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Flatfeet (or pes planus or pes valgus) simply mean a foot where there is no arch present. Flatfeet can be either flexible or rigid. The typical flexible flatfoot is usually asymptomatic. The child is taken to the physician because of the appearance of the foot, as families are concerned that the child's foot is rolling over with the child appearing to walk on the inside of his/her ankles. There is also concern that the child will not suffer a similar fate as some other adult in the family who has painful flat feet.
Most children do not begin to form an arch until about ages 3-5, so it is very common for flexible flatfeet to exist before this age. Eighty percent of children will develop an arch between the ages of 3 and 10 and for the 20 percent who do not, the condition is usually not painful. However there are some children with genetic problems such as Down's Syndrome or Marfan's Syndrome where the ligaments of the foot are lax, allowing the arch to fall, producing flat feet. These children are predisposed to flexible flatfeet and are more likely to become symptomatic that normal children due to the genetic ligament laxity.
For the vast majority of children, no treatment is ever necessary for flexible flatfeet. Studies show that there is no link between having flexible flatfeet and developing pain and foot problems later in life. Only the most severe flexible flatfeet produce pain.
The only reason to treat flexible flatfeet is when children are experiencing pain or having significant difficulty wearing through their shoes. In these cases, arch supports, and rarely braces (such as a UCBL) are used to help alleviate symptoms. Several excellent studies have shown that there are no specific types of shoes, arch supports, or braces that will lead to the development of an arch. These shoewear modifications only serve to help diminish symptoms by supporting the foot, they do not correct or reverse the deformity. The arch supports or brace are usually used between ages 3 to 10 to help treat symptoms and prevent the deformity from worsening, so that no pain or problems should occur as an adult. It is extremely rare to need surgery to correct a painful flexible flatfoot when arch supports or bracing has failed to improve symptoms.
Rigid Flatfeet arise from some type of abnormal foot development. This can be in the form or a congenital problem that the child is born with such as a vertical talus (convex pes valgus) or from an abnormal connection between bones in the foot that are not supposed to be connected (tarsal coalition). Rigid flatfeet are more serious than flexible flatfeet and are often painful and usually require treatment.
A vertical talus (convex pes valgus) is a rigid flatfoot where the talus (the lower bone in the ankle joint) is abnormally positioned in relation to bones in the middle part of the foot. This creates a rigid flatfoot that appears like a rocker bottom. This deformity usually is present at birth. It can be associated with neuromuscular conditions such as arthrogryposis or spina bifida, or it can occur on its own in an otherwise normal child.
Some studies suggest there is a hereditary component and others suggest that abnormal intrauterine positioning can cause the deformity. If left untreated, the child will walk on the bottom of his abnormal talus, causing a callous to form and eventually a painful foot. If the deformity progresses, it becomes difficult to shoe the foot, the callous may lead to skin breakdown, and the child will walk with a "peg leg" style with problems pushing off on the foot. Participating in normal childhood activities is extremely difficult and painful.
The earlier treatment is instituted, the better the result. This abnormality almost always requires surgery to correct, often with a period of stretching and casting prior to the surgery. Treatment begins as soon as the deformity is recognized with an attempt to stretch the foot with casting and/or manipulation. This alone will not completely correct the foot. The foot is usually operated on after 6 months of age and hopefully before age 2. The surgery consists of opening the foot and reducing the dislocations of the foot and pinning the bones in place followed by casting and ultimately bracing. Tendons may need to be lengthened as well depending on the degree of deformity. It is not uncommon for this deformity to need further surgery as the child ages, as the deformity may recur. Further surgery consists of fusing the bones in place to prevent any further deformity. This is only done in the older child when the foot is close to maturity. Despite surgery, these feet will be stiffer than normal feet but should be significantly better shock absorbers than if left in the deformed position.
A tarsal coalition is an abnormal connection between two bones in the foot that are not normally supposed to be connected. This occurs as a result of abnormal formation of joints during fetal development. The most common coalitions are between the calcaneus and the navicular bones and the talus and calcaneus bones. The coalitions are either fibrous, cartilaginous, or bony connections between the two bones. The coalition makes the foot less flexible and causes undue stress on other parts of the foot. Often the coalitions are present at birth and progress from fibrous to cartilage to bone, becoming more stiff with age.
As a result, children do not usually present to the doctor with this condition until the late first decade or early second decade of their lives. They often come in after an ankle sprain that "just never seems to get better", or that their foot is stiff and painful. Coalitions can occur in both feet in up to 50% of patients. On examination, the flatfoot is usually rigid and painful, and not correctable to a neural arch. The peroneal tendons are often is spasm (another name for tarsal coalition is peroneal spastic flatfoot).
The condition is initially diagnosed by X-rays and confirmed with either a CT scan or an MRI. Initial treatment is aimed at reducing symptoms by conservative means. This can consists of arch supports, bracing, casting, and/or anti-inflammatory medication. If these measures fail to relieve the symptoms, surgery to excise the coalition is considered. In the case of the calcaneonavicular coalition, muscle is inserted in the gap after the coalition is excised to prevent reformation of the coalition. Depending on the size of the talocalcaneal coalition, the coalition is either excised and replaced with fat, or the coalitions is excised and the remainder of the joint is fused. After successful surgery, reformation of the coalition is prevented and symptoms are usually resolved.
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For more information about flatfeet and available treatment options, please visit the Department of Orthopaedics Foot and Ankle Program.