The typically developing paediatric foot: how flat should it be? A systematic review

Foot arch asymmetry and its correlations with physical fitness level and body mass index among school-aged children

PURPOSE

To assess potential differences in foot arch structure between the left and right feet and how this is connected to physical fitness and BMI in school-age children.

METHODS

437 children (6-16 years) participated and were divided into group 1 (n = 188, aged 6-9 yrs), and group 2 (n = 249, aged 10-16 yrs). Bilateral foot arches' absolute values were obtained using a digital pressure platform, and arches' types based on the Chippaux-Smirak-Index (CSI) (high, normal, flat arches) were identified. Physical fitness levels using the modified Zuchora test's total score and categorization level, and the BMI were determined for all children.

RESULTS

Abnormal foot arches were more common in the non-dominant left foot compared to the dominant right foot, with a higher occurrence of high arches than flat feet in both groups. The foot arch CSI-mean values were significantly asymmetrical, with the left foot showing higher values (0.23 ± 0.17) than the right foot (0.22 ± 0.16) (p = 0.004). Group 2 showed a notable direct relationship between children's BMI and the CSI-absolute values of both left (p = 0.009) and right (p = 0.030) foot arches. While group 1 showed a strong link between children's BMI and left-foot CSI-absolute values (p = 0.028), there was no such correlation with right-foot CSI-absolute values (p = 0.055). Nonetheless, there was no significant correlation found between the left/right foot arches CSI-absolute values and either the children's gender or their overall physical fitness scores in both groups.

CONCLUSION

It is recommended to pay closer attention to the health impacts associated with the non-dominant foot and high arches as the left foot is more susceptible to abnormal arches, with high arches being more prevalent than flat arches.

Prevalence of flatfoot and gender differences in plantar pressure among third-year high school students in Tongzhou district Beijing

OBJECTIVE

To estimate the prevalence of flatfoot and to analyze the gender difference of plantar pressure in third-year high school students in Tongzhou District Beijing.

METHODS

From March 2019 to March 2021, 1217 third-year high school students in Tongzhou District, Beijing were tested for plantar pressure. The prevalence of flatfoot was calculated and related plantar pressure parameters were analyzed, including contact area and plantar pressure. The differences of plantar pressure parameters between different genders were analyzed.

RESULTS

The prevalence of flatfoot among third-year high school students in Tongzhou District, Beijing was 5.5% (95% CI: 4.3-6.7%), among which, the prevalence of flatfoot among boys was 5.3% (95% CI: 3.8-6.8%) and that among girls was 5.9% (95% CI: 3.9-7.9%). There was no significant difference in the prevalence of flatfoot among different genders (P = 0.326), and the left and right foot types were basically the same. The mean BMI of the study population was 22.6 ± 3.4 kg/m², with males having a slightly higher mean BMI (23.1 ± 3.6 kg/m²) compared to females (21.9 ± 3.0 kg/m²). In static phase, there were statistically significant differences in contact area, plantar pressure at great toe, plantar pressure at 2nd - 5th toe, plantar pressure at 2nd - 4th metatarsal, and plantar pressure at middle foot(P < 0.05) between male students and female students. In dynamic phase, there were significant differences in contact area, plantar pressure at great toe, plantar pressure at 2nd - 5th toe and plantar pressure at 5th metatarsal (P < 0.05).

CONCLUSION

The findings of this study suggest that while flatfoot prevalence is similar between genders in third-year high school students, significant gender-specific differences exist in plantar pressure distribution patterns. These differences persist in both static and dynamic phases, with potential implications for gender-specific foot health assessment and preventive interventions. Understanding these patterns may help in early detection of foot abnormalities and implementation of appropriate interventions to prevent long-term biomechanical issues in this age group.

W-SITTING IN CHILDHOOD: A SYSTEMATIC REVIEW

OBJECTIVE

Despite the lack of science-based evidence, many specialists and non-specialists consider W-sitting detrimental to children. This systematic review aims to find evidence on W-sitting.

