As form follows function, pedal anatomy is embedded in a history of evolution. This literature review seeks to further the understanding of physiologic and pathologic flatfoot through cross-disciplinary research of expired and extant members of the Homininae subfamily. Archaeological, anthropological, paleontological, and ontogenetic evidence presents multiple biomechanical similarities and anatomical parallels between flatfooted hominins and humans. Recognizing an evolutionary pattern in flatfoot pathologic disorders enhances anticipation and effective treatment. (J Am Podiatr Med Assoc 102(4): 319–323, 2012)
Background: Radiographic assessment is still used to evaluate flexible flatfoot in children.
Methods: To find a set of radiologic parameters for assessing this disease, we studied 53 children aged 10 to 14 years. The degree of plantar collapse was measured by Viladot’s classification (grades 0–4). The degree of valgus deformity measured in the heel in a standing position, the presence of painful points, and functional limitation during daily-living activities were also reported. The children underwent standard radiography of the foot under load. On the dorsoplantar view, the talocalcaneal, hallux metatarsophalangeal, and first intermetatarsal angles were measured. On the lateral view, the talocalcaneal, Costa Bertani, talometatarsal, talonavicular, and tibiotalar angles were measured. The radiographic measurements were compared with the data reported in the literature and were correlated with the clinical parameters studied (degree of flatfoot, valgus deviation of the heel, pain, and functional limitation).
Results: The radiographic measures that resulted increased with respect to the reference values reported in the literature for the Costa Bertani (93.1% of feet), talometatarsal (93.5%), talonavicular (89.1%), and tibiotalar (69.7%) angles, all in the lateral view. Of the angles assessed in the dorsoplantar view, the hallux metatarsophalangeal (11.1%) and first intermetatarsal (24.2%) angles were increased. The degree of flatfoot was correlated with the Costa Bertani angle (P < .0005). In the group with pain, the lateral talocalcaneal (P = .016) and first intermetatarsal (P = .02) angles were increased compared within the group without pain.
Conclusions: Despite technical limitations, we still consider standard radiography of the foot, combined with clinical examination, to be a valid tool for assessing flexible flatfoot in children, especially when surgical treatment is expected and when a basic measure of the structural setup of the foot is necessary. (J Am Podiatr Med Assoc 100(6): 463–471, 2010)
Background: This article addresses the treatment of pediatric flatfoot with foot orthoses and explores the existing knowledge from an evidence-based perspective.
Methods: Studies investigating the use of foot orthoses for pediatric flatfoot were reviewed and ranked on the evidence hierarchy model according to research designs. Clinical guidelines and efficacy rating methods were also reviewed.
Results: Three randomized controlled trials exist, and a systematic review and possible meta-analysis of these studies is in progress. The results of these studies, although not definitive for the use of orthoses for pediatric flatfoot, provide useful direction. Clinical guidelines for the management of flatfoot are a useful supplement for clinical decision making and have been enhanced.
Conclusion: This article presents a pragmatic and evidence-based clinical care pathway for clinicians to use for pediatric flatfoot. It uses a simple “traffic light” framework to identify three subtypes of pediatric flatfoot. The clinician is advised to 1) treat symptomatic pediatric flatfoot, 2) monitor (or with discretion simply treat) asymptomatic nondevelopmental pediatric flatfoot, and 3) identify and advise asymptomatic developmental pediatric flatfoot. (Children with juvenile arthritis should receive customized foot orthoses.) This approach will dispel much of the contention surrounding the use of foot orthoses in children. (J Am Podiatr Med Assoc 98(5): 386–393, 2008)
Flatfoot, or pes planus, is one of the most common foot posture problems in children that may lead to lower-extremity pain owing to a potential increase in plantar pressure. First, we compared plantar pressure distribution between children with and without flatfoot. Second, we examined the reliability and accuracy of a simple metric for characterization of foot posture: the Clarke angle. Third, we proposed a mathematical model to predict plantar pressure magnitude under the medial arch using body mass and the Clarke angle.
Sixty children with flatfoot and 33 aged-matched controls were recruited. Measurements included in-shoe plantar pressure distribution, ground reaction force, Clarke angle, and radiography assessment. The measured Clarke angle was compared with radiographic measurements, and its test-retest reliability was determined. A mathematical model was fitted to predict plantar pressure distribution under the medial arch using easy-to-measure variables (body mass and the Clarke angle).
A high correlation was observed between the Clarke angle and radiography measurements (r > 0.9; P < 10−6). Excellent between- and within-day test-retest reliability for Clarke angle measurement (intraclass correlation coefficient, >0.9) was observed. Results also suggest that pressure magnitude under the medial arch can be estimated using the Clarke angle and body mass (R2 = 0.95; error, <0.04 N/cm2 [2%]).
This study suggests that the Clarke angle is a practical, reliable, and sensitive metric for quantification of medial arch height in children and could be recommended for research and clinical applications. It can also be used to estimate plantar pressure under the medial arch, which, in turn, may assist in the timely intervention and prognosis of prospective problems associated with flatfoot posture.
Flexible flatfoot disturbs the load distribution of the foot. Various external supports are used to prevent abnormal plantar loading in flexible flatfoot. However, few studies have compared the effects of different external supports on plantar loading in flexible flatfoot. The objective of this study was to investigate the effects of elastic taping, nonelastic taping, and custom-made foot orthoses on plantar pressure-time integral and contact area in flexible flatfoot.
Twenty-seven participants with flexible flatfoot underwent dynamic pedobarographic analysis while barefoot and with elastic tape, nonelastic tape, and custom-made foot orthoses.
