This blog post starts a series of post on the different types of conditions that Dr. McIntyre treats at Milestone Pediatric Therapy. We will be starting out with a common condition in the pediatric world that while easy to treat with physical therapy and orthotics can potentially lead to unsuspecting consequences if left untreated.
Pediatric Flat Foot
Or bilateral pes planus (if you want the medical lingo) is a common pediatric condition where a child’s feet demonstrate minimal medial longitudinal arch development when they are in a weight bearing posture (i.e. standing or walking). Pediatric flat feet is a NORMAL part of the development of the structure of a child’s foot. ~97% of 2 year olds have a classification of flat feet and this presentation should resolve by the time a child is 10 years old (incidence as low as 4%). Recent research suggests that 3-6 years old is a critical time for medial longitudinal arch development given that only 26% of children have flat feet by the time they are 6 years old.
There are two types of pediatric flat foot. Flexible flat foot refers to a condition where the medial longitudinal arch is present in non-weight bearing postures. Rigid flat foot refers to a condition where the medial longitudinal arch is not present in weight bearing OR non-weight bearing postures. Typically rigid flat foot is associated with bony anomalies of the foot/ankle structure.
These feet show an example of the “too many toes sign” as well as a change in the angle where the lower leg meets the foot.
Pediatric Flat Foot is typically not considered pathological/symptomatic until a child complains of pain or excessive fatigue in their feet or legs, demonstrates poor balance or development of gross motor/coordination skills, or if the condition is associated with a greater developmental diagnosis (such as Down Syndrome).
Clinical Tests: there are a few easy tests to see if the flat foot is rigid or flexible and the child has the potential to spontaneously develop an arch over time with typical development or with mild orthotic treatment. Your physical therapist (or podiatrist/pediatrician/orthopedic MD) can perform these assessments and make a determination if your child needs orthotics and physical therapy or just to be monitored.
Potential associations/consequences:
There are some co-morbidities and other associated conditions that have been studied by the research and have shown to have some link to pediatric flat foot. Although the researchers are not sure which “comes first” with these scenarios, pediatric flat feet is typically seen in conjunction with the following conditions. (luckily physical therapy can help address a lot of these issues!!)
Flat feet place an internal rotation moment on the leg potentially causing toe-in. Flat feet can also cause the “too many toes” sign which might look more like toe-out when watching them stand and walk
Muscle Weakness: Core, hip, and lower extremity weakness is a typical finding during a physical therapy evaluation. Flat feet could contribute to this weakness by placing muscles as a disadvantage and vice versa as weakness can lead to decreased arch formation.
Mal-alignment/rotation of leg bones: Whether the toes be turned in or turned out- both are seen with some kids with pes planus. The increased loading of the medial foot can lead kids to rotate their legs to help with re-aligning themselves for better movement.
Hyper-mobility: Kiddos with excessive mobility (potentially from a genetic condition etc.) are at higher risk for pes planus presentation because the ligaments/joints in their feet are far more mobile. And the longer a child is developing in pes planus (beyond what is considered normal age- remember flat feet is normal until at least 6 years of age potentially 10years old depending on the literature you read) the more mobile the ligaments and joints in their feet become. In the case of a child with a genetic/neurological condition, orthotics may potentially be recommended even earlier depending on the severity of their foot position.
Foot and leg pain is a symptom you will want to bring to the attention of your pediatrician.
Obesity: The link here is an interesting one and not super well studied yet. The incidence of pes planus is much higher in children with obesity. Research does not show causation of one from the other but there is indeed a correlation between the two. Potentially because their feet are flat they have a harder time moving (remember weak muscles) so therefore play less and gain more weight… or because they have more weight it collapses the medial arch? No one knows for sure and maybe both reasons play into each other over time.
Pain/Fatigue: Given the changes in alignment and muscle firing patterns this can lead to pain and increased fatigue from changing pattern of stress on the body. Many of these kids complain of pain or fatigue after playing all day or going for long walks. Listen when your kids complain of consistent pain as any pain in a child is considered at least a yellow flag by medical providers and should be evaluated.
Treatment
There is not a lot of research on treatment of pediatric flat foot. But the American College of Foot and Ankle Surgeons has a clinical practice guideline on the treatment of this condition. Summarized:
Asymptomatic: observation is the best treatment
Symptomatic: physical therapy, over-the-counter orthotics, anti-inflammatories, rest; surgery is rarely indicated (mostly for rigid flat foot or boney abnormalities- to be determined by your child’s podiatrist or orthopedist)
A physical therapy evaluation of pediatric flat foot is always a good idea if your child is complaining of foot/leg pain, excessive fatigue, and you are noticing increased tripping/falling or trouble with balance and gross motor skills. If your physical therapist determines your child needs PT you can expect some of the following activities to help your child reach their goals:
Cascade DAFO makes great over-the-counter orthotics like the “Bug.” A clinician must measure your child and make the appropriate clinical determination on which type of orthotic would help best (be supportive without being overly supportive!) as well as any add-ons and modifications your child’s feet may need!
An orthotic recommendation: depending on your child’s severity of pes planus these may be over-the-counter or custom
Stretching: many times children with pes planus have tightness in at least their heel cords, if not other muscles like their hamstrings.
Strengthening: It is important to work on hip, core, and leg strength to help promote their gross motor skills and other delays. As well as working on inner feet strength with marble pick ups or other small object. - working on internal feet muscles (called intrinsic foot muscles) is VERY important in this population because those muscles can help support their medial arch while in weight bearing postures.
Balance training: many times these children have difficulty with balancing on one leg because of the flatness in their feet or weakness in their core (or both!). Balance exercises can have a whole body benefit for children with pes planus.
Manual interventions (if necessary): may include soft tissue interventions for painful muscles and taping for arch support
Resources/Citations
Diagnosis and Treatment of Pediatric Flatfoot: Clinical Practice Guideline. The Journal of Foot and Ankle Surgery.
Pes Planus and Pediatric Obesity: A Systematic Review of the Literature. Stolzman et al. Clin Obes. 2015 April ; 5(2): 52–59
Pathology and management of flexible flat foot in children. Ueki et al. J Orthop Sci. 2019 Jan;24(1):9-13. doi: 10.1016/j.jos.2018.09.018. Epub 2018 Oct 23
Carr JB, Yang S, Lather LA. Pediatric Pes Planus: A State-of-the-Art Review. Pediatrics. 2016;137(3):e20151230