Introduction

The foot is indeed a very intricate structure that remarkably bears the
weight placed upon
it without much repercussion for most people. As a result of its
location, the foot forms
a dynamic link between the human body and the ground. The foot is
essential to all
upright human locomotion, continually adapting to facilitate a
compatible coupling
between the body and its surroundings for effective movement . It is a
unique complex structure whose function includes weight-bearing,
balance, braking and
propulsion. Due to its anatomical complexity, many variations exist in
the structure and
function of the foot. Major deviations in foot structure are generally
symptomatic or
have known functional limitations. However, for others such as the
flexible flat foot the
.associated functional differences if any remain unclear
Since the foot is the interface with the ground during gait, structural “
change here may
cause compensatory misalignment and consequently mechanical
deviations of the entire
lower extremities.” (Williams et al 2001)
Numerous studies have been undertaken to examine this misalignment
and its effect on
performance and related injuries, particularly the relationship between
rearfoot pronation and injuries during running .
The height of
the medial longitudinal arch has also been the focus of a great amount
of foot research.
However, very few studies have looked at the performance effects of
the flexible flat
foot. Even at a more fundamental level, the structure and bony
interaction of what
constitutes a ‘normal’ foot has not been well defined. Hence a
universally accepted
definition of the flat foot still remains inconclusive.
Pes planus more commonly known as flat foot is the
condition characterised by reduced
height of the longitudinal arch and a large plantar contact
area. There is often associated
hindfoot valgus. In infants and toddlers, the longitudinal
arch is not developed and flat
feet are normal. The arch develops in childhood and by the
time adulthood is reached
most people have developed normal arches. However,
even when flat feet persist they
are mainly still considered variations of normal. Most feet
are flexible and an arch
appears when the person stands on his or her toes or lifts
the foot to a non weight-bearing
position. Stiff, inflexible, or painful flat feet may be
associated with other conditions
and require attention.
Flat feet and the medial longitudinal arch have been one of
the most popular topics for
research for many years. Accurate diagnosis and
categorisation of the flat foot, whether
flexible or rigid, is critical to the treatment of this apparent
abnormality. The definitionof flat foot has been a
controversial and frequently fought one in the literature,
, and yet even today remains ambiguous. Until some
agreement
is reached on the characteristics determining the flatfoot it
is difficult to confirm the
clinical implications for the flatfoot.
There are two main categories of flat feet, the rigid flat foot
and the flexible flat foot.
The following sections will identify the characteristics
associated with each type.
 Rigid Flat Foot
 The first type is the rigid flat foot, which is easily
identifiable. It is generally congenital
and often associated with a pathological condition.
Conditions commonly associated
with rigid flatfoot include central and peripheral
neurological disorders, diseases of
muscles, connective tissue pathologies, and diseases of
bone and joints (Agnew &
Raducanu, 2000). A rigid pronated foot is a rare but
significant finding, usually
indicative of tarsal coalition and peroneal spastic flat foot.
Tarsal coalition is a fibrous,
cartilaginous, or osseous union of two or more tarsal bones
and is congenital in origin
(Alexander, 1997). Tarsal coalitions usually become painful
during the second decade
of life when the coalition starts to ossify (Morton, 1964).
Coalition between the
calcaneus and the navicular and the middle facet of the
subtalar joint is the most common presentation and is
conclusively linked with the syndrome of peroneal spastic
flat foot,
which is a painful rigid pronation of the foot with tonic
spasm of the peroneal muscles.
This condition causes a breakdown of the midtarsal area
and the arch flattens. Therefore
the rigid flat foot demonstrates restriction in subtalar
motion. The arch remains flat
during a non weight-bearing position as well as during toe
standing. This type of flat
foot is most likely to cause pain. Both non-operative and
operative treatments have
been developed to treat the pain associated with these
conditions. Operative treatments
are subject to the condition that exists in the patient and
the degree of alteration of gait.
The use of orthotic devices is frequently recommended for
those not requiring surgery.
Given that the rigid flat foot generally causes pain some
intervention treatment is usually
necessary. Most of the research undertaken on this type of
flat foot is related to effective
surgical issues.
 Flexible Flat Foot
The second type of flat foot is the more common type
called flexible flat foot (FFF).
The flexible flat foot demonstrates a longitudinal arch in a
dependent non- weight
bearing posture, with a flattening of the arch in normal
weight-bearing. It can be
symptomatic or asymptomatic. Ligament laxity appears to
be an important consideration
in the development of a flexible flat foot. There is a certain
amount of laxity in the
normal child’s foot but this usually reduces with age.
According to Lin et al (2001),
flexible flat foot is considered to be a manifestation of a
constitutional laxity affecting all
ligaments. Ligamentous support is important in
maintaining the longitudinal medial
arch. Harris & Beath (1948) found that the FFF rarely
caused disability and concluded
that this most common variety of flat foot should be
considered as the "normal" contour
of a strong and stable foot. However, in the meantime
many researchers have thought
and proved differently. A shortened Achilles tendon often
accompanies this type of flat
foot and is likely to cause disability. Flexible flat feet often
become noticed with rapid
and uneven shoe wear in adolescents and adults. Research
shows that the flexible flat
foot is an anatomical variant affecting approximately 10-20
% of the adult population and
a higher percentage of children. It is necessary to establish
the clinical and functional
significance of flat feet before any treatment is prescribed.
In their study on flexible
flatfeet in school children, Lin et al (2001) reported that the
kinematics of the coronal and
horizontal planes of the ankle were significantly different in
the moderate and severe
flexible flat foot groups when compared with the normal
arched group. Although
radiographic studies were not routinely performed for
every child in their study for
ethical reasons, they investigated the relationship between
muscle performance and the
occurrence of FFF and found that FFF children scored lower
on the basic tasks performed
than children without FFF. These tasks included squats,
calf raisers, and hopping. They
concluded that flexible flat feet must be regarded not only
as a problem of static
alignment of the ankle and foot complex, but also a
dynamic functional abnormality of
the lower extremity (Lin et al., 2001). It was believed in
the past that muscle weakness
was responsible for flat footedness and muscle
strengthening exercises were
recommended to develop an arch in a child’s foot. The
most controversial modalities for
 the management of asymptomatic FF now include
corrective shoes, arch supports and
heel wedges. Foot orthoses have become an integral part
the treatment for flat feet
however there have been equivocal findings from the
various investigations on their
efficacy. According to Heiderscheidt et al (2001), despite
the differences in results, their
success in reducing pain and symptoms of foot problems
cannot be denied. Controversy
still exists regarding whether flexible flat feet should
receive any treatment but until there
is some agreement on the measurement of flat feet this
controversy will prevail. The
flexible flatfoot may prove advantageous when balance,
unstable walking surface,
textures, and repetitive stress are issues; but to date the
rigid flatfoot appears to lack any
functional advantage (Agnew & Raducanu, 2000).

 Foot orthosis:
is commonly recommended for the treatment of the flat foot 1,The
biomechanical effects of such orthoses are not yet fully clear and the
time duration of correctness for the follow-up is not clear 2,orthoses are
specially designed shoe inserts that help to support the feet and
correct foot imbalances. Some of the foot and lower limb problems
that can be successfully treated in the long term with orthoses include
Flat feet, corns and calluses, foot ulceration, recurrent ankle sprain,
plantar fasciitis, or heel spur syndrome3,Feet provide the base of
support and flat foot is common in children if not treated well in time
can lead to pain in the foot and various knee problems including hallux
valgus. It needs proper treatment which is necessary for children, but
currently, the time duration for the correctness of flat feet in children
with soft foot orthosis is unknown which is very necessary for a proper
1

3
treatment protocol, so that the children can follow that time duration
for using soft of foot orthosis made from EVA. Foot orthosis
prescription had always been beneficial for the patients as its
 Foot orthosis:
is commonly recommended for the treatment of the flat foot 4,The
biomechanical effects of such orthoses are not yet fully clear and the
time duration of correctness for the follow-up is not clear 5,orthoses are
specially designed shoe inserts that help to support the feet and
correct foot imbalances. Some of the foot and lower limb problems
that can be successfully treated in the long term with orthoses include
Flat feet, corns and calluses, foot ulceration, recurrent ankle sprain,
plantar fasciitis, or heel spur syndrome6,Feet provide the base of
support and flat foot is common in children if not treated well in time
can lead to pain in the foot and various knee problems including hallux
valgus. It needs proper treatment which is necessary for children, but
currently, the time duration for the correctness of flat feet in children
with soft foot orthosis is unknown which is very necessary for a proper
treatment protocol, so that the children can follow that time duration
for using soft of foot orthosis made from EVA. Foot orthosis
prescription had always been beneficial for the patients as its
 Foot orthosis:
is commonly recommended for the treatment of the flat foot 7,The
biomechanical effects of such orthoses are not yet fully clear and the
time duration of correctness for the follow-up is not clear 8,orthoses are
specially designed shoe inserts that help to support the feet and
correct foot imbalances. Some of the foot and lower limb problems
that can be successfully treated in the long term with orthoses include
Flat feet, corns and calluses, foot ulceration, recurrent ankle sprain,
plantar fasciitis, or heel spur syndrome9,Feet provide the base of
support and flat foot is common in children if not treated well in time
can lead to pain in the foot and various knee problems including hallux
valgus. It needs proper treatment which is necessary for children, but
currently, the time duration for the correctness of flat feet in children
4

