Pediatric flatfoot is a pathology that is characterized by a low, longitudinal medial arch and everted calcaneus. It is often accompanied by the presence of equinus. Pediatric flatfoot is commonly classified as either flexible or rigid. We focus on the flexible pediatric flatfoot since the fixed nature of rigid pediatric flatfoot does not respond well to functional orthoses.
Orthotic treatment for flexible pediatric flatfoot has been a topic of great debate for decades. While the theory that intervention may mitigate midlife symptoms is currently accepted by many practitioners, it remains unsubstantiated in clinical trials. The question that most practitioners deal with is if and when treatment should be instituted. Assuming the child will simply outgrow the problem, particularly if they are experiencing symptoms, ignores the current well-being of the child and the fact that untreated flatfoot likely contributes to foot pathology later in life.
Based on current evidence, children with symptomatic flexible flatfoot require treatment. The asymptomatic children with flexible pediatric flatfoot who are obese, have extreme hypermobility, or systemic or genetic abnormalities should also receive treatment. No treatment is currently recommended for the child with hypermobile flatfoot who has no symptoms and normal development. Normal development is commonly considered to be the presence of a vertical resting calcaneal stance position by age seven.
Clinical Goal for Orthotic Treatment
The goal of the prescribed device is to reduce pain and deformity associated with pediatric flatfoot by reducing the excessive pronatory forces across the subtalar joint. The orthoses must be rigid enough to support and realign the subtalar and midtarsal joints, while increasing supinatory torque across the subtalar joint axis.
To prescribe this device, check “Pediatric Flatfoot” under the Pathology Specific Orthoses section (Part A) of the prescription form.
Pediatric Flatfoot Prescription Recommendations
- Polypropylene Shell – rigid to semirigid
- Deep Heel Cup
- The deep heel cup increases surface area medial to the STJ axis, increasing supinatory torque
- Wide Width and Medial Flange
- A wider distal width with a medial flange through the arch significantly increases surface area under the arch, effectively supporting the arch and limiting excessive pronation.
- Minimum Cast Fill
- Minimum fill results in an orthosis that conforms closely to the arch of the foot and provides superior midtarsal joint control
- Medial Skive – 4mm
- The medial heel skive creates a greater force medial to the axis of the subtalar joint helping to reduce excessive STJ pronation and heel eversion.
- Inversion – 4 degrees
- Inversion creates tighter control of the medial arch and applies a varus wedge effect in the heel cup
- 4/4 Rearfoot Post – extra long
- The post acts to stabilize the orthosis in the shoe. The increased distal length provides more effective stabilization in the midfoot.
This orthosis is designed to reduce the extreme pronatory forces associated with the pediatric flatfoot. The increased width, the deep heel cup and the medial heel skive contribute to increased supinatory force across the subtalar joint axis. If you have further questions, ProLab clients can contact a Medical Consultant.