METHODS

This review was registered on PROSPERO under the number CRD42022313341. During January 2023, the term "W-sitting" and its variations were searched on the following databases: PubMed, Medline, Embase, PEDro, and Cochrane. Duplicate articles and those that addressed themes other than W-sitting were removed.

RESULTS

This review found 3641 articles, removed 614 duplicates, and excluded 3021 for focusing on subjects other than W-sitting. It included seven studies for analysis, one of which was a narrative review and two were methodologically inadequate cross-sectional to evaluate the causal effect in W-sitting. Another article evaluated muscular activation in adults according to sitting position. The last article found no causal relation between W-sitting and developmental dysplasia of the hip.

CONCLUSION

This review found no scientific evidence advise against W-sitting in children and no association with hip dysplasia. Moreover, muscular activation remains the same, regardless of the position chosen for sitting. Level of evidence III, review article.

Pedobarography and ankle-foot kinematics in children with symptomatic flexible flatfoot after medialising calcaneal osteotomy and controls: a comparative study

PURPOSE

Flexible flatfoot (FF) can interrupt children's activity through uneven pressure distribution to the medial column of the foot and may require surgery. Medialising calcaneal osteotomy (MCO) helps restore the foot‒tripod complex. The objective was to compare pedobarography and ankle‒foot kinematics in children with symptomatic FF after MCO to those in controls.

METHODS

Gait analysis was performed on 21 children with FF (37 feet, age 13.7 ± 4.9 years) 4.5 ± 3.4 years after MCO and on 21 controls (42 feet, age 12.1 ± 1.1 years). Ankle‒foot kinematics and pedobarography parameters (maximum pressure, impulse, contact area, and percentage of contact time in the stance phase) of ten anatomic foot regions from an average of five gait trials were compared. The functional outcome was determined by the AOFAS-AHFS score in the FF group.

RESULTS

The average AOFAS-AHFS score was 96. The FF group had a larger contact area and expressed more force on the medial column of the foot. The maximum pressure, impulse, contact area, and percentage of contact time in the stance phase in the midfoot region for the FF and control groups were 0.66 ± 0.5 vs. 0.24 ± 0.4 N/cm2 (p = 0.005), 0.12 ± 0.1 vs. 0.03 ± 0.1 Ns/cm2 (p = 0.02), 47.1 ± 13.4 vs. 30.1 ± 7.1 cm2 (p < 0.001), and 53.7 ± 17.4 vs. 68.2 ± 15.7% (p = 0.007), respectively. The kinematics of the FF exhibited a greater range of abduction and eversion during the mid- and terminal-stance phases of the gait cycle.

CONCLUSIONS

The MCO procedure did not normalise the pressure on the midfoot in FF to the level of that in the controls, and the deformity persisted in the forefoot.

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.

Predictors of flatfoot in 11-12-year olds: a longitudinal cohort study

BACKGROUND

The structures around the navicular bones, which constitute the medial longitudinal arch, develop by 10 years of age. While navicular bone height is often emphasized in the assessment of flatfoot, three-dimensional (3D) evaluations, including those of structural parameters during inversion, have rarely been investigated. If the development of flatfoot during the growth process could be predicted, appropriate interventions could be implemented. Therefore, in this longitudinal cohort study, we developed a system, utilizing smartphones, to measure the 3D structure of the foot, performed a longitudinal analysis of changes in midfoot structures in 124 children aged 9-12 years, and identified factors influencing the height of the navicular bone. The foot skeletal structure was measured using a 3D system.

RESULTS

Over 2 years, foot length and instep height increased during development, while navicular height decreased. The 25th percentile of the instep height ratio and navicular height ratio at ages 9-10 years did not exceed those at ages 11-12 years, with percentages of 17.9% and 71.6%, respectively, for boys, and 15.8% and 49.1%, respectively, for girls. As the quartiles of the second toe-heel-navicular angle (SHN angle) increased at ages 9-10 years, the axis of the bone distance (ABD) and SHN angles at ages 11-12 years also increased, resulting in a decrease in the navicular height ratio. A significant inverse correlation was found between changes in SHN angle and navicular height ratio. These findings indicate that the navicular bone rotation of the midfoot is a predictor of the descent of the navicular bone.

