Published in "Panorama"
When Flat Feet in Children Require Treatment
Saima, like a number of other parents, was worried that her one year old son was flat footed! This need not be cause for worry since 90% of children, infants, have the appearance of flat-footedness, reveals Dr.Salman Hameed, Specialist Orthopedic Surgeon, Welcare Hospital. “The sole of a normally developed foot has an arch (medial arch) which is formed by the muscles and ligaments. In infants, for the first two years of their lives, their feet appears to have fallen arches. Also, flat feet are normal in young children because they have weak muscle tone in their feet, loose ankle ligaments that allow the feet to lean inwards. The other reason why they have the appearance of flat feet is because the fat in the inside part of the foot, has a structure called a fat pad which makes the feet look flat. But most of these conditions resolve without any treatment because as the child begins walking, the ligaments and muscles will strengthen and the fat pads in the arch will be much less pronounced. Generally, by the age of six, most children develop the arches. And in any case, surgery is not indicated for these conditions until he has fully matured at about the age of 10 years.”
Only 10% of any population may have true flat feet, says Dr.Salman. “But it is important for the parents to seek medical assistance if they see their child has a flat feet, basically to see if there is any pathology, that is, if there is any underlying disease which is contributing to the flat feet, and to allay their anxiety.”
Flat feet may be flexible or fixed. A child is believed to have flexible flat feet when the foot arch reappears when the child extends its big toe upwards and when he stands on his toes. Flexible flat feet is often familial, in that it may run in families where one or both parents could have a flat feet. Often, it co-exists with knock knees and inset hips. Fixed or rigid flat feet do not develop a normal arch when the child stands on his toes.
What causes flat feet?
1. It may be hereditary.
2. Flexible flat feet may be seen in people with diseases of the nervous system or muscles such as cerebral palsy, Down’s Syndrome, Marfan’s Syndrome spina bifida or muscular dystrophy.
3. One of the very important muscle that elevate the arch of the inside of the feet can be weak on its own and this can cause flat feet.
4. Bones of the inside of the feet may not be developed very well, causing flat feet abnormality.
Dr.Salman emphasizes, “These are the conditions in flexible flat feet, which have to be ruled out before we conclude that the condition will resolve of itself as a child grows to about 10 years.
Rigid or fixed flat feet, a rare condition, may be caused due to malformed joint or fused bones which form when the feet are formed in the womb. These feet are stiff and flat and the problem is usually obvious in childhood, explains Dr.Salman. “Two conditions are very important regarding this: vertical talus and fused feet bones. The talus is a bone which is just under the ankle joint and it should be oblique, in an almost horizontal fashion. But when it is abnormally formed as in vertical talus, the bone is more or less at 90 degrees to the floor of the foot. This bone can then be felt on the inside part of the foot by the child’s parents or clinicians. This condition requires surgical treatment, which is best done before the child is 12 months of age.”
The second condition of rigid flat feet, children are born with abnormally fused foot bones. Dr.Salman explains, “The talus and the heel bone can be fused together; another bone, the navicular, can be fused with the heel bone. This can lead to a loss of movement at the heel. Usually, this condition is detected only when the child is much older, for instance, becomes about 12 – 14 years of age.”
For reasons unknown, the incidence of flat feet is very slightly more in females as compared to males, reveals Dr.Salman.
What trouble can flat feet cause and how do its symptoms manifest? “Usually, nothing at all,” assures Dr.Salman. “Some people may get pain in the arch, around the ankle or down the outer side of the foot, but this pain can also be felt by people with “normal” arches. Children with flat feet may not present with any real symptom except in their shoe wear. These include:
1. Abnormal shoe-wear which is mostly present on the inside part of the heel; it wears off more than the outside part of the heel.
2. The shoe can be caved in on the top of the feet on the inside, in the middle of the shoe.
3. Shoes don’t look normal and they wear off very quickly.
4. In certain conditions, if the flat feet progress on and have become fixed, it can cause some slowing down of the child when he/she runs; this is because the push-off of the foot is not as adequate as with the child with a normal foot.
5. In severe cases, if the feet have become rigid, there can be some pain in the feet as well.
6. In the case of fixed flat feet and where there are associated pathological conditions as various disease conditions, the child may have pain and other associated disability.
7. Where the child has fixed flat feet due to the fusing of bones, he/she may experience unusual cramps in the feet and legs. The pain is there because there is no movement at the heels.
How is flat feet diagnosed? The diagnosis of flat foot is made solely by physical examinations. The feet lean inward when the individual is in a standing position because of the foot pronation, that is the foot rolls out in flat foot. If other underlying diseases are suspected, further tests as X rays, CT Scan and MRI are done to exclude other conditions, explains Dr.Salman.
How is flat feet treated? Dr.Salman reassures: “Most of these children improve with time and by 10 years of age, 90% of the flat feet have resolved. Usually, orthotics or medial arch supports are not indicated, especially in those who have rigid flat feet, in whom these supports may actually cause pain. If the child is 10 years old and there’s a problem with shoe-wear, his gait and the flat foot is quite severe, then there are some surgeries that can be done to correct it. These are done basically to address the abnormalities. For instance, if the child has knock knees, then this can be treated to bring about a more normal alignment which would also correct the flat feet. If the heel bone is more tilted outwards, that too can be corrected with surgery. Also, if the person has pain in the feet and presents with some arthritic changes in the foot, surgery may be performed, but after he completes 10 years of age.”
Surgery is definitely indicated if the child has vertical talus. “As mentioned earlier, it should be done at the earliest possible, preferably by the time the child is 12 months old. In this condition which is very rare, parents can usually feel a bone protruding in the inside part of the middle of the foot. This is what normally prompts them to seek medical attention. As the child grows older and the condition is not treated, while there may be no pain, the joints which are dislocated, become more difficult to treat and this can lead to mal-development of the foot and pain in the future and also lead to gait abnormalities.”
Surgery may also be indicated in the case of fixed flat feet cause by fusing bones. Dr.Salman clarifies, “Usually, not all these children need surgery. If there is pain, initially we treat by putting a plaster cast for 3 – 4 weeks. If the condition still does not improve, then the child can have a surgery called excision or removal of this piece of joined bone. The part of the bone that is joined, is surgically removed and fat is placed in that space to disallow the bones from joining again. The success rate for this kind of surgery is well above 80%. The child may still have problems, post surgery in the unsuccessful cases.”
Can flat feet affect only one foot or does it affect both feet? While usually it is both feet, sometimes, a single foot may be affected, says Dr.Salman. “A mild or moderate flexible flat foot may not make any difference to the child; it will not hamper the child’s activities. To correct the mechanics, you can keep the medial arch support on the affected foot and this will balance both the feet. But even if you do not use these supports, the condition will not cause any pain or symptoms.”
Can a child participate in sporting and other activities if he has flat feet? Will the condition not affect the balance of his body? Dr.Salman is unequivocal on his assurance. “You have army recruits and sports people of the highest caliber who are flat-footed! Children who have normal flexible flat feet can take part in all kinds of activities, without any hindrance.”
“As regards balance, only the foot is flat, without causing any deviation of the forefoot, near the toes. Now, if this is deviated outwards, then the body mechanics may be disturbed. That means, the body line that is falling right in the centre of the foot, will not be falling there; rather, it will fall more towards the inside of the foot or completely miss the foot. If this happens, the conditions may have to be corrected. But most of the flat feet do not have those problems. If it’s a normal flat feet and if it’s mild to moderate in severity, there will be no balance problem. If it’s severe, there is a possibility that it could affect the balance,” concludes Dr.Salman.