Posted by: Indonesian Children | September 7, 2009

Flat Feet in Children

  • Flat feet (also called pes planus or fallen arches) is an informal reference to a medical condition in which the arch of the foot collapses, with the entire sole of the foot coming into complete or near-complete contact with the ground. In some individuals (an estimated 20–30% of the general population) the arch simply never develops in one foot (unilaterally) or both feet (bilaterally).
  • Being flatfooted does not decrease footspeed; having flat feet does not affect one’s response to the plantar reflex test
  • Flexible flat feet are normal in infants, children and adults.
  • Flat feet are often an inherited family trait.
  • The appearance of flat feet is normal and common in infants, partly due to “baby fat” which masks the developing arch and partly because the arch has not yet fully developed.
  • The human arch develops in infancy and early childhood as part of normal muscle, tendon, ligament and bone growth. Training of the feet, especially by foot gymnastics and going barefoot on varying terrain, can facilitate the formation of arches during childhood, with a developed arch occurring for most by the age of four to six years.
  • Flat arches in children usually become proper arches and high arches while the child progresses through adolescence and into adulthood.
  • Because young children are unlikely to suspect or identify flat feet on their own, it is a good idea for parents or other adult caregivers to check on this themselves.
  • Besides visual inspection, parents should notice whether a child begins to walk oddly, for example on the outer edges of the feet, or to limp, during long walks, and to ask the child whether he or she feels foot pain or fatigue during such walks.

They are also culturally and genetically normal in certain ethnic groups .

flat feet children1 Flat Feet in Children Fig1. Foot with normal arch (left) and a flat foot without an arch (right). 

Most children develop an arch in their feet when standing between 4–5 years old .

Normal ——Flat Foot

 
 


Flexible Flat Foot


Standing—–On Tip Toe


Insoles & Shoe Inserts



Congenital Vertical Talus



Tarsal Coalition


Talo-calceal —Calcaneo-navicular

However, one in five children never develop an arch in standing. Most of these children have low arches because they have loose ligaments. Their arch flattens when they are standing and their feet appear to roll in. However, an arch can be seen when the child stands on tiptoes or their feet are off the ground (Fig. 3).

flat feet children3 Flat Feet in Children Fig 3. The foot arch flattens when the child stands (a), but is visible when standing on tiptoes (b) or if the feet are off the ground (c). 

Flat feet will not cause long-term problems. Most adults with flexible flatfeet have strong, pain-free feet and are able to do all activities and sports.

Special shoes, shoe inserts (orthotics) or exercises will not make an arch develop in a child with flexible flat feet. Arch supports may create a temporary arch in the foot, but the posture of flat feet returns once the supports are removed. Many children do not feel comfortable with arch supports in their shoes.

 

Flat feet of a child are usually expected to develop into high or proper arches, as shown by feet of the mother.

  • Children who complain about calf muscle pains or any other pains around the foot area, may be developing or have flat feet. Pain or discomfort may also develop in the knee joints.
  • A recent randomized controlled trial found no evidence for the treatment of flat feet in children either for expensive prescribed orthoses (shoe inserts) or less expensive over-the-counter orthoses.

Flexible Flat Foot is the more common variety (95%). It is generally observed in the younger child and is frequently associated with generalised joint laxity. This condition is rarely symptomatic or limits the level of activity.

A classical finding in flexible flat foot is that the foot arch develops normally when the child stands on tip toes. whilst standing normally the flat foot deformity recurs.

In vast majority of cases flexible flat foot is an entirely benign condition and requires no treatment. Recent long-term studies have shown that old methods of treatment such as insoles or surgical shoes have no beneficial effect on the ultimate outcome.

Rigid Flat Foot on the other hand this is a sinister finding and often associated with serious conditions such as tarsal coalition or congenital vertical talus.

Unlike flexible flat foot, rigid flat foot is frequently a painful disorder. In this condition when the child stands on tip toes, the medial foot arch does not develop normally. On examination the foot is found to be stiff, lacking normal range of movement in the subtalar joint.

Congenital vertical talus (CVT) is a rare but serious foot deformity. It generally presents at birth and rarely responds to conservative treatment. 50% of cases are associated with underlying neuromuscular conditions or syndromes. Surgical intervention is frequently required as this is a painful condition as an adult. surgical correction is generally carried out at age 1 year.

Tarsal coalition is a relatively common condition (1-2% of population). Most cases are relatively asymptomatic and do not come to the attention of the medical profession.

