In preschool children with flat feet what are the indications of non-surgical treatment? An evidence based case report.

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1 In preschool children with flat feet what are the indications of non-surgical treatment? An evidence based case report. Introduction. The paediatric flat foot is a controversial topic. And although flat foot in childhood is a common diagnosis and well established clinical term, there is no universally accepted defintion (Evans et al. 2009) and the significance continues to be debated. Clinically, pes planus is a foot with a low or absent longitudinal arch often involving a valgus deviation of the hindfoot (Riccio et al. 2009). The flat contour is pronounced with weight bearing, but in a flexible flatfoot the arch can be reconstituted with extention of the great toe or when tip toeing. The primary goals of treatment of the paediatric flat foot are relief of pain or disability and the prevention of future disability (Evans and Rome 2011), due to the risk of secondary structural changes, either locally or proximally in other anatomical regions functionally connected to the foot, as the knee and hip (Riccio et al. 2009). But what are the current recommendations on management of pes planus, based on the best available evidence? And what is the effect of orthosis in preschool children? The case. Toddler B was brought to my practice at 4 years of age. The presenting complaint was that she stumbles over her feet constantly. Parents had noted that their daughters feet were flat, and was referred by the GP to a podiatrist, who developed custommade orthoses for her. She had no signs of pain or discomfort and the orthosis had not improved the steadiness on her feet. On examination the medial longitudinal arch was reduced in standing, but normal in the non-weightbering position. Heel inverted degrees on both feet, but resolved on tip toes. The knees were slightly medial to the midline and there was no tenderness to palpation at the feet. Moderate body-sway when standing on one leg, with a tendency to move into the pronation. However, with repetitions an improvement was observed within the first session. No in-toeing, nor out-toing was observed. Beightons score was 3/9 The working diagnosis was inadequate motor control of the lower limbs, partly due to poor proprioceptive input, and exercises to strengthen the supportive muscles of the

2 foot, intrinsic and extrinsic and proprioceptive training of the foot were given; furthermore exercises to encourage coordination and core stability was given. After instruction in exercises, the parents asked my advice on whether to continue or discontinue the use of orhtosis. To answer this question I needed to search the best available evidence: What is the effect of orthosis use in an asymptomatic preschool girl with flexible flatfeet? Does it influence the further development of the feet, either to improve the condition or perhaps even worsen it? Searching the evidence. Due to familiarity and its comprehensive source of current information, the search was initiated at PubMed database. The following key phrase: pes planus AND orthosis and limited the search by adding the filter: preschool Child: 2-5 years, yielded 32 results. Exchanging pes planus with the MeSH term flatfoot, gave no further result. The search was furhter limited to only include article types: review and systematic review, resulting in 9 results. 6 of these results were not included; 2 were not relevant to my question, 3 were in foreign languages and 1 only concerned orthosis in adolescents. A computer search of the AECC search (includes PubMed, Index to Chiropractic Literature, MEDLINE (full-text), AMED, Alt-Health-Watch, Cochrane Library, Best Bets) using the search term flatfoot AND children AND rehabilitation gave me 55 results, of which 3 further articles were added, and the two Cochrane reviews found the Cochrane library was already located in the PubMed search. Searching amongst the relevant citations of references amongst these articles lead to 5 further references. Results: The reported prevalence of the paediatric flat foot varies in the literature from 3-15% (Evans et al. 2009), possibly due to variable samples, assessment measures and differing age groups (Evans and Rome 2011): Consistently, flat foot has been found to normally reduce with age (Evans and Rome 2011): In a study of 835 children, Pfeiffer et al found prevalence decreased from 54% in 3-year-old children to 24% in 6-yearold children (Pfeiffer et al. 2006). This observation agreed with the findings by Leung et al. (2005), who found a continual decrease in prevalence between ages 4-10 years.

