July 2011

New papers revisit, rekindle flexible flatfoot controversy

Photo courtesy of SureStep.

“Other considerations” spark debate

By Cary Groner

Two recent literature reviews have reignited the debate over treatment options for pediatric flexible flatfoot.

In January 2010, when LER first covered the controversy, Australian podiatrist and researcher Angela Evans, PhD, had recently published a paper in the Journal of the American Podiatric Medical Association suggesting that children whose feet were flatter than expected, but asymptomatic, should be monitored rather than automatically treated with orthoses.1 This provoked the ire of some American pediatric foot specialists, who thought the approach downplayed important pathologies. Not everyone agreed, however; for example, Edwin Harris, DPM, the lead author of guidelines from the American College of Foot and Ankle Surgeons, concurred with the basic premise of Evans’s approach, and said it provided a practical direction for further investigation.2

More recently, Evans and a colleague, Keith Rome, DPM, professor of podiatry at Auckland University of Technology in New Zealand, published two literature reviews revisiting the topic—and rekindling the debate. In the first, comprising three trials involving 305 children, they concluded that the evidence was too limited to draw definitive conclusions about use of nonsurgical interventions for pediatric pes planus.3 The more recent review broadened the inclusion criteria for studies, reviewing 15 and proposing an algorithm for managing flexible flat feet.4

Part of the goal, Evans told LER, was to further develop the “yellow zone” in the original JAPMA paper—the asymptomatic children who, as mentioned, should simply be monitored.

“That seems to have been interpreted in an absolute sense of monitoring only,” she said. “But monitoring is a dynamic process; within that yellow zone, if a clinician sees a foot that’s not painful, but that also isn’t functioning well, that should direct some form of treatment. That may mean changing their shoes or using an inexpensive foot orthotic. Our criticism has been of the excessive use of expensive customized orthoses. But it also came out of the review that in children with arthritis and foot pain, customized orthoses are indicated because they improve both pain and function.”

Alan Ng, DPM, who practices with Advanced Orthopedics and Sports Medicine Specialists in Denver and is on the board of directors for the American Board of Podiatric Surgery, concurs with the monitoring approach in asymptomatic children.

“I think a lot of pediatric flatfoot can be treated conservatively, as long as there’s no coalition,” he said. “The initial evaluation should include weight-bearing, x-rays, gait analysis, resting calcaneal stance position, and mobility. Most of the time, initial treatment is physical therapy, muscle strengthening, functional orthotics, or good, supportive shoes, and eighty or ninety percent of the time they do fine. But if a kid is asymptomatic and can do full activity with no issues, I don’t touch them; putting them into an orthotic just because they have flat feet is inappropriate.”

Russell Volpe, DPM, who teaches at the New York College of Podiatric Medicine, said that the evaluation and treatment parameters in Evans and Rome’s most recent paper don’t go far enough.

“It’s an exemplary review and analysis of what’s been published, but it doesn’t cover the complicated topic of what makes asymptomatic flat feet a potential issue,” he said.

What Evans and Rome refer to passingly in the paper as “other considerations” are, to Volpe, a big issue and a significant part of his practice. They include superstructural and pedal influences on all three body planes.

“They miss the point about the huge role of lower extremity residual torsions, equinus, genu or tibial varum, calcaneal varus, and the like,” he said. “There’s a lot that goes into identifying the foot that is at risk to become dysfunctional and symptomatic over time, and the big tool for evaluating it is the biomechanical integrity of that lower extremity. In their paper I see one sentence about it in twenty pages. That’s the problem.”

Such influences, Volpe said, are better corrected with custom orthoses, and he took particular umbrage at the paper’s suggestion that custom approaches “desist.”

“I will not desist; in fact I will insist!” he said. “For the cohort with biomechanical comorbidities, I need to incorporate postings and modifications that allow me to manage both the primary structural comorbidity and the compensation in the foot, and for that I need to use a custom orthosis.”

No doubt as positions are refined on both sides of the argument, matters will become clearer. Stay tuned.

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


1. Evans AM. The flat-footed child—to treat or not to treat. J Am Podiatr Med Assoc 2008;98(5):386-393.

2. Groner C. Numbers needed to treat? The pediatric flexible flatfoot debate. LER Review 2010;2(1):22-29.

3. Rome K, Ashford RL, Evans A. Non-surgical interventions for pediatric pes planus. Cochrane Database Sys Rev 2010;7(7):CD006311.

4. Evans AM, Rome K. A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. Eur J Phys Rehabil Med 2011;47(1):69-89.

2 Responses to New papers revisit, rekindle flexible flatfoot controversy

  1. Jay A Shank, MS., PTA says:

    I am in at least partial agreement with Dr. Volpe on this issue. I see many young people in the Human Performance Lab at Hanover Hospital, that have planus feet. The mere fact that they have this condition is enough for me to look further into their dynamic and static biomechanics to search for a cause. Sometimes we have to look no farther that the child’s mom or dad. Forefoot varus deformities are many times an inherited condition. We can also see what our young patient will look like 20-30 years down the road if we don’t intervene with some sort of custom foot orthotic. Dad walks in with externally rotated feet and painfully valgus knees. Or, possibly mom limps in with painful bunions or arthritic midfeet. These are the things that can be prevented or at least mitigated if caught at an early age. Just because a child isn’t painful at the time of the exam doesn’t necessarily mean he or she doesn’t need orthotic management. The same child in the height of their soccer season may be having excruciating pain from such things as exertional compartment syndrome, shin splints, posterior tibial tendinitis, plantar fasciitis, the list goes on and on. Tibial torsions, medial knee pain, ACL stress are all likelihoods of an overpronating foot. Proper foot positions held in place by a custom foot orthotic can be an effective intervention to prevent or lessen these pathobiomechanical problems.

  2. Steve Blumenberg, C.Ped says:

    Pediatric flat feet are frequently the precursor to such adult foot deformities such as bunions, hammertoes, metatarsalgia, morton’s neuromas, plantar fasciitis and achilles tendonitis. Torsional rotation of the knee internally around the tibia can lead to knee, hip and lower back misalignment, pain and injury. Simply because a pediatric patient is asymptomatic is certainly not reason alone for lack of intervention. There is and should be preventative medicine.

    I also do not subscribe to typical Rootian orthotics with standard postings. For most pediatric patients and many adults I utilize MASS position casting with a weight and foot flexibility calibrated accomodative/functional shell. This has provided outstanding clinical results.

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