Paediatric Flexible Flatfoot A review of the literature

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Paediatric Flexible FlatfootA review of the
literature

• Jill Phethean

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Aim

• To review the literature on the diagnosis,
  prognosis and (non surgical) management of
  flexible flatfoot in infants aged one to six
  years of age.
• Restricted to flexible flatfoot that presented as
  an isolated condition and is not part of a larger
  clinical entity.

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Clinical Presentation

• Flattening of the medial longitudinal arch on
  weight bearing is a universal finding (Harris et
  al, 2004)
• Distinguished from rigid flatfoot using the
  Hubshire Manoeuvre and Jacks test.

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Diagnosis of Flexible Flatfoot

• Objective methods
• radiographs analysis of footprints and
• rear foot position (frontal plane)

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Radiographs

• Talo-first metatarsal angle
• Talohorizontal angle
• Talocalcaneal angle (AP and lateral views)
• Axes of the foot bones cannot be drawn accurately
  until after 6 years.

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Footprint Analysis
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Footprint Analysis

• No consensus on the arch height representing flat
  foot
• Only one measure has been shown to represent
  arch height Stahelis index (half weight
  bearing) with talohorizontal and talo-first
  metatarsal

• Measure arch morphology angles and indices
• Considered to be an indirect measure of arch
  height
• Provides a description and allows screening of
  MLA

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Rear foot position (frontal plane)

• Different reference points on the rear foot -
  TA extended distally, bisection of calc
• Different angles measured rear foot to leg to
  floor to TA
• No association between rear foot position and
  arch index (Kanatli et al, 2006)

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Rear foot position (frontal plane)

• Root and Valmassy suggested reduction in rear
  foot position to 0º 2º varus or valgus at 7 yrs
• Research shows- reduction to 4º valgus in RCSP
  by 6 years (Pfeiffer et al, 2006)mean of 4º
  valgus in 6 to 16 yrs olds (Sobel et al, 1999)
  mean 3.5º to 7º in adults (McPoil and Cornwall,
  1996 McPoil, Astrom and Avridson, 1995 and
  Cornwall, 1994.)

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Associated Factors

• Age is a predictive factor in determining the
  prevalence of flexible flatfoot
• Increased joint laxity, reduced walking speed and
  poor locomotion skills are associated with
  flexible flatfoot.
• Therefore flexible flatfoot may be considered to
  be part of musculoskeletal maturity and a
  functional entity of the lower limb.

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Prognosis

• Two opinions-flexible flatfoot is physiological
  and will self correct (Echarri and Forriol, 2003
  Forril and Pascual, 1990 Staheli, 1987 and
  Volpon, 1994)-flexible flatfoot may cause gait
  disorders in the future and is a precursor of
  foot dysfunction (Cohen-Sobel et al, 1995 and
  DAmico, 1984)

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Prognosis

• Children referred for flexible flatfoot between
• 0 and 6 years were re-examined at 16 years
• 33 prescribed orthoses
• All subjects considered to have normal feet at 16
  yrs, with no difference between treated and
  untreated feet
• High frequency of occasional pain in back and
  lower extremities (Widhe and Widhe, 2000)

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Management

• Orthoses improve the structural alignment of the
  foot bones determined by x-rays (Bordelon, 1980
  and Kuhn et al, 1999)
• Randomised control trial found that orthoses did
  not alter the natural progression of flexible
  flatfoot (Wenger et al, 1989 and Gould 1989)

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Management

• Orthoses are thought to be useful in alleviating
  the symptoms of foot or leg pain associated with
  flexible flatfeet (Cappello and Song, 1998
  Sullivan 1999 Pettengill and Jay, 2006 and
  Mortazavi et al, 2007)

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What does this tell us?

• The prevalence of flexible flatfoot decreases
  with age
• The alignment of the bones is changed with foot
  orthoses
• The development of flexible flatfoot is not
  changed with the use of foot orthoses
• Foot and leg pain symptoms associated with
  flexible flat foot can be alleviated with the use
  of foot orthoses