• 1

    Evans AM: The flat-footed child—to treat or not to treat: what is the clinician to do? JAPMA 98: 386, 2008.

  • 2

    D’Amico JC: The flat-footed child-to treat or not to treat: what is the clinician to do? JAPMA 99: 267, 2009.

  • 3

    Bresnahan P: Letter to the editor: the flat-footed child-to treat or not to treat what is the clinician to do? JAPMA 99: 178; 2009.

  • 4

    Ilfeld FW: Pes planus: military significance and treatment with simple arch support. JAMA 124: 281, 1944.

  • 5

    Bennett JDC, Stock DG: The longstanding problem of flat feet. J R Army Med Corps 135: 144, 1989.

  • 6

    Martinez-Nova A, Gijón-Noguerón G, Alfageme-Garcia P, et al: Foot posture development in children aged 5 to11 years: a three-year prospective study. Gait Posture 62: 280, 2018.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Evans AM, Nicholson H, Zakarias N: The paediatric flat foot proforma (p-FFP): improved and abridged following a reproducibility study. J Foot Ankle Res 2: 25, 2009.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Gijon-Nogueron G, Montes-Alguacil J, Alfageme-Garcia P, et al: Establishing normative foot posture index values for the paediatric population: a cross-sectional study. J Foot Ankle Res 9: 2, 2016.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 9

    Gijon-Nogueron G, Martinez-Nova A, Alfageme-Garcia P, et al: International normative data for paediatric foot posture assessment: a cross-sectional investigation. BMJ Open 9: e023341, 2019.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Mickle KJ, Steele JR, Munro BJ: The feet of overweight and obese young children: are they flat or fat? Obesity (Silver Spring) 14: 1949, 2006.

  • 11

    Mickle KJ, Steele JR, Munro BJ: Is the foot structure of preschool children moderated by gender? J Pediatr Orthop 28: 593, 2008.

  • 12

    Riddiford-Harland DL, Steele JR, Baur LA: Are the feet of obese children fat or flat? Revisiting the debate. Int J Obes (Lond) 35: 115, 2011.

  • 13

    Gijon-Nogueron G, Montes-Alguacil J, Martinez-Nova A, et al.. Overweight, obesity and foot posture in children: a cross-sectional study. J Paediatr Child Health 53: 33, 2017.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Evans AM, Karimi L: The relationship between paediatric foot posture and body mass index: do heavier children really have flatter feet? J Foot Ankle Res 8: 46, 2015.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Jordan KP, Kadam UT, Hayward R, et al: Annual consultation prevalence of regional musculoskeletal problems in primary care: an observational study. BMC Musculoskelet Disord 11: 144. 2010.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Carli A, Saran N, Kruijt J, et al: Physiological referrals for paediatric musculoskeletal complaints: a costly problem that needs to be addressed. Paediatr Child Health 17: e93, 2012.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Pfeiffer M, Kotz R, Ledl T, et al: Prevalence of flat foot in preschool-aged children. Pediatrics 118: 634, 2006.

  • 18

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

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Rome K, Ashford RL, Evans A: Non-surgical interventions for pediatric pes planus. Cochrane Database Syst Rev 7: CD006311, 2010.

  • 20

    Lovett HW, Dane J: The affections of the arch of the foot commonly classified as flat-foot. J Bone Joint Surg 78: s1, 1896.

  • 21

    Staheli L, Chew D: The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. J Bone Joint Surg Am 69: 426. 1987.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 22

    Gould N, Moreland M, Alvarez R, et al: Development of the child’s arch. Foot Ankle 9: 241, 1989.

  • 23

    Sullivan J: Pediatric flatfoot: evaluation and management. J Am Acad Orthop Surg 7: 44, 1999.

  • 24

    Kerr CM, Stebbins J, Theologis T, et al: Static postural differences between neutral and flat feet in children with and without symptoms. Clin Biomech (Bristol, Avon) 30: 314, 2015.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 25

    Moraleda L, Mubarak SJ: Flexible flatfoot: differences in the relative alignment of each segment of the foot between symptomatic and asymptomatic patients. J Pediatr Orthop 31: 421, 2011.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Yan GS, Yang Z, Lu M, et al: Relationship between symptoms and weight-bearing radiographic parameters of idiopathic flexible flatfoot in children. Chin Med J (Engl) 126: 2029, 2012.

    • Search Google Scholar
    • Export Citation
  • 27

    Kim HY, Shin HS, Ko JH, et al.. Gait analysis of symptomatic flatfoot in children: an observational study. Clin Orthop Surg 9: 363, 2017.

  • 28

    Moynihan R, Doust J, Henry D: Preventing overdiagnosis: how to stop harming the healthy. BMJ 344: e3502, 2012.

  • 29

    Pathirana T, Clark J, Moynihan R: Mapping the drivers of overdiagnosis to potential solutions. BMJ 358: j3879, 2017.

  • 30

    Evans AM: Screening for foot problems in children: is this practice justifiable? J Foot Ankle Res 5: 18, 2012.

