptomatic flatfoot with orthoses.

   The presentation of the pediatric flatfoot can become a conundrum for clinicians. It is a controversial issue that divides those who believe in treating many of these patients and those who do not subscribe to this tenet.1,2

   A review of the literature uncovers much opinion and passionate dictums from senior and respected professional peers who have variously proposed the ideal of structural foot correction based upon a belief in orthotic therapy (using largely customized or prescriptive foot orthoses).3 From a preventative standpoint, the premise of a finite window of opportunity within which to correct the child’s flatfoot has long been espoused. However, the corrective nature of foot orthoses in children remains unfounded.4

   Indeed, the literature is littered with opinions, notions and stated beliefs, yet none accord with the available scientific evidence. It may sound harsh to some but in this instance, such viewpoints, however passionate and strongly held, are a clear mismatch with the existing scientific research.

   A Cochrane Library systematic review summarizes the three existing randomized controlled trials and provides the best available recommendation for the management of pediatric flatfoot.5 In essence, the Cochrane Review found that the evidence from one randomized controlled trial investigating children with chronic juvenile arthritis suggests that custom-made foot orthoses may be effective in reducing pain.6 There is no evidence from randomized controlled trials for the efficacy of foot orthoses for asymptomatic pediatric flatfoot.4,5,7

A Closer Look At The Pediatric Flatfoot Proforma Decision Tree

   Clinical guidelines have recommended that one assess the pediatric flatfoot within the context of clinical history and signs, and consider certain subtypes that may contribute to the pediatric flatfoot.8 This approach has been further developed and merged with the evidence in the Cochrane review in the form of the pediatric flatfoot proforma (p-FFP), an evidence-based, reproducibility tested, clinical decision tree.9,10

   While not perfect, the pediatric flatfoot proforma represents a pragmatic approach to assessment and management of the pediatric flatfoot. The pediatric flatfoot proforma is a current synergy of the best available evidence, consensus guidelines and tested foot posture measures.5,8 Within a framework of context (history and signs), the pediatric flatfoot proforma is diagnostically comprehensive yet simple to use. As a tool, it allows reliable comparison from baselines and between examiners.

   The pediatric flatfoot proforma uses a simple “traffic light” framework, making it easy to explain to parents and other professionals. It ensures that all parties are on the same evidence-based page when evaluating the pediatric flatfoot.

   Red light. The painful pediatric flatfoot requires treatment. There is little debate about this presentation. However, treatment may not always mean foot orthoses. Footwear selection, training practices, muscle stretching and strengthening may all contribute to the painful flatfoot scenario.

   If foot orthoses are indicated, a generic version may well suffice, saving unnecessary expense.7 In a specific cohort of children with foot pain and rheumatoid arthritis, researchers found customized foot orthoses to be advantageous.6 Using a single patient experimental design, clinicians can easily monitor the efficacy of foot orthoses.9

   Yellow light. In this scenario, the child is too old for the obviously flat feet to be developmental but he or she is symptom free. This scenario is perplexing for those clinicians who have grown accustomed to being concerned by the clinical appearance of the flatfoot structure despite it being a painless entity. However habitual or tempting the practice, the clinician must exercise caution and avoid treating children on the basis of what “might” eventuate. There is a distinct lack of prospective data to support this approach.

   Some factors may raise or negate clinical suspicion related to the context or family history of these patients. A thorough diagnosis may reveal a latent and/or discrete flatfoot subtype, including the following possibilities:

   • genetic (Down’s syndrome, Marfan’s syndrome);
   • collagen (joint hypermobility, Ehlers-Danlos syndrome);
   • neurological (cerebral palsy, hypotonia);
   • muscular (muscular dystrophy, atrophy); or
   • osseous (tarsal coalition).

   Clearly, there are very different considerations and prognoses, both podiatric and systemic, which arise with each of these specific subtypes versus a more typical flatfoot.

   One then faces the burning question: Is treatment of pediatric flatfoot ever indicated in the absence of symptoms? The answer (to the relief of many readers) is yes. For example, consider the case of a hypermobile 10-year-old child with an apropulsive, slow, markedly abducted gait and running style. This patient, who is functionally under par, may benefit from judicious and sensible treatment of asymptomatic flat feet.

   One can incorporate simple and low-cost treatment options for many of these patients. Treatment remedies include strengthening exercises, calf stretches and generic foot orthoses. Physicians can also emphasize improved shoe selection.