CONCLUSIONS

This study revealed that some children exhibit decreases in navicular bone height with growth. As a distinct feature, the inversion of the navicular bone promotes flattening of the midfoot. Thus, this study provides insights into changes in midfoot development in children and provides an effective evaluation index.

The resting calcaneal stance position (RCSP): an old dog, with new tricks

The objective of this study was to establish the accuracy of the resting calcaneal stance position (RCSP) for the assessment of flat foot (FF) in children, aligned to the validity of the foot posture index (FPI). The RCSP cut-off point was explored, in context of both FF prevalence and the relationship between FF and body weight. A total of 205 healthy children, aged 5 to 10 years, participated in a cross-sectional study. Correlation was performed between RCSP and FPI. ROC curve technique was calculated to assess differentiation between groups. A score equal to or greater than 7 on the FPI was used as the 'gold standard' for analysis. The correlation between FPI and RCSP was significant (r = 0.63; p < 0.01). The discrimination score on the ROC curve (6 points/degrees) shows that the model can be used to identify FF through RCSP, with a sensitivity of 67% and specificity of 85% returned.  Conclusion: The results of this study indicate the role of RCSP for simple, accessible and quick screening of paediatric FF. This is especially pertinent for non-podiatric healthcare professional without specialised paediatric foot knowledge. What is Known: • Most children develop a normal arch quickly, and flat feet usually resolve on their own between 2 and 6 years of age. • The measurement used to diagnose flat foot in children must be accurate, consistent, and valid to characterize the standard foot position. The Resting Calcaneal Stance Position (RCSP) is another widely used measure to evaluate the position of the flat foot in children. What is New: • The RCSP cut-off point 6 shows a sensitivity of 67% and a specificity of 85% thanks to the FPI as the Gold standard. • The RCSP is useful for health professionals who are not specialised in pediatric foot health. The RCSP is useful to detect flat foot in children.

Protocol Article: A Cross-Sectional Evaluation of Children's Feet and Lower Extremities

BACKGROUND

The health of children's lower extremities and feet is a focus area for caregivers and healthcare professionals such as doctors, school nurses, and podiatrists. Our study aims to investigate the general health status of Danish children's lower extremities and feet to identify anthropometric parameters that might be preconditions for pain and evaluate for foot diseases and whether they are associated with pain intensity and location, three-dimensional foot dimensions and foot pressure mapping, shoe dimensions, types and intensity of sports activity, quality of life, and foot health. The aim is that we will be able to identify parameters pre-dispositioning for pain, thus providing recommendations for sports activities in relation to the anthropometric conditions of a child as a potential preventive measure for pain. This analysis will be stratified by socioeconomic status on a group level, and this perspective will be able to provide preventative recommendations to prevent pain.

METHODS

This study is a cross-sectional examination of a thousand children in the first, fifth, and ninth grades in randomized selected Danish primary schools. We will perform a clinical examination of the lower extremities and feet for misalignments, deformities, and diseases as well as rotational status and range of motion. Moreover, we will evaluate their pain levels, sports activities, three-dimensional foot dimensions, plantar pressure, footwear, and patient-related outcome measures (PROMs) for foot health and quality of life.

RESULTS

We aim to provide an anthropometrical overview of the lower extremities and feet in children. The obtained basic understanding of healthy normal material in children will be analyzed for its relationships with pain level, sports activities, and socioeconomic status on a group level. This could potentially provide us with an understanding of the factors that impact lower extremity and foot diseases in children. In conclusion, examining children's lower extremities and feet in Danish primary schools is a step toward identifying areas of improvement in self-care and shoe fitting, mapping podiatry-related needs of care in children's feet, and providing parental recommendations for preventive actions on shoe fitting and the choice and intensity of sports activity concerning pain.

