FLAT FEET IN CHILDHOOD
What is it?
We have come a long way over the past 30 years in the treatment of flat feet in childhood. It used to be thought that nothing could be done to change the pattern of development of the child’s flat foot.
The difficulty is distinguishing those children whose feet are going to become problematic, painful and deformed, from those children whose feet will remain flat but do not have symptoms associated with them.
There are a number of conditions in childhood and adolescence that can cause a flat foot. The most important issue we face in diagnosis of the condition is whether the foot, although flat, will remain flexible or whether it will become stiff or rigid.
If the foot is rigid, the inward and outward movement (inversion and eversion) is lost.
FLAT FEET: THE FLEXIBLE FLAT FOOT
What is it?
During the first few years of life a flat foot is perfectly normal. It is only around the fourth or fifth year that the arch really begins to develop. Flat feet at this age rarely require any treatment.
Only when the foot is very flat, causing pain with normal and sporting activities in addition to shoes that are wearing out rapidly is some sort of treatment required.
For these children we use an orthotic arch support.
The arch support does not change the shape of the foot nor will it change the development of the foot in any way. It simply maintains the foot in a slightly better position in the shoe, making the shoe wear a little easier.
If the feet are still very flat by the time the child is eight years old, they can become symptomatic. Children will complain of aching, fatigue in the arch of the feet and the legs and inability to “keep up” with other children in recreational and athletic activities.
Some children require treatment for the flexible flat foot if symptoms cannot be controlled with shoe changes and orthotic arch supports.
There are two types of surgical treatments that have been quite successful.
One is to insert a small cylindrical plug into the heel bone joint (the subtalar joint).
Two is to change the shape of the foot with bone cuts (an osteotomy) and combine this with the use of a bone graft.
The insertion of the cylindrical plug (arthroereisis screw ) is a device that has proven very successful in the correction of the child’s flat foot. See www.Arthrex.com on the web.
Note the fairly gross flatfoot in this adolescent boy on the left hand side. There is absolutely no arch, and his foot was collapsing inwards resulting in considerable discomfort with shoes, walking and exercise. Below are pictures 6 weeks post operatively.
General Recovery Facts
- Following surgery, a bandage with plaster is applied to the ankle if I am worried about swelling until the stitches are removed and the wound inspected in approximately two weeks or a cast is applied straight away for 6 weeks.
- No walking on the foot is permitted until 2weeks or until the cast feels loose.
- You may experience a variety of sensations whilst in the cast consisting of sharp shooting, dull aches, electric shocks, throbbing, sensation of itching and these are all normal and you should not panic.
- Cast will be removed at 6 weeks, and then you will be in a walking boot.
- Exercise activities are initiated in a swimming pool at 6 weeks, on a stationary bike at 8 weeks, and on machines supervised by a physical therapist thereafter.
- Physical therapy exercises, swimming and biking are important as part of the recovery process to maximize recovery.
- It will take about 3 months before the foot starts to feel comfortable and swelling will persist for about 6-9 months.
- Sometimes hardware must be removed at a later stage should irritation occur.
Before & After Pics
Specific post-operative recovery
- Foot is wrapped in a below knee cast.
- Elevate the leg on some pillows when awake however when sleeping elevate the base of the bed with 2 bricks or thick books so that the limb does not fall of the pillow at night and you wake up swollen.
- Take pain and DVT prophylaxis medication as prescribed.
- Expect numbness in foot 4-12 hours, followed by pain for usually one more day.
- Do not allow foot to hang down.
- If you are travelling, move the toes as much as possible to stimulate the calf muscle however travel during this time is not advisable.
- First follow-up in the office.
- Cast inspection for any possible complications or irritable areas +- adjustment of cast.
- Start full weight-bearing in cast with post-operative shoe and crutches initially to pain and swelling.
- Can allow foot to hang down at 3 weeks provided no pain and swelling occurs.
- Cast is removed by my dressing Sister and wound inspected.
- If incision is dry and completely healed, swimming is permitted for rehabilitation purposes taking care to not jump in the pool or apply any unnecessary force.
- Gentle exercise on bicycle with no resistance or swimming with flippers permitted preferably guided by physiotherapist.
- At this stage a removable Moon boot is fitted and foot is prevented from inverting or everting and must be used for 6 weeks for any form of walking however patient does not need to sleep with this boot.
- 30lbs/13.63kgs body weight on the leg is allowed 5 minutes twice a day when washing/bathing.
- If swelling is problematic you may require the use of a compression sock.
- Start physical therapy under supervision with my protocols and this will focus on scar desensitisation and joint range of motion mostly.
- Control x-ray is taken.
- Will require gait analysis and custom orthotics to be made on an individual basis and will be referred to appropriate Orthotics to have this made in order to allow foot to get use to its new position and speed up recovery.
- Orthotics will be phased out eventually once foot has regained all strength.
- More vigorous exercise with Biokineticist for the next 8-12 weeks in order to achieve strength within 10% of the unaffected side hence clearing you for return to sport.
- Control x-ray is taken.
- Can discontinue boot at this stage and use a shoe with a supportive sole.
- Flat running on treadmill by 3 months.
- Followup in my consultation rooms.
- Control x-ray is taken.
- Photographs and video taken of range of motion and strength.
- Cutting sports by 4-6 months.
- May require gait analysis and custom orthotics to be made on an individual basis.
- Patient is usually discharged at this stage.
- If an arthroereisis screw has been placed then this needs to be removed at 18-24 months and will be discussed at this consultation.
- Patient outcome score taken.