Pediatric Flatfoot: Evaluation and Management

Although the exact incidence of flatfoot in children is unknown, it is a common finding. All children have only a minimal arch at birth, and more than 30% of neonates have a calcaneovalgus deformity of both feet. This condition is not painful and generally resolves without treatment; very rarely is corrective casting necessary. Most children who present to an orthopaedist for evaluation of flatfoot will have a flexible flatfoot that does not require treatment. Nevertheless, the examining physician must rule out other conditions that do require treatment, such as congenital vertical talus, tarsal coalition, and skew-foot. Untreated, congenital vertical talus may result in an awkward gait; manipulation and casting have been tried, but most authors now agree that surgical treatment is required. Although tarsal coalitions can become asymptomatic in adulthood, the anatomy will never be normal. Resection and inter-position of the extensor digitorum brevis is the treatment of choice for calcaneonavicular coalitions; the results of treatment of talocalcaneal coalitions are less predictable. Skewfoot should be treated by manipulation and serial casting as soon as it is detected. In the older child, hindfoot stabilization and realignment of the midfoot may be necessary. Surgical management is rarely indicated for a true flexible flatfoot. A variety of tendon transfers and reconstructive procedures have been advocated, but none has proved uniformly successful. Nor has any of the various types of supports ever been shown to change the arch architecture. Although parents are often concerned about pediatric flatfoot, the child is usually found to be asymptomatic, and no treatment is indicated. In most instances, the best treatment is simply taking enough time to convince the family that no treatment is necessary.