In children and adults, flat feet are usually pliable and have a fairly normal appearance of the arch in a non-weight-bearing condition. If an acceptable medial longitudinal arch is not present even in the non-weight-bearing state, this flatfoot is defined as fixed or rigid. In practice the degree of stiffness varies. However, usually fixed and semi-rigid flat feet have structural changes in the bone and soft tissues, and treatment by changing the footwear alone does not provide relief.
In children with flexible clubfoot between the ages of toddler and 3 years, there is no reason to use expensive orthopedic shoes and pads that would be a burden on the parents and the patient, if there is no clear family history of clubfoot that would persist into adulthood. Even with such a family history, those orthopedic shoes with Thomas heels, medial wedge heels (1/8 to 3/16 inch) and navicular pads or various other modified orthopedic pads and orthopedic shoes for treating parents and grandparents in the family may be more appropriate than for children, whose arches are not fully developed until after the age of 7 to 10 years, which would support the above point. In addition, 15 to 20% of adults can have some degree of flexible flatfoot, but most of them are asymptomatic.
If the patient is a child between the ages of 3 and 9 years with asymptomatic flexural flatfoot, the physician should take the effort to obtain a natural history of the development of the deformity from the child’s parents. No long-term studies have been reported on the follow-up of asymptomatic children with untreated flexible flatfoot into adulthood, and there is no convincing information on the effectiveness of orthotic shoes and pads to modify the final structure of the foot. In fact, Wenger et al. concluded that 3 years of treatment with orthopedic shoes and pads did not affect the course of flexible flatfoot in children.
When a child develops symptoms and these symptoms are likely to be related to a flexible flatfoot deformity, orthopedic shoes should be started with arch supports placed in the shoe with a stiff heel vamp, enlarged medial vamp, steel arch supports, Thomas heel, and medial wedge heel pads. Although we note the encouraging findings of Bleck and Bordelon, which show that arch improvement is obtained both radiographically and clinically with the continued use of shaped orthotic supports over an extended period of time, we still rarely use custom orthotic supports. In any case, the question of whether bracing can permanently correct the flexural flatfoot deformity has not been resolved. In children with symptomatic, severe flexible flatfoot (3 to 9 years of age) with significant heel valgus, forefoot abduction, and significant medial protrusion of the talar head, custom orthotic braces are recommended, primarily for comfort or to treat secondary knee valgus deformities. Leather, cork, or polypropylene orthotic pads are most often used.
No specific treatment is recommended for asymptomatic flexible flatfoot patients aged 10 to 14 years. In symptomatic patients, a shaped orthopedic support can be made from a positive mold (plaster model) of their foot, usually of polypropylene, in which the affected foot is placed in the correct position (heel and forefoot in neutral position, first toe row plantarflexed, medial longitudinal arch restored). This orthopedic support needs to be placed in a stiff shoe. When the affected foot is placed in this orthopedic shoe, a lateral x-ray should be taken in the standing position to show the correction of the deformity. It is in this age group (10 to 14 years) that pars plana or incomplete tarsal fusion often causes clinical symptoms. However, the notion that the pars plana can cause flat feet remains questionable. Removal of the pars plana (anterior bunion) may alleviate painful bursitis, posterior tibial tendonitis, or chondromalacia (located between the pars plana and the navicular bone), which sometimes cannot be relieved by the application of orthopedic braces that elevate the heel and reduce heel valgus. If clinical data and radiographs suggest early heel-boat fusion, we advocate aggressive surgical excision of the fusion area.