Treatment of Pediatric Flexible Flatfoot with Functional Orthoses, by Paul R. Scherer, DPM
Treating Pediatric Foot and Leg Deformities, by Eric M. Feit, DPM and Alona Kashanian, DPM
- Blake R, Ferguson H: Foot orthoses for severe flatfoot in sports. J Am Pod Med Assoc, 81:10, 1991
- Bleck E, Berzins U: Conservative management of pes valgus with plantarflexed talus, flexible. Clinical Orthopedics 122:85, 1977
- Bordelon RL: Correction of hypermoblie flatfoot in children by molded insert. Foot Ankle, 1(3):143-150, 1980
- Bordelon, RL: Hypermobile flatfoot in children; comprehensive, evaluation and treatment. Clin Orthop Rel Research, 181:12,1983
- Bordin D, DeGiorgi G, Mazzocco G, Rigon F: Flat and cavus foot, indexes of obesity and overweight in a population of primary-school children. Minerva Pediatrics, 53:7-13, 2001
- Dowling AM, Steel JR, Baur LA: Does obesity influence foot structure and plantar pressure patterns in prepubescent children? Int J Obes Relat Metab Disord 25:845-52, 2001
- El O, Akacali O, Kosay C, et.al: Flexible flatfoot and related factors in primary school children; a report of a screening study. Rheumatol Int 26:1050, 2006
- Evans AM: The flat-footed child – to treat or not to treat. J Am Podiatr Med Assoc 98(5):386-393, 2008
- Franco A: Pes cavus and pes planus analysis and treatment. Phys Ther, 67:688, 1987
- Garcia-Rodriguez A, Martin-Jimenez F, Carney-Varo M, et al. Flexible flatfeet in children: a real problem? Pediatrics, 103-6, 1999
- Harris E, Vanore J, Thomas J, et al: Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg 43(6):341, 2004
- Kirby K, Green D: Evaluation and non operative management of pes valgus foot. De Valentine foot and Ankle Disorders in Children, New York, Churchill Livingstone 295: 1992
- Lin C, Lai K, Kuan T. Correlating factors and clinical significance of flexible flatfoot in preschool children. Jl of Pediat Orthop 21:378, 2001
- Mereday C, Dolan, CM, Luskin R: Evaluation of the University of California Biomechanics Laboratory shoe insert in “flexible” pes planus. Clin Orthop 82:45, 1972
- Mickle KJ, Steele JR, Munro BJ: The feet of overweight and obese children: are the flat or fat? Obesity, 14:1949-53, 2006
- Mickle KJ, Steele JR, Munro BJ: Does excess mass affect plantar pressure in young children? Int J Pediatr Obes, 1:83-8,2006
- Park I, Song K, Shin S: Flatfoot survey in 8 year old primary school children. J Korean Foot Ankle Soc. 8:7, 2004
- Paton JS, Spooner SK.: Effect of extrinsic rearfoot post design on the lateral-to-medial position and velocity of the center of pressure. J Am Pod Med Assoc, 96(5)383, 2006
- Penneau K, Lutter LD, Winter RB: Pes planus – radiographic changes with foot orthoses and shoes. Foot Ankle 2:299, 1982
- Pfeiffer M, Kotz R, Ledl T, et al: Prevalence of flatfoot in preschool-aged children. Pediatrics, 118:634-639, 2006
- Pomerantz WJ, Timm NL, Gittleman MA. Injury patterns in obese versus nonobese children presenting to a pediatric emergency department. Pediatrics 125(4):681-685, 2010
- Root, ML, Orien, W, Weed, JH: Normal and abnormal function of the foot. Los Angeles, Clinical Biomechanics, 1971
- Scranton PE, Goldner J, Leonard LL, et al: Management of hypermobile flatfoot in child. Contemporary Orthopedics. Philadelphia, W.B. Saunders 1972
- Selby-Silverstein L, Hillstrom H, Palisano R. The effect of foot orthoses on standing foot posture and gait of young children with Down syndrome. Neurorehab 16:183, 2001
- Staheli LT: Planovalgus foot deformity – current status. J Am Pod Med Assoc 89:94, 1999
- Sullivan JA: Pediatric flatfoot evaluation and management. Academy of Orthop Surg 7:44, 1999
- Timm NL, Grupp-Phelan J, Ho ML. Chronic ankle morbidity in obese children following an acute ankle injury. Arch Pediatr Adolesc Med 159(1):33-36, 2005
- Valmassy R: Lower extremity treatment modalities for the pediatric patient. Clinical Biomechanics of the Lower Extremity. 1st ed. St. Louis, MO: Mosby-Year Book Inc: 1996
- Wenger DF, Mauldin D, Speck G, et al: Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg 71A:800, 1989
- Whitford D, Esterman A: A Randomized controlled trial of two types of in-shoe orthoses in children with flexible excess pronation of the feet. Foot Ankle Int 28:6, 2007