3 Apart from age, other factors, such as gender, anatomical variation and weight, muscle tone and hypermobilty, influence the prevalence of flatfeet in children(abolarin et al. 2011): There is a predisposition in boys for flat feet (Pfeiffer et al. 2006). Joint hypermobility and increased weight or obesity may increase flat foot prevalence, independently of age: fifty percent of overweight children have flat feet and 62 % of obese children are flatfooted (Evans 2008). Pathological or rigid flat foot has multiple etiologies and leads to significant pain and disability (Pfeiffer et al. 2006), whereas only few flexible flatfeet haven beeb found to be symptomatic (Evans and Rome 2011). Compared to the flexible foot, the ridgid flatfoot it is a rare encounter and most often requires intervention, either surgical or non-surgical. Flatfeet are considered physiological normal in infants and toddlers, partly due to the plantar fat pad, laxity of the physiologcial ligaments and a lower activity of muscles involved in maintaining the medial arch and varus of the forefoot (Pfeiffer et al. 2006). The flat contour is pronounced with weight bearing, but the arch can be reconstituted with extention of the great toe or when the child stands on tiptoes (Pfeiffer et al. 2006) In 2011 the first meta-analysis on the treatment of paediatric flatfoot was published (Evans and Rome 2011). The authors analyzed research articles that used functional foot orthoses to treat paediatric flatfoot and after ranking them based on the quality of evidence each presented, identified three prominent articles which recommended orthosis for the treatment of pain and function disorders related to flat feet. The authors concluded that evidence from RCT studies are too limited to draw defintive conclusions, only in children with flat feet and juvenile idiopathic arthritis, custom foot orthoses may improve pain and function slightly. However, none of these articles demonstrated a change in morphology secondary to orthosis treatment. In addition to the meta-analysis, Evans also made definitive recommendations for the clinician (Evans and Rome 2011). Based on the available demographic data and the current knowledge-base regarding treatment of the flatfooted child, she presented a treatment algorithm for the typical paediatric flexible flatfoot (Evans et al. 2009). The patients were first categorized as symptomatic or asymptomatic. No treatment is recommended for the asymptomatic normally developing foot, but in cases where the asymptomatic foot remains flat or becomes flatter as the child ages, monitoring is

4 advised. For the symptomatic patient, treatment with orthosis, stretching and ridig footwear are recommended when indicated. A study, which was not included into the meta-analysis, due to the prospective cohort design, compared the effect in between a rehabilitative programme and the use orthoses in preschool children with flat feet. (Riccio et al. 2009). They found the rehabilitative approach to be more effective (Pearson x2= Pr<0.001) than treatment with orthosis. However, when analysing the baseline characteristics of the two cohorts (in all 637 children) the mean age of the orthosis cohort was 0.8 years younger than the rehabilitation cohort. In light of the natural development of flat feet; the decrease in prevalence with age, this difference might be explained by the age difference of the group. One other study examined the effect of gross motor therapy and orthotic intervention in children with hypotonia and flexible flatfeet, and found that therapy alone may improve some gait parameters, but the addition of orthosis significantly modified the arch index (Ross and Shore 2011). The authors concluded that use of orthosis on children with hypotonia and flatfeet could possibly prevent long-term complications. However, the size of the study was very small; only including tweenty-five children aged 18 months to 5 years Discussion In the past the notion that many foot disorders seen in adults begin in childhood were generelly accepted, and orthosis was used as a preventative measure of pain and disability (Evans 2009). Despite a uniform consensus in the medical profession today, that flatfeet reduce normally with age, many parents believe that their own flat feet were successfully treated in childhood and wish the same for their offspring (Harris 2010). And due to the concern that flatfeet are essentially painfull feet they seek professional help for their child as a preventative measure. The knowledge of the prevalence in different age groups, therefore provide the clinician with an important element in clinical decision making: besides the severity of the flattening, clinical judgement should take the age of the child into consideration. In the preschool agegroup alone, the prevalence halfs from the agegroup of 3 years

5 old to the agegroup of 6 years old. Thus from this perspective flatfeet in an 8 year old child, should be monitered more carefully than in a 3 year old with the same degree of flattening. Considering that flatfeet during normal physiological development reduces and as there are no predictive tests to detecht the errant cases (Evans et al. 2009), the question arises as to whether it is possible or necessary to prevent or reverse paediatric flatfeet. Besides the recommendations from Evans (Evans et al. 2009), there is no consensus on whom to treat, nor when or how to treat children with flexible flatfeet. According to Evans, children where the foot remains flat of becomes flatter as the child ages, even when asymptomatic, should be monitered more closely (Evans and Rome 2011). In these children, a sensible approach would be to focus on those modulating factors, that might respond to treatment, eventhough evidence of long-term outcome of treatment interventions is lacking. In case of the paediatric flexible flatfoot these factors are; strenght, weight and footwear. Research into the area of footwear and rehabilitation of the paediatric flatfoot is sparce. However, both studies sourced on footwear in the preschool population (Wegener et al. 2011), one large systematic review and meta-analysis and a very small cohort study of tweenty-five children (Ross and Shore 2011), found that shoes (Wegener et al. 2011) and orthosis (Ross and Shore 2011) affect the gait of children. Both studies concluded that eventhough the longterm effect of shoewear on growth and development remains unknown, the impact of footwear on gait should be considered when assessing and evaluating the effect of shoe or in-shoe interventions. The only study examining the effect of rehabilitation measures on the development of flatfeet (Riccio et al. 2009), found the rehabilitative approach to be more effective than treatment with orthosis. However, due to a pronounced age difference of the two cohorts, this results of this study are questionable. In the symptomatic patient, treatment with orthosis, stretching and rigid footwear are recommended when indicated (Evans and Rome 2011). Whenever a child developes symptoms from the foot and ankle, or more proximally at the knee and hip, and flatfoot are observed during clinical examination, it can be tempting to associate the two with one another. Perhaps this tendency adds to the statistical overprescription of foot orthosis seen in many western countries. However, symptoms are not neccesarily related to the flatfeet and in most cases flexible flatfeet are asymptomatic

