Can Pediatric Flat Feet Be Fixed?

Pediatric Flat Foot, University Foot and Ankle Institute Los Angeles

The field of podiatric medicine is not renowned for an abundance of conflict. There is a great deal of podiatric progress, of course, as new procedures, materials, and techniques are discovered, developed, and incorporated into the leading podiatric practices. But significant disputes over substantial matters are relatively rare among podiatrists.

This article concerns what may be the most significant conflict in pediatric podiatry in the last 20 years. That dispute revolves around three questions; if, when, and how should flatfeet in young children be treated?

Traditional treatments for flat feet in children

The standard approach might be described as benign neglect. This attitude was encapsulated in the January 1999, issue of the Journal of the AmericanAcademy of Orthopedic Surgeons, as follows:

“Although parents are often concerned about pediatric flat foot, the child is usually found to be asymptomatic, and no treatment is indicated. In most instances, the best treatment is simply taking enough time to convince the family that no treatment is necessary.”

That viewpoint was widespread, and it is still common. A current and usually well-respected publication advises that “If your child’s flexible flatfoot does not cause pain or discomfort, no treatment is needed.”

But “pain or discomfort” is by no means the only significant symptoms of permanent flatfeet. Parents may notice their child withdrawing from physical activities, behaving in ways that could be described as lazy, frequently asking to be carried, and choosing sedentary rather than active pastimes.

These symptoms are real, and they can be just as indicative of a need for treatment as are pain and discomfort. Long-term, as the child turns into an adult, the symptoms of childhood flat foot can evolve into adult foot pain and chronic foot problems.

What causes flat feet

Most children are born with flat feet because the ligaments in their feet are lax. As time goes by, most such cases of flatfeet will resolve, as the structure of a child’s foot naturally tightens up. But if flatfeet persist after the child is fully active, (around 5 years of age) there may be a structural abnormality. If untreated, that abnormality will last throughout the child’s lifetime.

Permanent flatfeet, whether in children or adults, are caused by a misalignment between the ankle bone (talus) and the calcaneus and navicular bones of the hindfoot. The junction of these bones is called the talotarsal joint (TTJ, for the sake of brevity).

There are two types of permanent flat foot, flexible and rigid

Both types are the result of abnormalities in the talotarsal joint.

Flexible flatfoot occurs when the TTJ flexes as weight-bearing is applied and released. When standing, the misalignment causes the ankle to roll, so that the arch of the foot disappears, and the entire sole is in complete contact with the underlying surface. When the foot is not bearing weight, the arch reappears.

Flexible flatfeet cause a repetitive redistribution of weight-bearing forces throughout the foot. This misdirection of force causes a cascade of excessive loading and unloading, which reoccurs with every step taken, whether by a flatfooted child or the grown-up version of that same untreated flat-footed child.

Rigid flatfoot is rare. It is caused by inflexible structural anomalies. There is no “bounce” and the sole remains flat, even when the foot is not bearing weight. Rigid flat feet are caused by either an abnormal joining of two bones in the foot (tarsal coalition) or a condition called congenital vertical talus.

How is pediatric flat foot diagnosed?

The most obvious sign of flatfeet is a visible absence of an arch in the foot. In Latin, that lack of arch is called “pes planus”, which translates to “flat foot”. The primary diagnostic tool for flexible flatfeet is simple: visual observation of whether, when the patient is standing, the entire sole of the foot is in contact with the surface beneath.

The distinction between the temporary sort of flatfeet caused by an infant’s loose ligaments and a permanent condition, caused by structural abnormalities, is not all that difficult. When in doubt, x-rays (and, if necessary, more advanced imaging, such as MRIs) will readily reveal whether the TTJ is properly aligned.

Careful diagnostic techniques will also distinguish flexible flatfeet from both types of rigid flatfeet.

Talotarsal joint maladjustment is not going to magically disappear

The type of flatfeet caused by lax ligaments will vanish as maturation tautens the biomechanics of the foot. But the varieties of pediatric flatfeet caused by joint maladjustment will not naturally disappear with time.

Briefly put, the belief that flatfeet caused by structural abnormalities of the TTJ can be naturally outgrown is based on faulty logic and flawed research. So whenever flatfeet are caused by misalignment of the TTJ, treatment is appropriate.

Conservative flat feet treatments for children

Physical therapy, including stretching exercises, can provide some relief. Over-the-counter pain relievers, such as ibuprofen or acetaminophen, can also be of temporary benefit.

Off-the-shelf shoe inserts can help redistribute weight-bearing forces for moderate cases. Supportive shoes and custom orthotics, with subtle, patient-specific modifications, are often required to optimize arch support in severe cases of flexible flatfeet.

Surgical flat feet treatments for children

When conservative treatment doesn’t provide a remedy, effective surgery to correct flat feet is available for all types.

The appropriate surgical procedures are designed to realign and stabilize the talotarsal joint. These techniques include lateral lengthening of the calcaneal column and opening the first cuneiform wedge. In more severe cases, a heel bone shift procedure may be required. Each of these surgeries will permanently establish the correct configuration of the TTJ’s components.

No more benign neglect of harmful flat foot abnormalities

Modern podiatry possesses the diagnostic tools to discern when flatfeet are caused by structural abnormalities. When that is the case, the passage of time is going to perpetuate the condition, not improve it.

So parents of a child with maladjusted TTJs should be made aware that, without treatment, their asymptomatic flat-footed child will grow into a symptomatic adult. Those parents should be given sound medical advice, and the choice to avert that unfortunate long-term outcome.

Why choose University Foot and Ankle Institute for your child’s flat feet problems?

If you or your child are experiencing any foot problems or issues with flat feet, we’re here to help. Our nationally recognized foot and ankle specialists offer the most advanced podiatric care and the highest success rates in the nation. We are leaders in researching, diagnosing, and treating pediatric flat foot.

For more information or to schedule a consultation, please call (877) 736-6001 or make an appointment online now.

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