Risk Factors of Flatfoot in Children: A Systematic Review and Meta-Analysis

Is a keystone Bone Anomaly the Main Cause of Flatfoot (Pes Planus)?

BACKGROUND

Flatfoot (pes planus) is a decrease or loss of longitudinal medial arch height. The cause of symptomatic flatfoot occurring in adolescents is still unclear. In this study, the relationship between adolescent pes planus and foot bone shape was investigated. For this purpose, the volume and superficial area data of the foot bones of adolescent individuals with flatfoot deformity and individuals without any foot deformity were compared.

METHODS

Between September 2022 and June 2023, 30 individuals with adolescent pes planus with a medial arch angle greater than 145 degrees and 30 individuals without any foot deformity were included in the study. Computed tomography (CT) images of the participants' feet were obtained with a General Electric brand IQ model 32 detector CT device with a section thickness of 0.625 mm in accordance with the bone protocol. Using the 3D Slicer program on CT images, foot bones were segmented and the volume and surface area ratios of each foot bone were determined.

RESULTS

Cuneiforme mediale and cuneiforme intermediale volume ratios in individuals with flatfoot deformity decreased by 14% and 24%, respectively, compared with the control group (P<0.05). Cuneiforme mediale and cuneiforme intermediale superficial area ratios were found to be 10% and 30% lower in the flatfoot group compared with the control group, respectively (P<0.05). There was no difference in the volume and superficial area ratios of other foot bones between the groups (P>0.05).

CONCLUSIONS

The study results suggest that symptomatic adolescent flatfoot deformity may be associated with developmental anomalies of the os cuneiforme mediale and os cuneiforme intermedium.

High Rate of Change of the Foot in Ecuadorian Children: The Need for Proper Shoe Design

BACKGROUND

Physiological changes in the foot may be influenced by external factors such as shoe types or demographic parameters, leading to podiatric conditions in adulthood. The aim of this study was to assess the changes in morphological measurements of the feet of boys and girls during childhood and adolescence.

METHODS

A total of 1678 Ecuadorian children aged 8 to 17 years participated in the study. The length, width, and height of the foot were analyzed using a 3D scanner to obtain the arch height ratio for the diagnosis of pediatric flat foot.

RESULTS

Statistical differences were observed for lengths, widths, and perimeters of the foot in boys aged 5 to 15-16 years and girls aged 5 to 12-13 years. Differences in the height of the navicular bone were found in all age groups, with changes from 2.8 to 4.1% in boys and from 1.3 to 1.5% in girls. The greatest differences between boys and girls of the same age were found at 14 years old onwards. The highest prevalence of flat foot was found in 8-year-old girls (64.9%) and in 12-year-old boys (82.5%).

CONCLUSIONS

The feet of Ecuadorian children develop progressively during childhood and adolescence. Boys presented with longer and wider feet than girls of the same age. The highest prevalence of flat foot was found in 12-year-old boys and 8-year-old girls.

Exploring flatfeet morphology in children aged 6-12 years: relationships with body mass and body height through footprints and three-dimensional measurements

The aim of the study was to determine the relationship between flatfoot morphology and body mass and height in children aged 6-12 years. A total of 6471 Chinese children (mean age 9.0 ± 1.9 years, 41% female) were assessed for foot morphometry, body height, and body mass index. Foot morphology, including foot length, width, girth, arch height, hallux valgus angle, and rearfoot valgus angle, was measured using a 3D laser scanner. Flatfoot evaluations were conducted using the Sztriter-Godunov index (KY) from footprints. All measurements were analyzed by age and sex using the mean values of the left and right sides. Comparisons were performed between flatfoot groups, between body mass index (BMI) groups, and between body height groups. The study revealed a significant decrease in the incidence of bipedal flatfoot with age (p < 0.001), whereas the prevalence of obesity remained consistent (p > 0.05). Bipedal flatfoot was associated with distinct morphological changes, including lower arches, reduced instep height, diminished ankle heights and a greater rearfoot valgus angle (p < 0.05). When comparing the BMI groups, overweight children had larger and thicker feet (p < 0.05), but no differences were found in arch height and ankle height (p > 0.05). When comparing the body height groups, short-statured children had a shorter feet girth, shorter arches, and shorter ankle height (p < 0.05), but no differences were found in the rearfoot valgus angle (p > 0.05).