Pressure-time integral percentage was higher with foot orthoses than in the barefoot and taping conditions in the midfoot (P < .001) and was lower with foot orthoses than in barefoot in the right forefoot (P < .05). Pressure-time integral values were lower with foot orthoses in the second, third, and fourth metatarsals and the lateral heel (P < .05). With foot orthoses, contact area values were higher in the toes; second, third, and fourth metatarsi; midfoot; and heel compared with the other conditions (P < .05). Pressure-time integral in the right lateral heel and contact area in the left fourth metatarsal increased with nonelastic taping versus barefoot (P < .05).
Foot orthoses are more effective in providing dynamic pressure redistribution in flexible flatfoot. Although nonelastic taping has some effects, taping methods may be insufficient in altering the measured pedobarographic values in this condition.
Orthotic insole is a popular physiotherapy for flatfoot. However, the effects and whether flexible flatfoot needs orthotic insole treatment are not clear, and how the plantar pressure changes while walking up and down stairs has not been studied. Therefore, this study observed the plantar pressures of different walking conditions to find the answers.
Fifteen adults with flexible flatfoot and 15 adults with normal foot were examined while walking on a level surface and while walking up and down 10- and 20-cm stairs before treatment. The maximum force and the arch index were acquired with a force plate system. Participants with flexible flatfoot were instructed to wear the orthotic insoles for 3 months, and plantar pressures were measured again after treatment. The repeated measure was performed to analyze the data.
The maximum force and the arch index of flatfoot after treatment were significantly decreased under different walking conditions (P < .01). When walking down 10- and 20-cm stairs, the plantar data of normal foot and flatfoot were significantly increased (P < .05).
Orthotic insoles could effectively improve the plantar pressure of flatfoot under different walking conditions. In addition, the arches of normal foot and flatfoot were obviously influenced when walking down stairs. It is, therefore, necessary to wear orthotic insoles for flexible flatfoot to prevent further deformation.
A talus control foot orthosis (TCFO) combines an inverted rigid foot orthosis (RFO) with a broad upright portion that rises well above the navicular to cover and protect the talonavicular joint. We sought to identify the therapeutic effect of TCFOs in children with flexible flatfoot.
Flexible flatfoot was diagnosed in 40 children when either of the feet had greater than 4° valgus of resting calcaneal stance position (RCSP) angle and one of the radiographic indicators was greater than 30° in anteroposterior talocalcaneal angles, 45° in lateral talocalcaneal angles, and 4° in lateral talometatarsal angles and less than 10° of calcaneal pitch in barefoot radiographs. Of 40 children with flexible flatfoot, 20 were fitted with a pair of RFOs and 20 with TCFOs, randomly. Follow-up clinical and radiographic measurements were completed 12 months later.
All of the radiographic indicators changed toward the corrective direction in both groups. There were significant improvements in calcaneal pitch and RCSP in both groups (P < .05). In the TCFO group, the anteroposterior talocalcaneal angle and the RCSP showed statistically significant improvement compared with the RFO group.
In this study, the TCFO was more effective than the RFO at treating children with flexible flatfoot.
Flat arches in children usually become proper arches and high arches as the child progresses through adolescence and into adulthood. Only if the deformity persists or presents in adolescence or adulthood is it considered abnormal. We sought to determine the incidence of flatfoot in schoolchildren and to make an anthropometric comparison between flat and normal feet with respect to age and sex in the Hausa ethnic group of Nigeria.
Two hundred 9- to 14-year-old students (100 boys and 100 girls) were studied. Navicular height, medial malleolar height, lateral malleolar height, foot length, and transverse arch length were measured with a ruler, marker, and measuring tape. Statistical analysis was conducted using analysis of variance and independent-samples t tests (P < .05).
The overall prevalence of flatfoot was 10% (n = 20) (7% in boys [n = 7] and 13% in girls [n = 13]). Statistically significant differences were found in all of the measured parameters except foot length. This study showed that flatfoot has a higher incidence in girls than in boys in the Hausa ethnic group, with the incidence decreasing with age.
Girls had a higher incidence of flatfoot than boys, and it was also influenced by age. (J Am Podiatr Med Assoc 103(5): 369–373, 2013)
Background: Clinical diagnosis of pediatric flexible flatfoot is still a challenging issue for health-care professionals. Clarke’s angle (CA) is frequently used clinically for assessing foot posture; however, there is still debate about its validity and diagnostic accuracy in evaluation of static foot posture especially in the pediatric population, with some previous studies supporting and others refuting its validity. The present study aimed to investigate the validity and diagnostic accuracy of the CA using radiographic findings as a criterion standard measure to determine flexible flatfoot between ages 6 and 18 years.
Methods: A cross-sectional study of 612 participants (1224 feet) with flexible flatfoot aged 6 to 18 years (mean ± SD age, 12.36 ± 3.39 years) was recruited. The clinical measure results were compared with the criterion standard radiographic measures and displayed on the receiver operating characteristic curve, and the area under the curve was computed. Intrarater reliability, sensitivity, specificity, predictive values, and likelihood ratios were calculated for the CA. A Fagan nomogram was used to detect post-test probability.
Results: The CA demonstrated higher intrarater reliability (intraclass correlation coefficient = 0.997), sensitivity (98.4%), specificity (98.8), positive predictive value (97.3), negative predictive value (99.3), positive likelihood ratio (84), and negative likelihood ratio (0.02). The area under the curve was 0.98. The positive likelihood ratio yielded a post-test probability of 97%, and the negative likelihood ratio yielded a post-test probability of 0.02.
Conclusions: The CA is a valid measure with high diagnostic accuracy in the diagnosis of flexible flatfoot between ages 6 and 18 years.