CONCLUSIONS

The tenet of this study is a long-term follow-up to evaluate the long-term socioeconomic course on a group level, foot status, and sports activity, using patient-related outcome measures evaluating quality of life and other lifestyle factors such as emotional functioning, social functioning and interaction, and school functioning. Potentially, this will improve children's quality of life and prevent future diseases.

Correlation analysis between body mass index and foot length in Chinese adolescents: a regional study

This study aims to analyse the relationship between body mass index and foot length in Chinese adolescents and to provide theoretical guidance for preventing a flat foot in Chinese adolescents. This study recruited 1477 students aged 14-23 years. The participants' height, weight, and body mass index were measured, as well as baseline data, including age, gender and foot length. Differences in foot length (bilateral) and flat foot distribution were statistically significant except for the normal foot and high arch foot distribution based on different body mass index groups. Linear correlation analysis demonstrated that body height, weight and body mass index were positively correlated with bilateral foot length regardless of gender. Body mass index acted as a risk factor for flat foot (bilateral) through disordered multi-classification logistic regression analysis. Body mass index was positively correlated with left and right foot length regardless of gender and acted as a risk factor for a flat foot in Chinese adolescents. Practitioner summary: Significant differences exist in the anthropometric data of various races and ethnic groups. The study was investigated in the form of a cross-sectional study. BMI was positively correlated with bilateral foot length and acted as a risk factor for a flat foot in Chinese adolescents.

The effect of biological maturation on foot morphology, and their relation to postural stability performance in male footballers

BACKGROUND

Biological maturity (BM) and foot morphology (FM) can independently alter neuromuscular loading on the ankle-foot complex, potentially causing stability deficits and injury predisposition. However, the influence of BM on FM, and how much both explain neuromuscular performance in postural stability (PS) tests, has been understudied. This study aimed to investigate the effect of BM on FM, and then discover to what extent both factors explain the variance in PS performance in adolescent footballers.

METHODS

Over one season, 399 three-dimensional foot scans were gathered from 72 footballers (U12-U15). PS was measured by center of pressure (COP) displacement in bilateral and unilateral stance. The Khamis and Roche equation determined maturity status (MS), while formulae from Mirwald and Khamis and Roche estimated timing of biological maturation (TBM). Principal component analysis determined nine principal components that explained the most variance in FM. An ANCOVA determined the effect of TBM on FM principal components, with covariates of age, height, weight, playing position, and foot preference. Step-wise linear regression determined the explanation of COP displacement by the above-mentioned predictors.

RESULTS

There was significantly increased foot pronation during and after peak height velocity/puberty. MS and four foot principal components (foot arch and width, great toe width and length) were significant predictors in all PS tests (R2: 0.105-0.180).

CONCLUSIONS

TBM had a significant effect on FM presentation, and should be a part of adolescent foot assessment. While they only explained a small amount of variance, determining MS and FM may identify those requiring additional PS attention.

Prevalence and Clinical Factors Associated With Pes Planus Among Children and Adults: A Population-Based Synthesis and Systematic Review