CONCLUSION

The main characteristics of flat feet include lower arches and instep heights and ankle heights but higher rearfoot valgus angles. In general, overweight children's feet do not have the common features of flat feet. In contrast, short children had similar features of flatfoot except for rearfoot valgus. Assessment of posture, such as rearfoot valgus, can be critical in identifying children with flat feet.

WHAT IS KNOWN

• The morphology of children's feet is associated with body growth, but the relationship between flatfeet and body mass and height remains controversial.

WHAT IS NEW

• Three-dimensional foot measurement shows that body mass is generally not associated with flatfeet, while short children have lower arches but no rearfoot valgus.

A 16-week school-based intervention improves physical fitness in Slovenian children: a randomized controlled trial

Introduction: The aim of this study was to evaluate the effects of a 16-week school-based physical activity (PA) intervention on physical fitness (PF) (speed, hand-eye coordination, flexibility) of 8- to 9-year-olds. Methods: A total of seventy-eight boys and girls (boys: n = 45, aged 8.4 ± 4.9 years; girls: n = 42, aged 8.6 ± 0.5 years) from a school in Slovenia were randomly assigned to either a group with an after-school PA program (EXP) or a control group (CON) that participated exclusively in mandatory physical education (PE). The EXP group engaged in the extracurricular PA program for 60 min twice a week for 16 weeks, concurrent with regular PE classes. The program primarily involved elementary PE games that included elements of athletics (e.g., skipping, push- off running, hopping, crossstepping, and jumping) and gymnastics (e.g., handstand, forward roll, backward roll, hand support jumps, squat jump on a vault box, climbing on horizontal bars, incline benches and ropes, crawling, and jumping rope). Standardized tests appropriate for this age group were used to assess PF, including the sit and reach test (SAR), the 30-meter sprint, and the alternate hand wall toss test at distances of 1.0 and 2.0 m (AHWT 1.0 and 2.0). Results: There was a significant group-time interaction for SAR test (EXP group increase: +1.6 cm, +6.3%; CON group decrease: -0.1 cm, -0.4%; p < 0.001, ηp2 = 0.361), and the 30 m sprint (EXP group improvement: -0.4 s, -6.3%; CON group decrease: +0.1 s, +1.6%; p < 0.001, ηp2 = 0.193). Similarly, the EXP group improved by +2.1 points (+25.6%) in the 1.0 m wall throw with the alternating hand, while the CON group showed only minimal changes (-0.2 points, -2.4%; p < 0.001, ηp2 = 0.545). No significant interaction was found for the 2.0 m toss (EXP and CON group both -0.1 points, -2.6%; p = 0.888, ηp2 = 0.001). Post-hoc analyses with paired t-tests revealed that the EXP group showed significant improvements in SAR test (p < 0.001), 30 m sprint (p < 0.001) and AHWT 1.0 test (p < 0.001), while the CON group showed no significant changes in SAR test (p = 0.533), 30 m sprint (p = 0.150), AHWT 1.0 test (p = 0.186) and AHWT 2.0 test (p = 0.430). Discussion: The results of the study showed that the extracurricular program with only two additional weekly sessions significantly improved the components of PF in 8- to 9-year olds. Significant improvements were observed in the areas of flexibility, speed and coordination, as shown in the SAR test, 30-meter sprint and 1.0-meter handwall toss tests. However, no similar improvements were observed in the 2.0-meter handwall toss, which illustrates the specific areas of impact of the program.

The relationship of three-dimensional foot morphology to clinical assessments and postural stability in adolescent male footballers

BACKGROUND

Foot morphology is associated with altered loading of the ankle-foot complex in adolescent footballers, predisposing to pain and injury. However, usual singular plane clinical assessments do not accurately capture the 3D nature of foot morphology. A new approach is 3D laser scanning, with statistical shape model techniques creating individual-to-group comparison. However, no research exists on the adolescent, football-playing foot. Furthermore, a link between 3D foot morphology, and usual clinical and performance measures would be beneficial for practical implementation.

