New papers revisit, rekindle flexible flatfoot controversy

Photo courtesy of SureStep.

“Other considerations” spark debate

By Cary Groner

Two recent literature reviews have reignited the debate over treatment options for pediatric flexible flatfoot.

In January 2010, when LER first covered the controversy, Australian podiatrist and researcher Angela Evans, PhD, had recently published a paper in the Journal of the American Podiatric Medical Association suggesting that children whose feet were flatter than expected, but asymptomatic, should be monitored rather than automatically treated with orthoses.1 This provoked the ire of some American pediatric foot specialists, who thought the approach downplayed important pathologies. Not everyone agreed, however; for example, Edwin Harris, DPM, the lead author of guidelines from the American College of Foot and Ankle Surgeons, concurred with the basic premise of Evans’s approach, and said it provided a practical direction for further investigation.2

More recently, Evans and a colleague, Keith Rome, DPM, professor of podiatry at Auckland University of Technology in New Zealand, published two literature reviews revisiting the topic—and rekindling the debate. In the first, comprising three trials involving 305 children, they concluded that the evidence was too limited to draw definitive conclusions about use of nonsurgical interventions for pediatric pes planus.3 The more recent review broadened the inclusion criteria for studies, reviewing 15 and proposing an algorithm for managing flexible flat feet.4

Part of the goal, Evans told LER, was to further develop the “yellow zone” in the original JAPMA paper—the asymptomatic children who, as mentioned, should simply be monitored.

“That seems to have been interpreted in an absolute sense of monitoring only,” she said. “But monitoring is a dynamic process; within that yellow zone, if a clinician sees a foot that’s not painful, but that also isn’t functioning well, that should direct some form of treatment. That may mean changing their shoes or using an inexpensive foot orthotic. Our criticism has been of the excessive use of expensive customized orthoses. But it also came out of the review that in children with arthritis and foot pain, customized orthoses are indicated because they improve both pain and function.”

Alan Ng, DPM, who practices with Advanced Orthopedics and Sports Medicine Specialists in Denver and is on the board of directors for the American Board of Podiatric Surgery, concurs with the monitoring approach in asymptomatic children.

“I think a lot of pediatric flatfoot can be treated conservatively, as long as there’s no coalition,” he said. “The initial evaluation should include weight-bearing, x-rays, gait analysis, resting calcaneal stance position, and mobility. Most of the time, initial treatment is physical therapy, muscle strengthening, functional orthotics, or good, supportive shoes, and eighty or ninety percent of the time they do fine. But if a kid is asymptomatic and can do full activity with no issues, I don’t touch them; putting them into an orthotic just because they have flat feet is inappropriate.”

Russell Volpe, DPM, who teaches at the New York College of Podiatric Medicine, said that the evaluation and treatment parameters in Evans and Rome’s most recent paper don’t go far enough.

“It’s an exemplary review and analysis of what’s been published, but it doesn’t cover the complicated topic of what makes asymptomatic flat feet a potential issue,” he said.

What Evans and Rome refer to passingly in the paper as “other considerations” are, to Volpe, a big issue and a significant part of his practice. They include superstructural and pedal influences on all three body planes.

“They miss the point about the huge role of lower extremity residual torsions, equinus, genu or tibial varum, calcaneal varus, and the like,” he said. “There’s a lot that goes into identifying the foot that is at risk to become dysfunctional and symptomatic over time, and the big tool for evaluating it is the biomechanical integrity of that lower extremity. In their paper I see one sentence about it in twenty pages. That’s the problem.”

Such influences, Volpe said, are better corrected with custom orthoses, and he took particular umbrage at the paper’s suggestion that custom approaches “desist.”

“I will not desist; in fact I will insist!” he said. “For the cohort with biomechanical comorbidities, I need to incorporate postings and modifications that allow me to manage both the primary structural comorbidity and the compensation in the foot, and for that I need to use a custom orthosis.”

No doubt as positions are refined on both sides of the argument, matters will become clearer. Stay tuned.

Cary Groner is a freelance writer in the San Francisco Bay area.


1. Evans AM. The flat-footed child—to treat or not to treat. J Am Podiatr Med Assoc 2008;98(5):386-393.

2. Groner C. Numbers needed to treat? The pediatric flexible flatfoot debate. LER Review 2010;2(1):22-29.

3. Rome K, Ashford RL, Evans A. Non-surgical interventions for pediatric pes planus. Cochrane Database Sys Rev 2010;7(7):CD006311.

4. Evans AM, Rome K. A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. Eur J Phys Rehabil Med 2011;47(1):69-89.

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