Orthotists - How do you decide when to intervene with paediatric flat feet?

The topic of paediatric flexible flat foot posture remains controversial, with little consensus on how this foot type should be measured, defined or assessed. Importantly a flat foot posture outside of expected norms may not require management. The structurally abnormal foot can present asymptomatically, whilst a seemingly structurally normal foot can present symptomatically. However, the experienced Orthotists discretion currently guides the decision on whether to treat or not to treat and remains variable from one to another.

There is a stigma about the paediatric foot which extends outside of just the Orthotist profession, as the progression of the foot is essential but it is critical that we avoid pathologising typical foot development. This is harmful to our patients, perpetuates unnecessary expectations and damages our profession. Most clinical concerns are physiological, nonpathological and not requiring intervention. Most debate is largely in identifying when a flat foot is atypical.

Working within paediatrics requires the clinician to assess the whole child, rather than simply the aesthetics of their foot posture. The static weight-bearing foot structure of the paediatric foot is only a small part of the clinical picture, as the dynamic function must be considered. Static foot posture measures fail to fully represent foot function and require placement within the clinical context. However, concentrating on a consensus for best practice for static measures that are validated and repeated is a good place to start. How many of you follow a validated tool such as the paediatric flat foot proforma (p-FFP) and the Foot posture index (FPI-6)?  The only flat foot scale that accommodates differences between normal and overweight/obese children.

It seems that the current approach to clinical practice is a mirroring of the clinical models for managing adult feet, whereby some foot types are assumed problematic, even though there is no strong evidence for this. Parents are frequently concerned by the appearance of children’s feet and worried that their child’s future will be impacted by deformity and pain. It has been established that adults with flexible flat feet have a significantly increased likelihood of reporting back or lower limb pain, foot pain, hallux abducto valgus and degenerative joint disease. The question of the paediatric foot divides clinical opinion, as we need an ethical and reasoned approach to clinical practice that is evidentially required, with a uniformed approach to rethink and dispel unproven beliefs based on adult comparison and yes ‘shock horror’ - vertical heels aren’t the norm!

Children’s feet are developing structures and the absence of an arch is a typical stage of development. Children are born with flexible flat feet, progressively developing a medial longitudinal arch during the first decade of life. This trend of reducing flat foot with increasing age is consistently noted within the literature. Despite flat feet being a typical developmental occurrence, it is still a frequent reason for which parents seek opinion.

So, what do clinicians say with any certainty? Currently it is clinically accepted that all typically developing children are born with flexible flat feet, progressively developing a medial longitudinal arch during the first decade of life. Healthy, typically developing children can be expected to have a flat foot type during their development which can reach normality at 7-8 years old. We are however still waiting for the original reference for this and it’s never been found! Most studies show this ‘normalising’ which is more like the foot posture becoming static at a slower velocity than those earlier years, it can in fact occur from anywhere between 3 to 8 years depending on which research you read, with strong evidence for maturation up to at least 10 years of age. Most prefer not to see children until 2.5 years, with at least 6 months independent walking.

With regard to ‘normality’ of paediatric foot posture, this will need to change with further research. Ideally it needs to move to align more readily with reference values, in keeping with the majority of other developmental children’s milestones and growth assessment methods. The typical red book of children’s weight, height, head circumference is readily reported against percentile values. Whereby, not only the percentile score at any one point in time is of importance, but indeed the consistent trajectory of that measure over time offers a clear, validated measure of change. This is the future of paediatric foot research, as this would help with clarity for those often-hard decision feet that seem extreme, but maybe are just developing towards the extremes of typical and aren’t anything other than examples of the normal statistical variation which is expected within a normally distributed population.

The author however would suggest that you at least use the paediatric flat foot proforma (p-FFP), as it is diagnostically rich, repeatable and yet simple. As a tool it allows reliable comparison from baselines and between clinicians or researchers. In addition, the p-FFP maintains the simple 'traffic light" framework, making it easy to explain to parents and other health professionals, whilst ensuring that all are literally on the same evidence-based page when considering the child's flat foot. The simplicity of pain or no pain is an easy decision to treat, but for those with no pain what do you do when you are chairside? p-FFP will help you rationalise and make those decisions. As part of this the Foot posture index (FPI-6) is a multi-planar measurement process, which has also demonstrated good reliability and ease of use. It is frequently used within clinical practice, evidenced by its inclusion in the Gait and Lower Limb Observation of Paediatrics tool, which is based on expert consensus and is an excellent record for those that we are just monitoring over time. However, we have a huge disparity between how paediatric flat foot is measured in the literature and how it is assessed in the Orthotists room, but if we can at least all be on the same page as clinicians it's a start - rather than assuming and issuing on a hunch!  Monitor those feet, don’t feel pressured to just issue orthoses.

How do you approach this in your clinic?  Do you regularly challenge meaningfulness of a referral whose primary concern is just how “flat” the foot is?