METHODS

Four hundred forty-seven 3D foot scans from 224 elite male footballers (U12-U19) in bilateral stance were collected and further processed with statistical shape model techniques. Weighted shape parameters for individual principal components (Modes) were extracted for each foot. Centre of pressure displacement expressed as total travelled way in millimetres was calculated for bilateral and unilateral postural stability measures. Clinical assessments (Clarke's Angle, Resting Calcaneal Stance Position) were calculated on the 3D foot scans. Differences in weighted shape parameters, postural stability measures, and clinical assessments between age groups were determined by ANOVA. Correlations determined the relationship of Modes and clinical assessments to postural stability measures. Linear regression established if clinical assessments predicted the mode describing foot arch variation.

RESULTS

Age groups significantly differed for Mode 1 (foot length), Mode 2 (foot arch), and Mode 5 (tibial rotation relative to the foot) (p < 0.05). Resting Calcaneal Stance Position (r = .663) and Clarke's Angle (r = -.445) were low-to-moderately correlated to Mode 2 (both p < 0.001), and linear regression found they were both significant predictors of Mode 2, though only moderately (R2 = .522). There were low correlations of foot morphology to the postural stability tests.

CONCLUSION

This is the first study to describe the 3D foot morphology of male football-playing adolescents, and discover the differences between age groups. This will improve understanding and assessment of foot morphology in male adolescents because 2D techniques, as discovered in this study, do not strongly correlate to, nor predict, the 3D foot arch. Foot morphology was only lowly correlated to postural stability, thus a multifaceted program would be required for improvements.

Pediatric Flatfoot: Is There a Need for Surgical Referral?

Pediatric foot deformities are a common finding, concerning up to 44% of preschool aged children. The absence of accepted international guidelines, as well as heterogeneity in definitions and measurements, makes management of pediatric flatfoot a challenge, and decisions surrounding specialized care referral confusing and biased. The objective of this narrative review is to provide guidance to primary care physicians treating these patients. A non-systematic review of the literature regarding the development, etiology, and clinical and radiographic assessment of flatfeet using the PubMed and Cochrane Library databases was performed. The exclusion criteria for the review were adult populations, papers detailing the outcome of a specific surgical procedure, and publications prior to 2001. The included articles showed great heterogeneity in definition and proposed management, which makes the study of pediatric flatfoot challenging. Flatfoot is a common finding in children under 10 years old, and should not be considered pathological unless stiffness or functional limitation are present. Surgical referral should be reserved to children with stiff or painful flatfoot, while simple observation is indicated for flexible, asymptomatic flatfeet.

Pediatric and Adolescent Flatfoot: A Questionnaire Based Middle East and North Africa Study

Background

Flatfoot is commonly seen in the community and is a common cause of concern for parents because it could become symptomatic and lead to decreased quality of life. One of the most used management approaches is foot orthoses, although no clear evidence supports their use. We aimed to study flatfoot symptoms' prevalence, effect on activities of daily living, and the use and effectiveness of orthoses.

Methodology

This was a cross-sectional study that included five countries from the Middle East and North Africa region (Jordan, Palestine, Syria, Egypt, and Iraq). Data were collected using an online questionnaire directed toward parents of children aged 0 to 16 from September to December 2020. The demographic factors were expressed as frequencies (percentages) using standard descriptive statistical parameters, and Pearson's chi-square test was used to examine the relationship between study factors.

Results

1256 participants were recruited using this online survey. The majority (29.6%) of children were diagnosed in the age group of 0 to 2. The abnormal appearance of the foot was the most common (78.7%) complaint. Overall, 54.2% of patients were prescribed orthoses, of which 36.8% noticed improvement in flatness and 37.6% reported relief of symptoms.

Conclusion

This study demonstrated that most participants have no or minimal symptoms and that there is a mismatch between participants' expectations and the actual effectiveness of orthoses. Taking into consideration that there is no clear evidence to support the corrective effect of orthoses, we recommend that physicians prescribing them adhere more to their proper indications and spend more time and effort counseling and addressing patients' and parents' concerns about this developmental stage.

