Evidence-Based Treatment of Flexible Flat Foot in Children

Fig. 19.1

Flexible flat feet, which resolve on tip toeing

Table 19.1

Table of recommendations

Statement	Grade of recommendation
Most flexible flat feet in children do not cause symptoms	B
Shoe-wearing in early childhood is detrimental to the development of a normal longitudinal arch	C
Wearing shoe modifications during childhood is ineffective and unnecessary	B
Wearing shoe modifications during childhood may lead long-term psychosocial effects	I

Flexible flatfeet account for approximately two thirds of all flat feet and do not seem to cause disability. We acknowledge the importance of identifying within this normal variation any cases with pathological features for a fuller evaluation; specific attention ought to be paid to any with foot pain or stiffness, especially if the subtalar joint is involved. Investigations to identify any tarsal coalition or children with inflammatory joint conditions may be pertinent for these. Feet with these pathological features are not included in this brief review. Children ought to be specifically examined for any contracture of the Achilles tendon associated with a flat foot appearance especially in the older child. It is unclear whether the tendon contracture is primary or a secondary development but attention to improving that aspect seems reasonable.

There are a number of different aetiological causes proposed for paediatric pes planus in the literature. These include clinical pathologies such as ligamentous laxity, neurological and muscular, genetic and collagen disorders. Staheli and colleagues [5] demonstrated that in most children, the arch develops normally by the age of 5 years. They studied the feet of 441 normal subjects, who ranged in age from 1 to 80 years, to document the configuration of the longitudinal arch. They showed that flat feet are usual in infants, common in children, and within the normal range of the observations made in adult feet. Pfeifer et al. [6], reported that whilst 54 % of children aged 3 years had a flat foot appearance only 24 % of children had a flat foot at 6 years of age. These authors also found the incidence was higher in boys and found that children classed as obese were three times as likely to retain flat feet than those with a healthy weight.

There are two main theories described in the literature to explain the development of a flexible flat foot appearance. Basmajian and Stecko [7] believe that the height of the arch is determined by the bone-ligament complex and that muscles only function to maintain balance, propel the body and navigate uneven surfaces rather than determine the shape of the foot. Duchenne [8] and Jones [9] believe that the maintenance of the longitudinal arch is based on muscle strength.

The management of flexible flat foot can vary from conservative to surgical, nevertheless for the vast majority of typical cases reassurance with an explanation of the natural history and education is all that is required. Whilst selected cases may merit follow-up for confirmation, the majority do not require review. In addition to advice, a variety of conservative treatments are described: stretching, activity modification, orthotics, manipulation and casting. Surgical treatment is only selectively employed by some, generally after failure of conservative treatment, for atypical cases with indications being individualised [10].

What Is the Long-Term Effect of Flexible Flat Feet?

There is no good evidence that flexible flat feet cause symptoms. There is anecdotal evidence of an association with knee, foot and leg pain but controlled studies are lacking. The evidence for children with flat feet becoming adults with flat feet is also absent. Esterman and Piletto [2] showed that the shape of a foot in adulthood had no significant effect on pain, injury or function. This included adults with pes planus.

Hogan and Staheli [11] found no relationship between arch configuration and pain scores in adults and suggested that flexible flatfeet are not a source of disability. This study is consistent with previous studies and provides additional evidence against the practice of treating flexible flatfeet in children.

What Is the Effect of Wearing Shoes on Flexible Flat Feet?

Rao and Joseph [12] analysed 2300 children between the ages of 4–13 years and showed that the incidence of flat feet among children who used footwear was 8.6 % compared with 2.8 % in those who did not (p < 0.001). Significant differences between the predominance in shod and unshod children were noted in all age groups, most marked in those with generalised ligament laxity. Flat foot was most common in children who wore closed-toe shoes, less common in those who wore sandals or slippers, and least in the unshod. The authors suggested that shoe-wearing in early childhood is detrimental to the development of a normal longitudinal arch. Sachithanandam and Joseph [13] studied 1846 skeletally mature individuals to establish the influence of the age at which shoe-wearing began on the prevalence of flat foot. They showed that the incidence was higher the earlier shoe wearing started and least in those where it had not occurred until they were older: 3.24 % among those who started to wear shoes before the age of six, 3.27 % in those who began between 6–15 years of age and 1.75 % in those who first wore shoes at the age of 16 (p < 0.001). Flat foot was most common: in those who, as children, wore footwear for over eight hours each day; in the obese individuals (p < 0.01); and in those with ligament laxity (p < 0.0001). Even after adjusting for these two variables, significantly higher rates of prevalence were noted among those who began to wear shoes before 6 years old. All this suggests an association between the wearing of shoes in early childhood and flat foot.

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