Pes Planus: A Common Concern in Pediatric Care

using terminology such as "pronated foot," "pes planus," or "hypermobile flatfoot" were incorporated to address the lack of agreement on a universal definition for flatfoot (11-13).

Flatfoot is a common condition seen in pediatric health care, which can occur independently or as a part of a larger pathology related to ligamentous laxity, neurological or muscular abnormalities, genetic syndromes and collagen disorders. To prepare this review, the following databases were searched: Medline (1966-present), AMED, CINAHL via Clinicians Health Channel, Cochrane library, Pubmed and Google Scholar. The search terms used were "pediatric," "flatfoot," and "foot orthoses." Additional studies were found through checking reference lists, abstracts in conference proceedings and special issues of journals, and correspondence letters by professionals in the field using BMJ.

When it comes to flat foot, there is no standard definition. However, clinically speaking, it refers to a condition characterized by a low or absent medial longitudinal arch and a valgus heel. There are two types of flat foot - flexible (physiological) and rigid (pathological). When examining a child with this condition, determining which classification they fall under is critical. Additionally, other risk factors such as ligament laxity, obesity, rotational deformities, varus and valgus deformities of the tibia or equinus deformity should be taken into consideration when creating a treatment plan. Family history, trauma history, activity level and prior treatment must also be considered. Although clinicians generally agree that symptomatic children require treatment for their flat foot condition; asymptomatic children make up the majority of those affected in the pediatric population which makes things more controversial.

Due to insufficient high-quality research, further longitudinal studies are necessary for clinicians to effectively treat flatfoot in children. There are two

classifications for flatfoot based on its etiology, clinical features, natural history, and potential for causing disability: physiologic or pathologic. Flexible flatfoot is considered a harmless condition that is an anatomical variant associated with ligament laxity. The arch flattens on weight-bearing and reappears upon non-weight-bearing and toe-standing. These feet are hypermobile with flexible talo-calcaneal joints and may have an Achilles tendon contracture or not (7)(9).

(5) Flexible flatfoot can either have no symptoms or exhibit symptoms. (6) In cases of asymptomatic flexible flatfoot, clinical monitoring is advised to observe for the appearance of symptoms and signs of progression. (6) Symptomatic flexible flatfoot results in subjective complaints such as pain in the medial foot, sinus tarsi, leg, knee, and eversion of the heels. (6) Rigid flatfoot is identified by a diminished medial longitudinal arch on both weight-bearing and non-weight-bearing positions, as well as stiffness in the rearfoot and midfoot.

Children with underlying pathology commonly experience persistent disability, including the development of flat feet. When diagnosing this condition, it is crucial to understand the normal evolution of the medial longitudinal arch in a child's foot. At birth, the foot appears in a calcaneo valgus position, lacking a longitudinal arch but having a pad of fat on the medial side (shown in figure 1). The arch begins development around 2-3 years of age and progressively evolves throughout the first decade of life.

Fixsen suggests that the great toe extension test, also known as Jack's test, is the most effective way to distinguish between flexible and rigid flatfoot. During this test, when a child stands on their tip toes, the medial arch becomes visible, the heel turns inward and the tibia rotates outward.

If these changes occur, then the flatfoot is likely flexible rather than pathological. Fixsen's findings from 1998, as published in the Journal of the Royal Society of Medicine, were used to support this argument. Table 1 of this publication summarizes the results of two randomized control trials which provide the best available research on the use of foot orthoses for treating pediatric flatfoot.

Whitford and Esterman, 2007 conducted a controlled trial to compare the effects of custom-made and prefabricated orthoses on 178 children aged 7-11 years with "flexible excess pronation". The trial was randomized parallel, single-blinded, and based on calcaneal eversion and navicular drop. The study evaluated outcomes such as gross motor proficiency, self perception, exercise efficiency, and pain, with pain being measured using a visual analogue scale at baseline and follow-up. Pain in the lower limb was considered critical for provision of orthoses.

The data analysis concerning children experiencing pain yielded no indication of the effectiveness of orthoses in alleviating discomfort.