Estimates of pes planus ("flatfoot") prevalence vary considerably across studies. Moreover, there is uncertainty over which factors are associated with the pes planus prevalence. We aimed to systematically review the prevalence and clinical factors associated with flatfoot among children and adults. We searched Web of Science, PubMed/MEDLINE, and Google Scholar databases reporting population-based flatfoot prevalence. Two reviewers independently extracted the data and assessed the qualities of the studies. Subgroup analysis was conducted to analyze the associated factors on flatfoot prevalence. Frequencies, odds ratios (OR), and 95% confidence intervals (CI) were performed using descriptive analysis and chi-square test accounting for heterogeneity. Any conflict in the data analysis was discussed by all the reviewers. Twelve studies including 2509 flatfoot cases were analyzed (overall prevalence 15.6%, n = 16,000). The subgroup analysis indicated that male gender (OR = 1.26, 95% CI: 1.15-1.37), age groups 3 to 5 years (OR = 2.02, 95% CI: 1.78-2.30) and 11 to 17 years (OR = 1.91, 95% CI: 1.64-2.22), Asian race (OR = 2.34, 95% CI: 2.10-2.60), and obesity (OR = 2.62, 95% CI: 2.06-3.32) were more associated with flatfoot (p < .001). Conversely, female gender (OR = 0.44, 95% CI: 0.40-0.48) and White race (OR = 0.52, 95% CI: 0.47-0.57) were less associated with flatfoot (p < .001). Our findings may be valuable for clinical/surgical settings, particularly, for those modifiable findings and targeted populations. However, we suggest that future studies estimating flatfoot should consider prospective/multicenter designs using a common screening methods in random samples populations.

Prospective, Long-Term Functional Outcomes of Extra-Osseous Talotarsal Stabilization (EOTTS) Using HyProCure in Adult Patients with Talotarsal Joint Instability: Assessment of Physical Activity and Patient Satisfaction

BACKGROUND

The partial dislocation of the talus from the calcaneus and navicular bones is a primary factor leading to a prolonged overpronation during weightbearing. This study aimed to assess the possibility of returning to physical activity and long-term patient satisfaction after an extra-osseous talotarsal stabilization (EOTTS) procedure with a HyProCure sinus tarsi implant for partial talotarsal joint dislocation (TTJ).

METHODS

A total of 41 adult patients (61 feet), with an average age of 46.41, were included and treated surgically with EOTTS as a stand-alone surgery. Physical activity and functional scores were assessed pre- and post-operatively using questionnaires-the UCLA Activity Score, Symptom-Related Ankle Activity Scale (SAAS), Sports Frequency Score (SFS), Lower Extremity Functional Scale (LEFS), and VAS scale. Satisfaction was assessed on a ten-point scale. The follow-up period was on average 8.61 years (from 7.33 to 10.31).

RESULTS

EOTTS had a positive impact on physical activity, and a high rate of patient satisfaction (8.95 ± 1.9) was noted. The treatment led to a reduction in foot pain, as well as an increase in SAAS and LEFS scores (15,6% and 19,3%, respectively, p <0.01). The VAS pain score decreased by 18,6% (p <0.001). SFS and UCLA scores showed a small increase, but it was not statistically significant. A positive correlation was noted between patient satisfaction and time of physical activity per week (R = 0.33, p =0.04), and also between patient satisfaction and SAAS scores (R = 0.43, p =0.005). Pain from other joints (knee, hip) was eliminated or reduced in 40% of patients after surgery.

CONCLUSIONS

EOTTS with a HyProCure implant is an effective long-term treatment option for partial talotarsal joint dislocation, leading to a reduction in foot pain and increased patient satisfaction, and allowing for a return to physical activity.

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.

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.

Using surface markers to describe the kinematics of the medial longitudinal arch

BACKGROUND

Static and dynamic assessment of the medial longitudinal arch (MLA) is an essential aspect for measuring foot function in both clinical and research fields. Despite this, most multi-segment foot models lack the ability to directly track the MLA. This study aimed to assess various methods of MLA assessment, through motion capture of surface markers on the foot during various activities.

METHODS

Thirty general population participants (mean age 20 years) without morphological alterations to their feet underwent gait analysis. Eight measures, each representing a unique definition of the MLA angle using either real only, or both real and floor-projected markers, were created. Participants performed tasks including standing, sitting, heel lift, Jack's test and walking, and had their Arch Height Index (AHI) measured using callipers. Multiple-criteria decision analysis (MCDA) with 10 criteria was utilised for selecting the optimal measure for dynamic and static MLA assessment.

