The flat footed child

1
The flat footed child

• To treat or not to treat,
• what is the clinician to do?
• Society of Chiropodists and Podiatrists Annual
  Conference 2008
• Angela M. Evans, PhD
• Bournemouth International Centre, UK

2
Presentation outline

• Background to paediatric flat foot
• Best evidence
• Randomised controlled trials
• Systematic review
• Guidelines
• Clinical pathways
• Evidence-based clinicians summary

3
Introduction

• Flatfoot is a common concern
• No universally accepted definition
• Valgus rearfoot, flattened medial longitudinal
  arch
• It is accepted that flatfeet are of different
  types
• Pathological or non-pathological
• Prevalence estimates range 2.7 12.3
• Recent prevalence research 835 children aged 3-6
  years
• Age 3 year olds 54, 6 year olds 24
• Gender boys 52, girls 36
• Weight overweight 51, obese 62, normal 42
• Treatment abounds
• greater than 90 treatments unnecessary
• Pfeiffer M Pediatrics 2006

4
Presentation outline

• Background to paediatric flat foot
• Best evidence for treating paediatric flat foot
• Randomised controlled trials
• Systematic review
• Guidelines
• Clinical pathways
• Evidence-based clinicians summary

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Best Evidence for treating paediatric flat foot

• Compliant research
• Cochrane systematic review (protocol) 2006
• Wenger 1989, Powell 2005, Whitford 2007
• Mereday 1972, Bleck Berzins 1977, Bordelon
  1980, Penneau 1982, Kilmartin 1994, Jay 1995,
  Redmond 1998, Evans 2003, Camin 2004

• Levels of evidence
• Systematic review
• (meta-analysis)
• Randomised controlled trial
• Cohort study
• Case/control study
• Case series

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Findings of research with design limitations
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Randomised controlled trials
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Systematic review

• Wenger 1989
• Powell 2005
• Whitford 2007
• Rome K, Ashford R, Evans A. Non-surgical
  interventions for paediatric pes planus.
• (Protocol) Cochrane Database of Systematic
  Reviews
• 2006, Issue 4. Art. No. CD006311. DOI
  10.1002/14651858.CD006311.

• Prescribed foot orthoses
• No significant difference to foot structure,
  physical activity, motor skills, self-perception
• Seem to help pain
• Beneficial for pain and function in children with
  rheumatoid arthritis

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Presentation outline

• Background to paediatric flat foot
• Best evidence
• Randomised controlled trials
• Systematic review
• Guidelines
• Clinical pathways
• Evidence-based clinicians summary

10
Diagnosis treatment of pediatric
flatfootHarris EJ et al, J Foot Ankle Surg
43(6) 341-370, 2004
11
Diagnosis treatment of pediatric
flatfootHarris EJ et al, J Foot Ankle Surg
43(6) 341-370, 2004
Age Family Hx Associations Symptoms Trauma Activit
y Systems review Previous Tx
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Diagnosis treatment of pediatric
flatfootHarris EJ et al, J Foot Ankle Surg
43(6) 341-370, 2004
Arch vs loading ROM Tender areas Gait Diagnostic
studies
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Diagnosis treatment of pediatric
flatfootHarris EJ et al, J Foot Ankle Surg
43(6) 341-370, 2004
Arch vs loading ROM Tender areas Gait Diagnostic
studies

• X-ray
• CT
• MRI
• Bone scan
• -lab tests

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Diagnosis treatment of pediatric
flatfootHarris EJ et al, J Foot Ankle Surg
43(6) 341-370, 2004

• Cerebral palsy, hypotonia
• Muscular dystrophies
• Downs, Marfans
• Ehlers Danlos, ligament laxity

15
Diagnosis treatment of pediatric
flatfootmodified after Harris EJ et al, 2004
Typical flat foot
Symptomatic
Asymptomatic
Non-developmental
Developmental
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Typical paediatric flatfoot
Asymptomatic
Non-developmental
Developmental
Progresses with age
Reduces with age
? Structural deformity ?
Observe medial arch height heel eversion talar
prominence lesions
Assess ankle range forefoot / rearfoot local
tenderness gait barefoot shoes
MONITOR
Consider heel inversion with tip toe tibial,
knee positions windlass effect tibial,
femoral torsions vs positions
obesity muscle tone, ligament laxity
(Beighton) imaging blood tests os tibiale
externum gender
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Typical paediatric flatfoot
Asymptomatic
Non-developmental
Developmental
Progresses with age
Reduces with age
? Structural deformity ?
MONITOR

• Best available clinical measures of structural
  form
• RCSP / Navicular Height / Forefoot to
  rearfoot
• FPI-6 TNJ congruence / MLA height / calcaneal
  position
• Evans et al, JAPMA 2003

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Diagnosis treatment of paediatric
flatfootmodified after Harris EJ et al, 2004
Typical flat foot
Symptomatic
Asymptomatic
Non-developmental
Developmental
TREAT
MONITOR
LEAVE ALONE
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Orthotic options, costs

• Customised
• Generic
• Wedges
• Shoes -

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Clinical control

• Single case experimental design (SCED)
• Patient generated index (PGI)

A
B
A
B
?
?
Pain
?
No Pain

• Specify areas affected
• Rate affect
• Weight importance
• Index reflects reality
• vs expectations

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Typical flexible flatfeet
1. symptomatic 2. no pain, too flat 3.
developmental
Tim, aged 8 leg aches with/after sport Dad has
FF, knee pain, orthotics Treat generic orthotics
Cam, aged 13 orthopaedic referral Equinus,
forefoot varus Monitor stretch (generic
orthoses?)
Alice, aged 2 parents concerned Nil
findings Leave alone general advice
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Presentation outline

• Background to paediatric flat foot
• Best evidence
• Randomised controlled trials
• Systematic review
• Guidelines
• Clinical pathways
• Evidence-based clinicians summary - 2007

23
Paediatric flatfoot clinical pathway (FFP) v1,
2007Evans AM (2008). J Am Podiatr Med Assoc
98(5) 386 393.
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Evidence-based clinicians summary

• Diagnosis of flatfoot type
• Significant history, findings
• Flexible, rigid, skewfoot, other
• Typical flat foot
• 1. Symptomatic
• 2. Asymptomatic non-developmental
• 3. Asymptomatic developmental
• p-FFP (JFAR, 2009)
• Best available evidence
• Standardised, simple

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Australasian Podiatry Convention May 12-16, 2009
Thank you