   If there is improvement in the designated clinical outcome measures (such as running with more propulsion, running faster and running in a less abducted manner), the treatment has clinical support. The patient generated index can be a useful composite outcome measure when assessing flatfoot that is functionally deficient rather than painful.9 Monitoring progress is an informed approach to addressing the pediatric flatfoot that is clinically suspicious but not overtly problematic. This approach enables clinicians to avoid unnecessary treatment and detect change over time.

   Green light. It is normal for young children to have flat feet as a part of their physiologic development and ontogeny. While one must appreciate the familial context and factors such as joint hypermobility, this age group should receive largely general advice about foot development and footwear selection.

   It may be wise to examine these patients if there is a positive family history of foot problems or if other aforementioned factors (such as genetic/collagen/ neurological/muscular/osseous) are contributing to the deformity. Research has shown that normal developmental flatfoot reduces appreciably with age.11-13

In Summary

   Ensuring an accurate diagnosis is the key factor when it comes to addressing the asymptomatic pediatric flatfoot. It is always relevant to check the family history, age, gait function and typical flatfoot versus the various subtypes.

   Utilize the decision-making framework of the pediatric flatfoot proforma and then think in terms of red/yellow/green categories rather than a black or white, “treat or not” approach. Judicious clinical assessment, evidence-based management (clinical experience in balance with scientific evidence) and monitored outcomes represent a more sound clinical approach.14

   Any treatment of the asymptomatic pediatric flatfoot should be simple and one should monitor for outcomes over time. Ample mainstays include improved footwear selection, exercises and inexpensive generic foot orthoses or even simpler additions such as in-shoe wedges.

   In the absence of symptoms, the clinician prescribing customized foot orthoses for a child with flat feet is practicing contrary to the best available evidence. There is simply no basis for this approach.

   Given the lack of rigorous scientific evidence for treating the asymptomatic pediatric flatfoot, the informed clinician must always err on the side of non-treatment. Uncomfortable as this may be for some, it is the definitive evidence-based approach.5

Dr. Evans is a Researcher and Lecturer with the Division of Health Sciences, Podiatry Research Group in the School of Health Sciences at the University of South Australia in Adelaide, Australia. She is a Fellow of the Australasian Academy of Podiatric Sports Medicine.

For related articles, see “How To Recognize Pediatric Gait Abnormalities” in the April 2002 issue of Podiatry Today or “Essential Treatment Tips For Flexible Flatfoot” in the April 2003 issue.

References:

1. Bresnahan P. 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. 2. Evans AM. The flat-footed child - to treat or not to treat. What is the clinician to do? J Am Podiatr Med Assoc 2009, 99(2):179. 3. Giannestras NJ. Recognition and treatment of flatfeet in infancy. Clin Orthop Rel Res 1970; 70:10-29. 4. Wenger DR, Mauldin D, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am 1989; 71(6):800-810. 5. Rome K, Ashford RL, Evans AM. Non-surgical interventions for paediatric pes planus. Cochrane Database of Systematic Reviews 2007, Art. No.: CD006311. DOI: 10.1002/14651858.CD006311: 1-7. 6. Powell M, Seid M, Szer IS. Efficacy of custom foot orthoses in improving pain and functional status in children with juvenile idiopathic arthriris: a randomized trial. J Rheum 2005; 32(5):943-950. 7. Whitford D, Esterman A. A randomized controlled trial of two types of in-shoe orthoses in children with flexible excess pronation of the feet. Foot Ankle Int 2007, 28(6):715-723. 8. Harris EJ, Vanore JV, Thomas JL, Kravitz SR, Mendicino RW, Silvani SH et al. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg 2004; 43(6):341-373. 9. 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):386-393. 10. Evans AM, Nicholson H, Zakaris N. The paediatric flat foot proforma (p-FFP): improved and abridged following a reproducibility study. J Foot Ankle Res 2009; 19(2):25. 11. Gould N, Moreland M, Alvarez R, Trevino S, Fenwick J. Development of the child’s arch. Foot Ankle 1989; 9(5):241-245. 12. Gould N, Moreland M, Trevino S, Alvarez R, Fenwick J, Bach N. Foot growth in children aged one to five years. Foot Ankle 1990; 10(4):211-213. 13. Wenger DR, Mauldin D, Morgan D, Sobol MG, Pennebaker M, Thaler R. Foot growth rate in children age one to six years. Foot Ankle 1983; 3(4):207-210. 14. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine. How to practice and teach EBM, second ed. Churchill Livingstone, London, 2000.