Understanding the Role of Children's Footwear on Children's Feet and Gait Development: A Systematic Scoping Review

Children's footwear plays an important role in the healthy growth of foot and gait development during the growing stage. This review aims to synthesize findings of previous investigations and to explore the biomechanical influences of different types of children's footwear on foot health and gait development, thus guiding the healthy and safe growth of children's feet and gait. Online databases were searched for potential eligible articles, including Web of Science, Google Scholar, and PubMed. In total, nineteen articles were identified after searching based on the inclusion requirements. The following five aspects of biomechanical parameters were identified in the literature, including spatiotemporal, kinematics, kinetics, electromyography (EMG), and plantar pressure distribution. Children's footwear can affect their foot health and gait performance. In addition, children's shoes with different flexibility and sole hardness have different effects on children's feet and gait development. Compared to barefoot, the stride length, step length, stride time, and step time were increased, but cadence was decreased with wearing shoes. Furthermore, the support base and toe-off time increased. Double support time and stance time increased, but single support time decreased. The hip, knee, and ankle joints showed increased range of motion in children with the rear-foot strike with larger ground reaction force as well. Future studies may need to evaluate the influence of footwear types on gait performance of children in different age groups. Findings in this study may provide recommendations for suitable footwear types for different ages, achieving the aim of growth and development in a healthy and safe manner.

Really Asymptomatic? Health-Related Quality of Life and Objective Clinical Foot Characteristics among 5-10-Year-Old Children with a Flexible FlatFoot

The potential effects of asymptomatic flexible flatfoot (FF) on children's health-related quality of life (QoL) and objective clinical foot characteristics have been poorly investigated in the literature. Therefore, this study aimed to analyse these indicators, comparing the children with asymptomatic FF and a control group.

METHODS

In total, 351 children were enrolled in this cross-sectional study-160 children with asymptomatic FF and 191 controls (children with normal feet). The children and their parents completed the Paediatric Quality of Life Inventory (PedsQL^TM 4.0). The objective foot characteristics included clinical foot posture measures, footprints, general hyperlaxity, and X-ray measurements.

RESULTS

Children with asymptomatic FF had a significantly lower QoL (overall and all four dimensions). The parents' assessment of the QoL of their children with asymptomatic FF in most cases was lower compared to their children's self-reported QoL. Moreover, almost all clinical foot measures also had significantly worse profiles among asymptomatic FF cases compared to the controls. This was observed with the Foot Posture Index-6 (FPI-6), the navicular drop (ND) test, the Chippaux-Smirak Index (CSI), Staheli's Index (SI), the Beighton scale, and radiological angles (except the talo-first metatarsal angle).

CONCLUSION

The findings suggest that asymptomatic FF not always reflects a normal foot development. This condition is related to decreased health-related quality of life, so the 5-10-year-old children's and their parents' complaints should be considered more closely in identification, treatment, and monitoring plans.

Classification of the Os Calcis Subtalar Morphology in Symptomatic Flexible Pediatric Pes Planus Deformity Using Weightbearing CT and Distance Mapping

BACKGROUND

The etiology of symptomatic pediatric pes planus (PP) deformity is unclear. Reduced os calcis subtalar joint (OCST) anterior facet morphology has been suggested to result in less support to the talar head and a higher propensity to develop PP deformity. Weightbearing computed tomography (WBCT) and distance mapping (DM) offer new opportunities to investigate PP deformity in general and the OCST specifically. The purpose of this study is to investigate the OCST morphology using DM and to classify PP subtalar subtypes with DM using Bruckner's A-D classification system.

METHODS

Forty feet in 25 patients in a national referral center were evaluated for symptomatic PP deformity that failed nonoperative treatment. A WBCT scan was performed as part of the preoperative evaluation. Visualization of the distance distribution between the articulating surfaces of the subtalar joint was based on a DM technique. Intra- and interobserver agreement of the subtalar morphology was assessed using Bruckner's classification system.

RESULTS

The mean age was 10.7 ± 1.4 years. The following mean ± SD and median ± ranges were semiautomatically measured for this group: Meary angle -21 ± 8, calcaneal inclination 15 ± 4 degrees, talar coverage angle 39 (range 32.6-49) degrees, and hindfoot moment-arm 16 ± 5 mm. Classifying subtalar morphology using DM yielded an excellent intra- and interobserver agreement. The individual percentages of each individual subtype were calculated: type A 5%, type B 48%, type C 4%, and type D in 44%.

