FLATFOOT IN CHILDREN

΄Flatfoot’ is describe a foot shape in which the medial longitudinal arch is depressed toward the ground. When a child with flexible flatfoot stands, the arch of the foot disappears. Upon sitting or when the child is on tiptoes, the arch reappears. Although called "flexible flatfoot," this condition always affects both feet.

Flexible flatfoot is common in children. Parents and other family members often worry needlessly that an abnormally low or absent arch in a child's foot will lead to permanent deformities or disabilities. Flexible flatfoot is usually painless and does not interfere with walking or sports participation. Most children eventually outgrow it without any problems. Often accompanied by a turn of the heel to the outside and called pes planovalgus.


Flatfoot in boy 11 years old.  The arch of the foot does not exist


The heels are beginning to be inclined outwardly. Pes planovalgus

Flat foot Types

  • Flexible flatfoot
  • Flexible flat foot combined with a short Achilles tendon
  • Rigid flat foot

The flexible flatfoot is 2/3 of the entire flat foot in adults and in children the percentage is higher and usually does not cause clinical problems. It causes pain in children and not usually affect their participation in sports. It is considered that this type of flat foot is a variation of the normal foot and not a pathological clinical entity.

Most children born with little or no arch. The muscles and the joints loose form that is physiologically and operate harmoniously.
During the development of the child the soft tissues in the leg mature and 'tightening, gradually creating the arch - usually after the age of five years;.

If flatfoot continue during adolescence or adulthood, the individual may report pain in the leg

 
The laxity of the ligaments are characteristic of certain individuals which then comes to the rest of their lives. These people usually have flexible flat feet.

The flexible flatfoot combined with short Achilles tendon is the 25% of cases in adults and a smaller percentage in children and can be a cause of malfunction of the foot. The gait of some children on tiptoe (ballet dancer walking), which continued for long time may be a clinical point being short Achilles tendon and should be evaluated by the specialist Orthopaedic and not only by the pediatrician.

 
 The most common cause of a rigid flatfoot is a tarsal coalition.  The most common sites for a coalition are between the calcaneus and vavicular and between the talus and calcaneus. The synostosis causes increased load in the neighboring joints and creates pain and premature wear. These symptoms develop in adolescence or later.

Other causes of rigid flatfoot include, congenital vertical talus, juvenile rheumatoid arthritis, septic arthritis, and traumatic arthritis following intra-articular fracture of the subtalar joint.

CAUSE

Creating and maintaining the arch defined by the shape of the bones and the general laxity of the body ligaments. Some children are born with loose joints in the body without this constituting a pathological entity and has inherited basis.
Children are very often has flexible pes planovalgus.

The tarsal coalitions (middle part of the foot), is often familial, may appear in one or both legs and occur in both sexes equally.
There are rare forms of flat foot due to neurological diseases the child as cerebral palsy, polio, or syndromes such as Down's syndrome, Marfan syndrome in which the joint are pathological lax.

CLINICAL EXAMINATION

Role of Orthopaedic surgeon is to recognize the cause of flat foot in the child. The clinical examination for the detection and separation of flexible form from the rigid form or a type with short Achilles tendon is the cornerstone for the design of the treatment plan for the child. In case of suspected neurological disease the child should be evaluated by a specialist pediatric neurologist.

 

The clinical examination of the foot helps the Orthopaedic surgeon separate the flexible or stiff nature of flat foot


Flexible flat foot with soft tissue protrusion (arrow)


The inclination of the calcaneus outwardly is established with the person overview from behind (calcaneus valgus)
 

X-RAY

Plain radiographs of the foot with the child upright, may stand feet on the ground, gives information on the situation of the foot and exploring existence synostosis.


Radiological control with the person upright, highlights the nature and seriousness of the problem

FOOT ANALYSIS

After the age of 4-5 years should be done in the child foot analysis - static and dynamic - to obtain information on how loaded the feet, the pressure points on the surface of the plantar surface and how much pressure is applied to different parts of foot (heel, metatarsal heads, etc). 
The foot analysis constitute a database (measure) for comparison of future examinations and Orthopaedist can evaluate the progress of each therapeutic approach if course necessary, or worsening of the clinical picture of the small patient over time.

Mechanical foot analysis




Static feet analysis

Dynamic feet analysis (walking analysis)


Mechanical foot analysis with special foam


Severe flat feet with valgus orientation of the heel in boy 4 years old

Combining electronic and mechanical feet analysis is a complete system of evaluation of the child's feet, whose data will be used to create special insoles or special footwear.

CONSERVATIVE TREATMENT
THERAPY: 

Flexible flatfoot

Most often needs no special treatment. The child will develop the arch gradually as the age of 10 years. It consists child to walk home without wearing shoes -bare foot- to trains thus the small foot muscles which will help develop the arch.

The shoes must have a very soft bottom and is especially spacious front toes. The hard bottom essentially functions as the leg immobilization -splint- and leaves the muscles without exercise which of course is not desirable.


The shoe to be worn by a child should have very soft and flexible bottom so that it is easy to bend with one hand (put the shoe between thumb and finger and push). There are children's designer shoes that have nowhere hard bottom which are not suitable for younger ages

The use of specific pads to support arch in the shoe indicated in those cases with flexible flat foot with combination with the heel which begins to pivot outwardly (pes planovalgus). This parent will see if stand behind the child who stand upright and will see the heel sticking out. The use of the feet is not just playing corrective role as to restrain the tendency of the calcaneus to incline outwardly and to allow the foot to the right direction in specially important years of development of the foot.


Flexible flat feet in children 4 years of age. The problem was found in time and by age 2.5 years wearing pad inside the shoe.


The development of valgus heels (outward inclination of heels) is typical - pes planovalgus


Special orthotic sole reinforcing arch and balancing the forces torsion of the calcaneus​


The sole place in the athletic shoe of child, but can be placed in any enclosed shoe.


The orthotic pad located in the shoe replacing the factory shoe pad

Flexible flatfoot combine with short Achilles tendon

The use of corrective insoles will not help if the flat feet combined with short Achilles tendon. Sometimes it can worsen the symptoms of the child causing pain or increasing an existing pain.

The therapeutic approach aimed at stretching the Achilles tendon program initially will be qualified physiotherapist and then by their parents on a daily and intensive basis.
If conservative treatment fails then surgical solution is appropriate.


Passive Achilles tendon stretching
 

Flatfoot due to tarsal coalition

Because this form of flat foot creates besides leg pain and functional problems are treated surgically. Initially placed in child skilled splint below the knee to immobilize the foot for 4-6 weeks.
The pain is reduced immediately after application confirming that the synostosis is a cause of the problem.

Thus the surgical removal of coalition, i.e. the separation of the bones in the foot is the treatment of choice.