  • 31

    Bourgleh SM, Nemeş RN, Hetaimish BM, et al: Prevalence of musculoskeletal normal variations of the lower limbs in pediatric orthopedic clinic. Saudi Med J 40: 930, 2019.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Evans AM: Mitigating clinician and community concerns about children’s flatfeet, intoeing gait, knock knees or bow legs. J Paediatr Child Health 53: 1050, 2017.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 33

    Evans A, Nicholson H: The paediatric flat foot proforma (p-FFP): improved and abridged following a reproducibility study. J Foot Ankle Res 2: 25, 2009.

  • 34

    Redmond AC, Crane YZ, Menz HB: Normative values for the Foot Posture Index. J Foot Ankle Res 1: 6, 2008.

  • 35

    Cho Y, Park J-W, Nam K: The relationship between foot posture index and resting calcaneal stance position in elementary school students. Gait Posture 74: 142, 2019.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Wenger DR, Mauldin D, Speck G, et al: Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am 71: 800, 1989.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Morton DJ: Foot disorders in general practice. JAMA 109: 1112, 1937.

  • 38

    Bresnahan PJ, Juanto MA. Pediatric flatfeet—a disease entity that demands greater attention and treatment. Front Pediatr 8: 19, 2020.

  • 39

    Gijon-Nogueron G, Marchena-Rodriguez A, Montes-Alguacil J, et al: Evaluation of the paediatric foot using footprints and foot posture index: a cross-sectional study. J Paediatr Child Health 56: 201, 2020.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Tashiro Y, Fukumoto M, Uritani D, et al.. Children with flat feet have weaker toe grip strength than those having a normal arch. J Phys Ther Sci 27: 3533, 2015.

  • 41

    Li YH, Leong JC: Intoeing gait in children. Hong Kong Med J 5: 360, 1999.

  • 42

    Harris E: The intoeing child: etiology, prognosis, and current treatment options. Clin Podiatr Med Surg 30: 531, 2013.

  • 43

    Foster HE, Jandial S: pGALS - paediatric Gait Arms Legs and Spine: a simple examination of the musculoskeletal system. Pediatr Rheumatol Online J 11: 44, 2013.

  • 44

    Rowan AL, Jandial S, Myers A, et al: pGALS performs well in the hands of a medical student. Pediatr Rheumatol Online J 6(suppl 1): P152, 2008.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 45

    Kerr CM, Zavatsky AB, Theologis T, et al: Kinematic differences between neutral and flat feet with and without symptoms as measured by the Oxford foot model. Gait Posture 67: 213, 2018.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46

    Evans AM, Rome K, Carroll M, et al: Foot orthoses for treating paediatric flat feet. Cochrane Database Syst Rev 1: CD006311, 2022.

  • 47

    Jenniskens K, de Groot JAH, Reitsma JB, et al: Overdiagnosis across medical disciplines: a scoping review. BMJ Open 7: e018448, 2017.

  • 48

    Kale MS, Korenstein D: Overdiagnosis in primary care: framing the problem and finding solutions. BMJ 362: k2820, 2018.

  • 49

    Levinson W, Kallewaard M, Bhatia RS, et al: “Choosing Wisely”: a growing international campaign. BMJ Qual Saf 24: 167, 2015.

  • 50

    Fleck LM: Choosing Wisely. Camb Q Healthc Ethics 25: 366, 2016.

  • Evans AM: Children’s Feet information for parents: Available at: https://angelaevanspodiatrists.com.au/evidence-essentials-blog-8-june-2019/.

    • Search Google Scholar
    • Export Citation
  • Evans AM: Paediatric Foot ‘Ready’ Reckoner: Available at: https://angelaevanspodiatrists.com.au/evidence-essentials-blog-7-may-2019/.

    • Search Google Scholar
    • Export Citation

Pediatric Flat Feet: A 2020 Guide for Clinicians to Identify the Boomerangs

Angela M. Evans PhD, FFPM, RCPS(Glasg)1
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  • 1 La Trobe University, Discipline of Podiatry, School of Allied Health, Human Services and Sport, College of Science, Health and Engineering.
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The pediatric flatfoot has long occupied a place in the medical literature, with concerns about the significance of its appearance. At the end of the first decade of the 21st century, an article in this journal provoked active debate about the pediatric flatfoot as part of development, and proposed a considered titration of presenting cases in an effort to justify treatment and appreciated the range and expected change in normal foot posture with growth. A decade later, the availability of normative pediatric foot posture data, and the prospective findings to confirm lessening flat feet with age, encourage a structured and considered approach to this frequent primary care presentation. The pragmatic concept of the “boomerang” is built on the research identifying pediatric flat feet likely to be symptomatic, thus requiring intervention, and filtering from those likely to remain asymptomatic. Differential diagnoses are advisedly considered, and gait remains the hallmark outcome. In this contemporary guide, an eight-step strategy has been developed to improve the approach to community pediatric flatfoot concerns. Furthermore, the three boomerang flat feet factors delineating symptomatic from asymptomatic flat feet, and applicable cutoff levels, are availed for practical reference and use. Given the recognized state of overdiagnosis and resulting unnecessary treatment that pervades the 21st century, it is timely for clear 20/20 vision for the presentation of pediatric flatfoot.