6 (Harris 2010). It is therefore appropriate to consider the history of the complaint; is it chronic or acut; recurrent or constant; history of trauma. And the assessment of the dynamical functional of the biomechanical chain in the clinical decision-making. An interresting question is how to approach children with unilateral flatfeet! Although this issue has not been addressed in the literature, I find it intriquing. In these children factors such as connective tissue properties, muscle tone and weight are theoretically similar. This condition is therefore not to be consideres as normal physiological development, is an expression of focal hypermobility, either of structural or functional nature. The physical examination of the child, will provide the clinician with information about proprioception, muscle stability and endurance, postural control and joint mobility and thus reveal the weight of each component. If joint stability is inadequate despite appropriate muscle control, foot orhtosis should be considered. These reflections are purely based on my own clinical experience, and not no any research evidence. Toddler B was brought to my clinic because she stumbled a lot. The physical examination revealed poor proprioceptive input and inadequate motor control and exercises to address these issues were perscript. Whether these findings were related to the flatfeet or not, (there is no evidence to suggest that children with flat feet, have poor neuromuscular control) and whether the exercise will influence the development of the flatfeet, remains undisclosed. According to the recommendations made by Evans (Evans et al. 2009), the asymptomatic natur of Toddler B flatfeet, suggests that she is not eligible for any treatment intervention. Especially when considering her young age and the knowledge that the prevalence of flatfeet decreases significantly with age, and that physical examination revealed no signs hypermobility, hypotonia or overweight, known to increase the prevalence of flatfeet. However, orthosis had already been made, and hence there is no evidence to suggest that this could influence the development in a detrimental direction either, there is no reason to recommend a discontinuation of use. I therefore provided the parents with these findings, so they themselves could make an informed choise. Conclusion Despite it being so common, little is known about the long-term consequences of paediatric flatfoot and the importance of the condition (Evans 2008). There is a lack of

7 evidence from prospective data to demonstrate which paediatric flat feet require and may benefit from treatment (Evans and Rome 2011). Based on the current knowledge-base regarding treatment of flatfooted children, treatment orthosis is only recommended in cases of for the symptomatic flatfoot or disability. Thus in a preschool child, with no symptoms and no sign of hypermobility or hypotonia, there is no indication of orthosis. On the other hand, there is no evidence to suggest that orthosis might have a detrimental effect on the development of paediatric flatfeet. I will supply parents with these information, so they can make an informed choise themselves. But I will discourage new orthosis as Toddler B, grows out of current once. References. Abolarin, T., Aiyegbusi, A., Tella, A., and Akinbo, S., Predictive factors for flatfoot: The role of age and footwear in children in urban and rural communities in south west nigeria. The Foot, 21 (4), Evans, A., The flat-footed child - to treat or not to treat, what is the clinician to do? J Am Podiatr Med Assoc, 98, Evans, A., The flat-footed child - to treat or not to treat. What is the clinician to do? J Am Podiatr Med Assoc, 99, 179. Evans, A., Nicholson, H., and Zakarias, N., The paediatric flat foot proforma (pffp): Improved and abridged following a reproducibility study. Journal of Foot and Ankle Research, 2 (1), 25. Evans, A. M., and Rome, K., A cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. European Journal of Physical and Rehabilitation Medicine, 47, Harris, E. J., The natural history and pathophysiology of flexible flatfoot. Clinics in Podiatric Medicine and Surgery, 27 (1), Leung, A. K. L., Cheng, J. C. Y., and Mak, A. F. T., A cross-sectional study on the development of foot arch function of 2715 chinese children. Prosthetics And Orthotics International, 29 (3), Pfeiffer, M., Kotz, R., Ledl, T., Hauser, G., and Sluga, M., Prevalence of flat foot in preschool-aged children. Pediatrics, 118 (2), Riccio, I., Gimigliano, F., Gimigliano, R., Porpora, G., and Iolascon, G., Rehabilitative treatment in flexible flatfoot: A perspective cohort study. Musculoskeletal Surgery, 93 ( (Electronic)),

8 Ross, C. C., and Shore, S., The effect of gross motor therapy and orthotic intervention in children with hypotonia and flexible flatfeet. JOURNAL OF PROSTHETICS AND ORTHOTICS, 23 (3), 149. Wegener, C., Hunt, A., Vanwanseele, B., Burns, J., and Smith, R., Effect of children's shoes on gait: A systematic review and meta-analysis. Journal of Foot and Ankle Research, 4 (1), 3.