October 2012

Experts debate relative benefits of screening feet for risk factors

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Most question emphasis on flatfoot

By Cary Groner

The value of screening programs for pediatric foot problems—primarily flatfoot—was recently challenged in a commentary by Australian podiatrist Angela Evans, PhD, a researcher and lecturer in the Division of Health Sciences at the University of Adelaide.

This summer, in the Journal of Foot and Ankle Research, Evans examined the Australian practice of school-based screen­­ing and found it wanting from the perspective of World Health Organization (WHO) criteria. Reaction in the US has been muted because there are few such programs here, but Evans’s paper may serve as a caveat to those who want to start them—and some do.

WHO guidelines specify that screening programs for health conditions should meet several criteria: the problem should be important and clearly defined; it should be recognizable while latent or at an early symptomatic stage, and its natural history adequately understood; and treatment should modify its course.

“These criteria are not fulfilled for pediatric flatfoot,” Evans told LER.

Her paper points out that developmental (sometimes called physiologic or normal) flatfoot occurs in 45% of preschool children, but decreases to 15% in 10-year-olds as the foot develops.

“Some flat feet do remain in older children,” she said, “but unless they’re symptomatic, the need to treat is unclear.”

So why screen? Some argue that pediatric flatfoot shouldn’t necessarily be the focus.

“We need more screening, not less, because there are huge numbers of children in the US with foot malalignments that are not identified until they are well into adulthood, when they have significant problems,” said Russell Volpe, DPM, professor of orthopedics and pediatrics  at the New York College of Podiatric Medicine in New York City.

Volpe includes femoral or tibial torsion, equinus, and genu varum among problems that could be identified or prevented through screening.

For Ron Raducanu, DPM, who practices in Philadelphia and serves as president of the American College of Foot and Ankle Pediatrics (ACFAP), the argument against screening doesn’t take a long enough time frame into consideration.

“They’re not following these children into adulthood, so they don’t know if the kids experience pain as they get older,” Raducanu said. “Is there malalignment of the joints? Does it resolve? Are there very flat feet, or in-toeing, or hip problems? If screening can prevent even one percent of them from having issues down the road, then we are doing our jobs.”

Louis DeCaro, DPM, who practices in Amherst, MA, and is vice president of the ACFAP, plans to roll out a school screening program to help identify at-risk foot types in the near future, beginning with an assessment of the methodology in his local district.

“I agree with Dr. Evans that the way foot screenings have been done is a waste of time,” DeCaro said. “Basically, they’re checking for flat-footedness, which has flaws related to subjectivity and doesn’t consider the natural maturity of the foot. When we go into the schools, I propose putting every child into one of six categories, taking a brief social and family history, and assessing other symptoms such as coordination, fatigue, and endurance.”

DeCaro’s goal is to train school nurses to assess children’s foot types according to his system, then sort the data and refer to the appropriate specialists.

The problem with such an approach, according to Edwin Harris, DPM, is that there may be so many potential issues associated with each category that school nurses could end up classifying nearly every foot as pathological. Harris, an associate professor of orthopedics and rehabilitation at Loyola University Medical Center in Maywood, IL, saw a similar phenomenon when he was involved in school screening for scoliosis 20 years ago.

“It led to the term ‘schooliosis,’ because orthopedists were dealing with this huge incidence of false positive screening results,” he said. “If you’re going to use the kind of classification DeCaro proposes, you have to have some feet that are considered normal, and the number of classifications cannot lead to a high incidence of false positives. The instrument must be validated to ensure that it accurately identifies cases with a high risk of future pathology. Also, it must be possible to train school nurses to use the instrument as accurately as a podiatrist, with a low rate of false positives.”

Cary Groner is a freelance writer in the San Francisco Bay Area.


Evans AM. Screening of foot problems in children: is this practice justifiable? J Foot Ankle Res 2012; 5(1):18.

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