Day: March 30, 2015

When Do Feet Have Arches?

Patient Presentation
A 3.5-year-old female came to clinic with a history of intermittently saying that her feet hurt. Her father said that it started recently but could not say for how long. The child only said her feet hurt but it did not stop her from playing or other activities. He was also unable to say when it occurred throughout the day or how many times per week. He was certain that it never bothered her sleep nor did she have limping, falling, or redness or stiffness of any body parts. The father was worried because he had flat feet that bothered him doing his job which required him to walk or stand for long periods of time on a hard surface. He had gotten relief with orthotically fitted shoes. He thought that his daughter should have some special shoes also because she had flat feet also. The past medical history showed a healthy child. The family history showed no orthopaedic, rheumatological or neurological problems in the family. The review of systems was negative for fevers, rashes, eye problems, excessive fatigue or lethargy.

The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters in the 10-25%. HEENT showed no obvious eye abnormalities. She had no rashes, or changes in her nails. Neurologically she had good tone and strength with normal DTRs. Her lower extremities including her hips showed no erythema or edema and had normal range of motion. No pain could be elicited with movement or pressure. She had a normal gait. When standing, her feet were flat with a minimal medial arch. When on her tiptoes or when sitting her arch became curved. Alignment of the lower leg with the foot was normal. Her shoes did not appear to have excessive or abnormal wear, and appeared to fit well.

The diagnosis of a flexible flat foot that appeared to be normal for age was made. As the child did not appear to be bothered by the flat feet and the history was somewhat vague, the pediatrician counseled to monitor the child and keep a symptom diary. She pointed out how the feet did have an arch but when standing the arch became flat and the flatness by itself was not a reason to intervene. The father agreed to followup at her next well child appointment in a couple months if the symptoms did not change or worsen before then.

Discussion
Pes planus or flat foot is a common presentation in children and is defined as the absent or diminished longitudinal medial foot arch. Parents usually become more concerned if the child appears to have problems with walking, tripping or falling, problems with alignment (i.e. feet turning outward or inward) or if there is perceived discomfort. Some parents of older children will become concerned when they notice excessive or abnormal shoe wear.

The differential diagnosis in rare cases also includes rheumatologic, neurologic, neoplastic and genetic syndromes such as Ehler-Danlos and Marfan syndrome. The differential diagnosis of leg pain can be found here, and the differential diagnosis for intoeing and outtoeing can be found here.

A history of chronic pain and/or rheumatological or neurological origins makes other diagnoses more likely. A history of trauma, gait abnormalities or refusal to bear weight should be gathered.

Examination of the entire extremity is important checking for decreased range of motion, joint swelling or specific areas of pain. Feet should be examined with barefeet on a flat surface about shoulder width apart. The foot’s longitudinal arch may be absent or minimal with the heel in slight valgus. When asked to raise on toes or when seated, the arch returns. With weight bearing the heal swings varus also. When these arch changes are accompanied by no changes in range of motion, it is called a flexible flatfoot. The legs should also examined for possible torsion, and ligamentous laxity should be assessed throughout the body. Gait should also be examined. Any decrease in motion of the foot joint should be of concern for other disease processes. However, there are many patients who also have rigid flat feet who do not have other problems or need treatment.

For most patients no testing is necessary. If a child has a significant abnormality such as severe flat feet, real pain, rigidity or other concerns for alternative diagnoses then plain radiographs are a first step. Additional imaging or blood work depends on the clinical scenario. The majority of flexible flat feet do not require any treatment. Orthotics or other specially fitted shoes are sometimes prescribed and may be helpful in truly painful flexible flat feet.

Learning Point
The natural arch in infants is flat and because of normal ligamentous laxity continues throughout early childhood. Most children < 6 years old have flexible flat feet. The arch usually fully develops by age 10 but 15-23% of adults have flat feet.

Questions for Further Discussion
1. What are indications for referral to a podiatrist?
2. How often do children outgrow their shoes?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Foot Injuries and Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Jane MacKenzie A, Rome K, Evans AM. The efficacy of nonsurgical interventions for pediatric flexible flat foot: a critical review. J Pediatr Orthop. 2012 Dec;32(8):830-4.

Graham ME. Congenital talotarsal joint displacement and pes planovalgus: evaluation, conservative management, and surgical management. Clin Podiatr Med Surg. 2013 Oct;30(4):567-81.

Dare DM, Dodwell ER. Pediatric flatfoot: cause, epidemiology, assessment, and treatment. Curr Opin Pediatr. 2014 Feb;26(1):93-100.

Author

Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital