GV Basavaraja

National President 2024

An Algorithm
Yogesh Parikh
Secretary 2024–25 Approach
to Pediatric
Atanu Bhadra
Treasurer 2024–25

National Scientific Convenor

Sumitha Nayak
Advisor
Diagnosis
Gnanamurthy Narasimha

Core Team Members

B Rajsekhar
Janani Shankar
Kripasindhu Chatterjee
Nehal Patel
Rupesh Masand

Section Editor
Janani Shankar
Section Co-Editor
Arathi Srinivasan
 Flatfeet 13
Shama Sowdagar

Introduction

 Flatfoot or pes planus refers to a diminished or absent medial longitudinal arch (MLA). It is relatively
common and affects up to 14% of children.
 It may occur in isolation or associated with a hindfoot abnormality called valgus alignment (pes
planovalgus).

Normal Physiological
Development of Foot

 All infants are born with flatfeet because of physiologic ligamentous laxity and lack of MLA.
 At birth, a fat pad is the dominant visible structure in this region, which slowly decreases as children
grow. Normal foot arch develops during the first decade of life, by the age of 5–6 years.
 Flatfeet

Types

 Flexible flatfoot: It is usually physiologic and accounts for 95% of all cases.
T he MLA is present while sitting but disappears with weight-bearing or stance phase of walk.
It usually resolves by the age of 10 years but may persist into adolescence and adulthood.
 Rigid flatfoot: It is nonphysiologic. There is restriction of subtalar joint motion.
It is associated with pain and serious underlying pathology.
T iptoe walking differentiates rigid from flexible flatfoot by the absence of arch formation, and the heel
remains in valgus alignment.

Causes

FLEXIBLE FLATFOOT RIGID FLATFOOT

Physiological ligamentous and joint laxity
Inherited (positive family history)
Generalized ligamentous laxity
(Down syndrome)
Familial flatfeet
Benign hypermobile joint syndrome
Congenital vertical talus (rocker-bottom foot with equinus heel)
Tarsal coalition (peroneal spastic flatfoot syndrome)
Inflammatory arthritis of the subtalar joint [juvenile idiopathic
arthritis (JIA), e.g., enthesitis-related arthritis (ERA)]
Accessory navicular bone
Cerebral palsy and other neurodevelopmental disorders

Examination

 Gait assessment with shoes and barefoot including heel and tiptoe walking, and extension of
great toe
 Look for hallux valgus, crowding of lesser toes, Achilles valgus, and callosities.
 Signs of inflammation
 Active and passive dorsiflexion of ankle and inversion and eversion of foot
 Look for ligamentous laxity in other joints (Beighton score) and skin laxity.
 Complete neurological examination

Delaying shoe wear until childhood and barefoot walking decrease the propensity for flatfeet. 3
 Flatfeet

Red Flag Signs

 Feet, which are painful, stiff, weak, or numb

 Repeated feet or ankle injuries
 Problems with walking or balance
 Late onset of flatfeet
 Unilateral flatfoot
 Persistent flatfeet after 10 years of age

Approach

(CP: cerebral palsy; JIA: juvenile idiopathic arthritis)

4
 Flatfeet

Suggested Reading

 Carr JB 2nd, Yang S, Lather LA. Pediatric pes planus: A state-of-the-art review. Pediatrics. 2016;137(3):e20151230.
 Dare DM, Dodwell ER. Pediatric flatfoot: Cause, epidemiology, assessment, and treatment. Curr Opin in Pediatr.
2014;26(1):93-100.
 Morley AJM. Knock-knee in children. BMJ. 1957;2(5051):976-9.
 Mortazavi SJ, Espandar R, Baghdadi T. Flatfoot in children: How to approach? Iran J of Pediatr. 2007;17(2).
 Rome K, Ashford RL, Evans A. Non-surgical interventions for paediatric pes planus. Cochrane Database Syst Rev.
2010;(7):CD006311.
 Turner C, Gardiner MD, Midgley A, Stefanis A. A guide to the management of paediatric pes planus. Aust J Gen
Pract. 2020;49(5):245-9.
 Vulcano E, Maccario C, Myerson MS. How to approach the pediatric flatfoot. World J Orthop. 2016;7(1):1-7.