Pediatric Flatfoot: Common Kids’ Foot Problem - Jeffrie C. Leibovitz, DPM

Pediatric Flatfoot: A Common Kids’ Foot Problem

One of the greatest gifts of youth is accelerated growth. Part of this mind-boggling growth is the ability to change. Besides the rapid changes you see in a baby’s face (especially when they get teeth), their bones are rapidly evolving – especially in their feet. 

It is astounding to see an x-ray of an infant’s foot. It appears that most of the bones are missing. In reality they are present but in a cartilage state and invisible on x-ray. During infancy, bones are similar to Play-Doh and can be molded and changed.

The ability to change provides us with good and bad news. Let’s start off with the bad news: The bones will develop in a tilted position if the foot rolls inward, like a flat foot. The good news is if we control the position of the rearfoot, they will grow in a straight vertical position.

Are these your people? 

There is more good news and bad news. 

Again with the bad news: if generations before you have flat feet, then you have a great chance of your children  inheriting this. The good news, as I said earlier, is with the proper and adequate control of bone growth, these changes can be nipped in the bud and prevented.

I find it is very helpful to have both parents and grandparents at a child’s initial flat foot evaluation. Looking at a foot from the previous 1 or 2 generations gives a high predictability for foot deformities. 

If I see no deformity or symptoms in the parents and grandparents, my level of concern for future problems is reduced. My spider senses will be on full alert if I see foot and ankle deformities or hear a history of symptoms from the parents and grandparents. 

There is a strong and common connection between a child’s flat feet and adult foot deformities. Few children inherit a deformity, but a child will inherit the mechanics that will create the deformity later in life. This delay is a tribute to how well and long  the foot works under duress. The majority of problems show up after the third, fourth or even fifth decade of life.

What is as cute as a baby’s foot?

Even Anne Geddes cannot make a baby’s little piggies any cuter. 

That adorable pudgy appearance of an infant foot is from a fat pad on the arch. This will make every baby’s foot look flat, so a good assessment of foot function should not be made until the baby is two years old. 

There are two things that get my attention in an infant’s foot. Unfortunately these are not cute. The first thing is more than 10 toes. The second is a very curved or “C” shape of the outside part of the foot. The second problem is called a metatarsus adductus. This is one third of the club foot deformity. This can be a BIG deal. A mild to moderate metatarsus adductus can be treated with gentle positional therapy.

What four words do you never want to hear? 

There are some things your child will outgrow. These hopefully include “the terrible twos”, diapers, and sticking dirty things in their mouth. 

But be cautious if you hear “they will outgrow this” if it involves metatarsus adductus or excessive pronation. If this diagnosis is missed, it can wreak havoc on the adult foot and there may be a high price to be paid decades down the road. 

“Growing like a weed” is good

The foot has 25 percent  of all the bones in the body and an adult x-ray looks pretty busy with so many parts. In a child’s foot it appears like someone took an eraser and removed most of the bones. 

The bones are actually there, but very difficult to see on x-ray because they are mostly cartilage. The bone will become more visible as it calcifies. 

The early bones and growth plates (see service area about Severs disease) grow fast and are very soft. That means they will bend before they break and when they bend for an extended time, will stay in that position. This is exactly what happens in the foot when an infant walks too early with flat feet. 

“I’m tired. Mom, pick me up!”

Infants and children definitely do not like pain. How idyllic would a child’s life be if they never cut teeth or had an ear infection? After those two experiences it is no wonder that a child will elect to stop activity to avoid pain. 

Those sly and manipulative children will ask to be picked up early during a long walk. They stop playing in the group before the other children. And worst of all, they sit down during a soccer game when all the other players are running to the opposite end of the field (although this could also be from boredom). 

A pronating foot works harder, uses more energy, and tires out quickly. This would be the difference between walking 5 miles on pavement with normal feet versus walking 5 miles on sand with flat feet. That is a whopping difference in energy expenditure. You may not hear specific complaints about any foot pain coming from your child, but you may see the effects of early fatigue.

Are video games bad for flat feet?

It might be the other way around. An adolescent with flat feet may migrate to the couch and choose video games instead of physical activity.

A decrease in physical activity is one of the primary contributors to early age obesity. It is far too easy to substitute physical activity for gaming when a child’s flat feet fail them (say that 3 times real fast). This combination creates a barrier between lifelong fitness and a healthy lifestyle. (LINK to blog about weight gain affecting the foot)

How easy is it to treat flat feet?

Not only is a child’s mind pliable and moldable, but their bones can also be easily changed. This is a great advantage in treating a pediatric flatfoot. This is also true of the more aggressive deformities of club foot and metatarsus adductus. 

Changing the way the foot works is accomplished through orthotics. Kids’ orthotics are hidden in a shoe and keep the rearfoot in a more vertical position to the ground, reducing pronation. The bones will now develop in this preferred position. 

Kids’ orthotics don’t help if the shoe is not worn or the orthotics themselves sit on the shelf. Typically we would see changes in appearance and x-rays within 1-2 years. Although the bones in a child’s foot can change relatively fast, it still takes time. 

If present, a tightness in the Achilles tendon must be addressed. An extremely boring stretching program is used. This may be the most difficult part of the treatment plan. Kids don’t like pain and they really don’t like boring.

Shoe selection is very important for orthotics to reach their full potential. The more sturdy and firm the back of the heel is, the better it will assist the orthotic. I’m not interested in a specific brand or manufacture, but in the characteristic of the shoe. This is something that will be easily demonstrated at your visit.

Like sand in an hourglass, time is running out 

There are three things that will make flatfoot treatment successful.

  1. The length of time we get to change the bone. The closer the child is to skeletal maturity the less potential there is for change. A 4-year-old child will have almost 10 years of change. After the age of 10, I would anticipate minimal to moderate change in the bone structure. Early treatment is so important in pediatric flatfoot. (Imagine telling a 10-year-old they are too old.)
  2. The number of steps. If the orthotic is used with every step, I expect the best possible results. If the orthotic is only used 50 percent of the time, we have also decreased the success rate by 50 percent. The more steps and activity during which the orthotic is used, the more influence there will be on the foot.
  3. Providing adequate correction. As the foot grows, the orthotic provide less correction. Follow-up care is important to monitor for growth. Typically a change of 1 ½-2 shoe sizes is enough to make orthotics ineffective. Sometimes this much change can take 2 years, but it could also be 3 months. 

A child will become attached (no pun intended) to their orthotics if they provide appropriate correction and are the right size and fit. Positive reinforcement will be from reduced fatigue and improved comfort. I know some parents that use orthotics as a form of discipline. They threaten to take the devices away if their child does not behave. 

If the mini you does not want to wear the device, there may be a fitting issue that is providing discomfort.

Can orthotics help your child?

Just as in the adult world, orthotics are not for everybody. If your child is the energizer bunny, plays longer than all the other kids, has no history of family foot problems and no evidence of metatarsus adductus, they may not need orthotics

Whether orthotics or another form of treatment (or even no treatment at all) best suits your child’s needs, it is important to find out sooner rather than later. Contact our office at (317) 545-0505 to schedule an appointment and take those first steps toward peace of mind.

doctor checking a child's foot
a child's feet