9
with soft foot orthosis is unknown which is very necessary for a proper
treatment protocol, so that the children can follow that time duration
for using soft of foot orthosis made from EVA. Foot orthosis
prescription had always been beneficial for the patients as its
customized and as per the measurements of the patient’s sizes causing
less discomfort and more durable 10,This particular experimental
research was conducted to check the effectiveness and time duration
of the correctness of flat feet with soft foot orthosis i.e., made from
EVA so that we can check the effectiveness of soft foot orthosis.

 Problem statement ;
Flat feet are commonly found in children with various
symptoms [12]. 'Flat feet' is a term referring to
deformation of feet from hyperpronation caused by
loss or immaturity of the medial longitudinal arch [3].
Flat feet are divided into pathologic flat feet with
various primary causes and physiologic flat feet
lacking the development of the medial longitudinal
arch [4]. Flat feet in children are mostly physiologic
flat feet. They are found in approximately 90%
children under age of 2. Development of normal
longitudinal arch begins at the age of 3 to 5 years old.
It is completed before the age of 10,
Treatment for patients suffering from symptomatic
flexible flat feet include nonsurgical method and
surgical method. Examples of nonsurgical methods
include revision of living habits, wearing proper shoes
or foot orthoses, stretching, muscle strengthening
exercises, and nonsteroidal anti-inflammatory drugs.
Research effort using foot orthosis nonsurgical
method has been attempted to lessen foot pain.
Powell et al. [16] has reported that custom-molded
foot orthosis is highly effective for pediatric patients

10
 suffering from symptomatic flexible flat feet (SFFF)
with symptoms of juvenile arthritis and foot pain.
Although several research studies have concluded
that foot orthosis could be used to control foot pain
[1617], no research has been conducted to examine
the changes of patient's balancing ability at the same
time. While treating patients suffering from flat feet
for 15 years, we realized that children with severe
flat feet had more difficulties in balancing when they
stood on one leg trying to maintain their posture. In a
preliminary testing for approximately 10 children
with flat feet through computerized posturography to
enable quantitative analysis, we verified that children
with flat feet lacked balancing abilities. It has been
reported that patients suffering from flat feet do lack
balancing abilities while standing on one leg [1218].
Therefore, the objective of this study was to
comparatively analyze the frequency of pain
occurrence, pain degree, changes in their ability to
perform static and dynamic balancing, and functional
activities of children with symptomatic flexible flat
feet after wearing customized foot orthoses

 Objective of study ;
Scenery - To evaluate the effect of custom-molded
foot orthoses on flat foot and balance in children
with symptomatic flexible flat foot 1 month and 3
months after fitting foot orthosis."
 - Primary: Determine the effectiveness of foot orthosis in
relation of foot flat in children.
  Research hypothesis ;

 SIGNIFICANTIN OF STUDY ;

 SEARCH LIMITS :

 Operational definition:
1. Effectiveness: the degree to which something is successful
in producing a desired result.
2. Foot: the lower extremity of the leg below the ankle, on
which a person stands or walks.
 The lower or lowest part of something, the base or
bottom.
3. Orthosis: the correction of disorders of the limb of spine
by use of braces or other devices to correct alignment or
provide support.
4. Correctness: the quality or stats of being free from error,
accuracy.
5. Flat feet (pes planus): is a relatively common foot
deformity that refers to the loss of the medial longitudinal
arch of the foot, resulting in this region of the foot coming
closer to the ground or making contact with the contacting
the ground.
6. Children: a young human being (son or daughter) below
the age of puberty or below the legal age of majority