DEVELOPMENTAL FLATFOOT
Robert H. Sheinberg, DPM

Most children's feet are flat, don't hurt and are not deformed; they are, therefore, assumed to be "normal." Nothing could be further from the truth. Developmental flatfoot is one of the most common conditions affecting the musculoskeletal system of children and teenagers. There is a tendency for the child's flatfoot to be ignored or treated with benign neglect. The facts are that it is NOT normal, the majority of children do NOT outgrow it and there IS cause for some concern.

Symptoms

• Children may not be able to communicate adequately as to their pain or fatigue in the legs or the feet. They may constantly prefer to be carried by a parent during normal walking.
• Leg or calf pain and spasms may be present especially at night.
• Premature fatigue in the legs or feet while walking or during sports participation.
• Leg, ankle and arch pain most often located toward the inside of the lower leg. The muscles are attempting to stabilize the foot. After a short period of time they fail and pain develops.
• Pain just below the knee on the inside of the leg. This is often seen together with children who are knock-kneed.

Signs

• The arch may appear normal off weight bearing but when standing, the arch may be significantly lowered or totally collapsed.
  
• The arch may be of normal height; the front half of the foot, however, is turned out relative to the rear half of the foot.
• When viewing the child from behind, the heel appears to be turned out and the arch bulges on the inside just below the ankle.
• Knock-Knees: When standing in normal position the knees almost touch each other.
• Bad Stance: The feet, ankles, and legs just don't appear right on gross examination when the child stands.
• While watching the child walk, there may be clumsiness or looseness to their gait. The feet pint outward excessively and general balance appears poor.
• Inactivity. Children with poor functioning or flatfeet do not keep up with other children during sports. This doesn't encourage them to continue with sports that require running. They will often choose more sedentary activities that will often lead to gaining weight.

Causes

• Ligaments connect bones together. They may be strong or loose. When excessively loose the bones tend to move away from each other allowing the arch to drop. Excessive flexibility or ligamentous laxity ("double jointed") is the primary reason that flatfeet are very common in children. It may be normal until age 6.
• Bone abnormalities are an uncommon cause of developmental flatfeet but needs to be ruled out.
• Trauma to tendons and ligamentous structures is an uncommon cause. A thorough medical history gathered by the foot and ankle specialist will rule this out.
• Tightness in the muscles and calf.

Treatment

Before instituting treatment, a thorough history of the chief complaint, pre and postnatal history, developmental and family history are taken. A complete physical examination of the lower extremities is of utmost importance. Observation of the child's gait (walking pattern), worn shoes and occasionally radiographs (x rays) are taken. This gives us all the information necessary to make an accurate diagnosis and formulate a treatment plan.

Treatment of lower extremity malalignment and the developmental flatfoot will relieve "growing pains" in 90% of the cases. This is especially true if the foot is flexible. More rigid types of feet do not respond as well. We believe mechanical instability of the foot during weight bearing activities is a substantial cause of growing pain in children.

Many children have minimal symptoms and little deformity. An athletic shoe, not necessarily a high top, is often recommended. The heel counter of the shoe should be rigid and the sole firm. Worn out sneakers need to be quickly replaced. Shoes lose their material strength after 4-6 months of wear. A running shoe is superior to other types of sneakers for overall general wear. Make sure your child does not go barefoot.

Treatment of painful or fatigued developmental flatfeet with orthoses (custom-molded supports for the feet) has consistently benefited children. They will often relieve stains of the foot, leg, knee, hip, and lower back. Orthotics help to realign the lower extremity. This limits abnormal or excessive movements that put the foot and leg in a poor position. If the position of the extremity is straightened, muscles are put in a better position, thus allowing them to function normally and not excessively which causes pain and fatigue.

Excessive strain and altered pull of muscles from flat feet can increase the chances for development of hammertoes, heel spurs, neuromas, and sagging joints which can result in osteoarthritis in the foot, ankle, hips and back . Back, leg, knee problems can also result from a lack of proper base of support from the feet. Severe collapse of the foot can result from a foot that is not properly supported, necessitating reconstructive bone surgery. Activity is limited, causing weight gain and poor cardiovascular activity. Muscular tightness in the foot, legs and back can occur.

Orthotics will NOT change the structure of the foot; they will not help your child "develop an arch." They will provide significant support to the foot as glasses do for the eyes. Many types of orthoses are available. Custom molded orthotics are the best. Over the counter supports may be of some, but usually limited, benefit as well. We make an impression of the foot with plaster while holding the foot in the optimum position of function. The type of orthotics chosen is tailored to the child by taking into account a multitude of factors including gait, flexibility of arch, muscular tightness, activity and shoe gear.

Patient's foot brought into a straight alignment in relation to the ground.

If muscle tightness is playing a role in the problem, exercises to stimulate flexibility are critical for long-term wellness. Often weakness may be observed in certain muscle groups due to imbalance of synchronicity between muscles. Physical therapy is a wonderful adjunct to orthotics in the early stages of treatment.

The decision to perform foot surgery is a very difficult one. If various foot orthoses and shoes have been tried, as well as therapy and casting the extremity and limited results have been obtained, the doctor and parents may decide that surgery is in the best interest of the child. Failure to consider a surgical alternative may condemn a child with severe deformity to an adulthood of pain and suffering.

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