CHILDREN AND FLAT FEET When Should I Worry?

from Our City Miramar: May 2023

Preparing Your Small Business FOR THE UNEXPECTED

By Dr. Michael M. Cohen, DPM, FACFAS

flat foot or fallen arch is referred to medically as pes planus. Foot and ankle specialists understand that flatfoot is a frequently encountered problem in children. In this condition, the foot collapses or loses the gentle curving arch on the inner side of the sole. A pediatric flatfoot is generally divided into 2 sub-groups. The first, a flexible flatfoot is characterized by a normal arch during non-weightbearing and a flattened arch while standing. The flexible flatfoot may be painful (symptomatic) or not painful (asymptomatic). The second of the subgroup is referred to as a rigid flatfoot which is characterized by a stiff flattened arch regardless of whether the child is weight-bearing or not. Such deformities include a congenital vertical talus, a tarsal coalition (a condition where the bones in the foot did not separate properly by childbirth), peroneal spastic flatfoot or traumatic causes. A flatfoot may exist as an isolated problem, or as part of a larger clinical entity. This may include genetically lax ligaments, neurologic or muscular problems, genetic syndromes, and other collagen vascular disorders such as rheumatoid arthritis.

Flexible flat feet are generally considered normal in young children as babies lack a normal arch. The arch subsequently forms fully between the ages of 7 and 10. A study published in a reputable medical journal evaluated 835 children, approximately half of which were boys and girls equally. Using a laser surface scanner, the children’s feet were measured carefully. The results indicated that the prevalence of flexible flatfoot in the group of 3-6-year old children was 44% but the prevalence of symptomatic (painful or pathological) flatfoot was less than 1%. Additionally, 13% of the children were overweight or obese. During adulthood, 15-25% of people may have flexible flatfeet. Most of these adults never develop symptoms. Adults with flexible flat feet likely inherited their condition due to the laxity of their ligaments.

Pediatricians and parents are often the first to recognize foot deformities in infants and children, but too often the problem may go unrecognized for a long period of time.

When a flatfoot is being evaluated, a foot and ankle specialist would include a thorough family history which involves a review of the medical conditions including a history of trauma or problems during childbirth. Investigating the progressive flatfoot in a child’s family often gives

Aa physician an idea how the condition will evolve. After this, a comprehensive physical exam should be conducted. The foot and ankle specialist will want to evaluate the foot for areas of tenderness and observe the child during gait (walking). There is a prominent bulge in the arch, a heel that leans to the outside resulting in toes that are easily visualized from behind and referred to as the "too many toes sign". Besides evaluating the foot, the child with a flat foot must be examined for possible contributing factors occurring above the level of the foot and ankle which would cause the foot to compensate by becoming flat. This would include the hip and knee, and lower leg. At times a leg length discrepancy may result in a flatfoot condition as well.

The flatfoot is often associated with a number of subjective symptoms which would include pain in the foot leg and knee as well as other postural complaints. Interestingly a flatfoot has been shown to have a direct relationship with medial compartment knee arthritis and bunion deformities later in life. Additionally, a study published in a pediatric journal indicated that a relationship between adolescent bunions and flat feet was 8 to 24 times greater than expected. The flatfoot can result in decreased endurance and voluntary withdrawal from physical activities. At times apparent may relate that the child is clumsy and prone to falling frequently. Children may find it difficult to climb or run and prefer not to participate in sports.

Imaging studies may include standing x-rays, CT scans or magnetic resonance imaging. This will help make a determination as to what the cause of the flatfoot deformity is, particularly if it is rigid. Additionally, a blood test can be ordered to rule out certain arthritic or inflammatory conditions if a larger clinical picture is suspected.

The nonpainful or asymptomatic flexible flatfoot may be physiologic or non-physiologic. Most flexible flat feet are physiologic, asymptomatic, and require no treatment. Physiologic flat feet follow a natural history of improvement over time. Periodic observation may be indicated to monitor for signs of progression. In these patient’s treatment is generally not indicated and patients often do very well.

The non-physiologic flatfoot is characterized by progression over time. The degree of deformity is much more severe in non-physiologic than in physiologic flexible flatfoot. The degree of deformity is visibly much more evident causing the patient to compensate in several ways. Pain and symptoms resulting from flexible flat feet include discomfort on the inside of the foot pain, on the outside of the ankle, leg, and knee.

Initial treatment for the flatfoot deformity includes stretching exercises, orthotics, at times immobilization if the patient is limping, physical therapy to strengthen muscles and tendons which hold up the arch, and stretching exercises for the heel cord which is often very tight. Nonsteroidal anti-inflammatories may also be used, but not advised on a chronic basis. If there is a positive clinical response and symptoms improve the patient will just be monitored.

Lastly, when all non-surgical treatment options have been exhausted surgical intervention can be considered. This may be provided in a variety of ways depending on the diagnosis and degree of deformity. Surgical treatment may consist of tightening of the ligaments and lengthening of tendons, a technique referred to as arthroereisis which involves the insertion of a small metallic implant through a small incision between the joints of the foot to restore the arch, to more aggressive traditional treatments such as cutting and realigning bones, known as osteotomies, or fusing the bones in the hindfoot together to stabilize the very deformed unstable flatfoot. In conditions such as a tarsal coalition, the area involved in the coalition is cut away so the bones can move more freely on each other.

▸ Dr. Michael Cohen is a Board-Certified Foot and Ankle Surgeon and Diplomate of the American Board of Foot and Ankle Surgery. He is a Fellow of the American Board of Foot and Ankle Surgeons and Board Certified and Diplomat of the American Board of Podiatric Medicine. He practices with the Foot, Ankle and Leg Specialists of South Florida specializing in lower leg injuries and reconstructive surgery of the foot and ankle. The South Florida Institute of Sports Medicine in Weston is located at 1600 Town Center Blvd., Suite C, (954) 3895900 and in Pembroke Pines at 17842 NW 2nd Street, (954) 430-9901. The practice website is www.SOUTHFLORIDASPORTSMEDICINE.org.