Tarsal coalition is usually asymptomatic in the younger child and only becomes painful during the adolescent growth spurt. There 2 main varieties of tarsal coalition are: Talo-calcaneal coalition and Calcaneo-navicular coalition. Both varieties present with pain and stiffness in the foot.

Treatment for tarsal coalition is controversial. My preference for early cases is to excise the coalition and insert a fat graft into the gap to stop the coalition from reforming. Other methods of treatment are: short period of casting in a walking plaster or subtalar fusion.

Diagnosis

  • A podiatrist, osteopath, physiotherapist or chiropodist can diagnose a flat foot condition during a consultation. An easy and traditional home diagnosis is the “wet footprint” test, performed by wetting the feet in water and then standing on a smooth, level surface such as smooth concrete or thin cardboard or heavy paper. Usually, the more the sole of the foot that makes contact (leaves a footprint), the flatter the foot.
  • In more extreme cases, known as a kinked flatfoot, the entire inner edge of the footprint may actually bulge outward, where in a normal to high arch this part of the sole of the foot does not make contact with the ground at all.
  • Most flexible flat feet are asymptomatic and do not cause pain. In these cases, there is usually no real cause for concern. Rigid flatfoot, a condition where the sole of the foot is rigidly flat even when a person is not standing, often indicates a significant problem in the bones of the affected feet, and can cause pain in about a quarter of those affected.
  • Other flatfoot-related conditions, such as various forms of tarsal coalition (two or more bones in the midfoot or hindfoot abnormally joined) or an accessory navicular (extra bone on the inner side of the foot) should be treated promptly, usually by the very early teen years, before a child’s bone structure firms up permanently as a young adult. Both tarsal coalition and an accessory navicular can be confirmed by x-ray.
  • Rheumatoid Arthritis can destroy tendons in the foot (or both feet) which can cause this condition, and untreated can result in deformity and early onset of Osteoarthritis of the joint.
  •  Such a condition can cause severe pain and considerably reduced ability to walk, even with orthoses. Ankle fusion is usually recommended.

Treatment

  • Going barefoot, particularly over terrain such as a beach where muscles are given a good workout, is good for all but the most extremely flatfooted, or those with certain related conditions such as plantar fasciitis.
  • One medical study in India with a large sample size of children who had grown up wearing shoes and others going barefoot, found that the longitudinal arches of the barefooters were generally strongest and highest as a group, and that flat feet were less common in children who had grown up wearing sandals or slippers than among those who had worn closed-toe shoes.
  • Flat feet can be treated by insoles.Flat feet can also be inherited genetically.
  • Treatment of flat feet may also be appropriate if there is associated foot or lower leg pain, or if the condition affects the knees or the lower back. Treatment may include using Orthotics such as an arch support, foot gymnastics or other exercises as recommended by a podiatrist or other physician. In cases of severe flat feet, orthoses should be used through a gradual process to lessen discomfort. Over several weeks, slightly more material is added to the orthosis to raise the arch. These small changes allow the foot structure to adjust gradually, as well as giving the patient time to acclimatise to the sensation of wearing orthoses. Once prescribed, orthoses are generally worn for the rest of the patient’s life. In some cases, surgery can provide lasting relief, and even create an arch where none existed before; it should be considered a last resort, as it is usually very time consuming and costly.
  • Studies analyzing the correlation between flat feet and physical injury in soldiers have been inconclusive. A recent study of Royal Australian Air Force recruits that tracked the recruits over the course of their basic training found that neither flat feet or high arched feet had any impact on physical functioning, injury rates or foot health. If anything, there was a tendency for those with flat feet to have fewer injuries.
  • But another study of 287 Israel Defense Forces recruits found that those with high arches suffered almost four times as many stress fractures as those with the lowest arches. And a later study of 449 U.S. Navy special warfare trainees found no significant difference in the incidence of stress fractures among sailors and Marines with different arch heights.

Important to consult a paediatric orthopaedic surgeon if the flat feet are:

  • stiff
  • painful
  • causing difficulty with activities (e.g. running, jumping)
  • only one side is affected.

 

REFERENCE

 

Supported  by
CLINIC FOR CHILDREN 

Yudhasmara Foundation 

JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010

phone : 62(021) 70081995 – 5703646 

http://childrenclinic.wordpress.com/

 

 

Clinical and Editor in Chief :

DR WIDODO JUDARWANTO

email : judarwanto@gmail.com

 

 

 

 

 

                                                                                                            

Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.

Copyright © 2009, Clinic For Children Information Education Network. All rights reserved.


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