CONCLUSION

This study demonstrated excellent intraobserver and interobserver agreement in classifying the OCST using DM. A higher prevalence of types B and D was observed compared to types A and C in this PP cohort.

LEVEL OF EVIDENCE

Level III, retrospective study.

Efficacy of Plantar Orthoses in Paediatric Flexible Flatfoot: A Five-Year Systematic Review

Paediatric flexible flatfoot (PFF) is a very common condition and a common concern among parents and various healthcare professionals. There is a multitude of conservative and surgical treatments, with foot orthoses (FO) being the first line of treatment due to their lack of contraindications and because the active participation of the child is not required, although the evidence supporting them is weak. It is not clear what the effect of FO is, nor when it is advisable to recommend them. PFF, if left untreated or uncorrected, could eventually cause problems in the foot itself or adjacent structures. It was necessary to update the existing information on the efficacy of FO as a conservative treatment for the reduction in signs and symptoms in patients with PFF, to know the best type of FO and the minimum time of use and to identify the diagnostic techniques most commonly used for PFF and the definition of PFF. A systematic review was carried out in the databases PubMed, EBSCO, Web of Science, Cochrane, SCOPUS and PEDro using the following strategy: randomised controlled trials (RCTs) and controlled clinical trials (CCTs) on child patients with PFF, compared to those treated with FO or not being treated, assessing the improvement of signs and symptoms of PFF. Studies in which subjects had neurological or systemic disease or had undergone surgery were excluded. Two of the authors independently assessed study quality. PRISMA guidelines were followed, and the systematic review was registered in PROSPERO: CRD42021240163. Of the 237 initial studies considered, 7 RCTs and CCTs published between 2017 and 2022 met the inclusion criteria, representing 679 participants with PFF aged 3-14 years. The interventions of the included studies differed in diagnostic criteria, types of FO and duration of treatment, among others. All articles conclude that FO are beneficial, although the results must be taken with caution due to the risk of bias of the included articles. There is evidence for the efficacy of FO as a treatment for PFF signs and symptoms. There is no treatment algorithm. There is no clear definition for PFF. There is no ideal type of FO, although all have in common the incorporation of a large internal longitudinal arch.

Correlation between flat foot and patellar instability in adolescents and analysis of related risk factors

INTRODUCTION

Flatfoot and patellar instability are both developmental limb deformities that occur frequently in adolescents. A high number of patients with both diseases can be seen in clinic, and there are no studies showing a correlation between the two. The goal of this study is to investigate the association between developmental patellar instability and flat feet in adolescents and its associated risk factors.

METHODS

This experiment uses a cross-sectional study to select 74 adolescent patients with flat foot from a randomly selected middle school in this city since December 2021 and obtain relevant data. SPSS26.0 statistical software was used for data analysis. Quantitative data were expressed as mean ± standard deviation, and Pearson correlation coefficient was used for analysis. p < 0.05 indicates a statistically significant difference.

RESULTS

A total of 74 people (40 men and 34 women) were included in this study. The correlation coefficients between Meary angle, Pitch angle, calcaneal valgus angle, CSI, BMI, and Beighton scores and knee joint Q angle are 0.358 (p < 0.01), -0.312 (p < 0.01), 0.403 (p < 0.01), 0.596 (p < 0.01), 0.427 (p < 0.01), and 0.293 (p < 0.05), respectively, indicating that flat foot, overweight, and Beighton scores are all correlated with Q angle. The correlation coefficients between Meary angle, Pitch angle, calcaneal valgus angle, CSI, and BMI were 0.431 (p < 0.01), -0.399 (p < 0.01), 0.319 (p < 0.01), and 0.563 (p < 0.01), respectively, indicating a correlation between flat foot and BMI. The correlation coefficients between Meary's angle, Pitch's angle, calcaneal valgus angle, CSI, and Beighton's score were 0.207 (p > 0.05), -0.240 (p < 0.05), 0.204 (p > 0.05), and 0.413 (p < 0.01), respectively, indicating a correlation between flat foot and Beighton's score.

CONCLUSION

We believe that there is a significant correlation between adolescent flatfoot and patellar instability. Excessive weight and ligamental laxity during adolescent development are among the risk factors for flatfoot and patellar instability.