RESULTS

In static tasks, the standing MLA angle was significantly greater in all measures but one when compared to sitting, Jack's test and heel lift. The MLA angle in Jack's test was significantly greater than in heel lift in all measures. Across the compared dynamic tasks, significant differences were noted in all measures except one for foot strike in comparison to 50% gait cycle. All MLA measures held significant inverse correlations with MLA measured from static and dynamic tasks. Based on MCDA criteria, a measure comprising the first metatarsal head, fifth metatarsal base, navicular and heel markers was deemed the best for MLA assessment.

SIGNIFICANCE

This study aligns with the current literature recommendations for the use of a navicular marker for characterising the MLA. It contrasts with previous recommendations and advocates against the use of projected markers in most situations.

How to Define Pediatric Flatfoot: Comparison of 2 Methods: Foot Posture in Static and Dynamic Conditions in Children 5 to 9 Years Old

LEVELS OF EVIDENCE

Prospective cohort study.

Foot orthoses for flexible flatfeet in children and adults: a systematic review and meta-analysis of patient-reported outcomes

BACKGROUND

This systematic review and meta-analysis examined the effectiveness of orthoses for flexible flatfeet in terms of patient-reported outcomes in children and adults.

METHODS

EMBASE, Medline (OvidSP), Web-of-Science, Scopus, CINAHL, Cochrane Central Register of Controlled Clinical Trials, i.e., Cochrane Central and Pubmed were searched to identify relevant studies since their inception up to February 2021. We included randomized controlled trials (RCT) and prospective studies in which patient reported outcomes at baseline and follow-up in an orthoses group were compared with a no orthoses or sham sole group. Methodological quality of the studies was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) and the Risk Of Bias In Non-Randomized Studies of Interventions (ROBINS-I). A meta-analysis was performed where there were multiple studies with the same outcome measures, which was the case for the Visual Analogue Scale (VAS) for pain in adults.

RESULTS

In total nine studies were included: four RCT in children (N = 353) and four RCT and one prospective study in adults (N = 268) were included. There was considerable heterogeneity between studies. A meta-analysis demonstrated that pain reduction between baseline and follow-up was significantly larger in the orthoses (N = 167) than in the control groups in adults (N = 157; - 4.76, 95% CI [- 9.46, - 0.06], p0.05).

CONCLUSION

Due to heterogeneity in study designs, we cannot conclude that foot orthoses are useful for flexible flatfoot in children and adults. However, based on the meta-analysis orthoses might be useful in decreasing pain in adults. The authors did not receive support from any organization for the submitted work.

Foot morphology and correlation with lower extremity pain in Japanese children: A cross-sectional study of the foot posture Index-6

BACKGROUND

Abnormal foot morphology in children and adolescents is a possible risk factor for lower extremity pain. Foot posture index-6 (FPI-6) is a valid and reliable tool to assess foot morphology. However, the normative data on the age distribution for FPI-6 in Asian children and adolescents are still minimal. Further, the correlation of FPI-6 with lower extremity pain is poorly understood. We aimed to investigate the normative distribution for FPI-6 and the relationship between FPI-6 scores and knee and heel pain in Japanese children.

METHODS

We included 2569 Japanese children, aged 9-15 years, at a single school from 2016 to 2018. We summarized the age distribution of children and their mean bilateral FPI-6 scores. Additionally, we assessed the tenderness at the apophysis or tendon insertions at the knee and heel. We performed a cross-sectional analysis to investigate the correlations between FPI-6 scores and sex, age, and knee and heel pain for the data obtained each year.

RESULTS

The mean FPI-6 score was 3.1 ± 2.4, 3.4 ± 2.0, and 3.2 ± 1.9 for the left foot and 3.0 ± 2.4, 3.2 ± 1.9, and 3.1 ± 1.9 for the right foot in 2016, 2017, and 2018, respectively. Boys tended to have higher scores than girls, and the FPI-6 score of the left foot was significantly higher than that of the right foot (p < 0.05). There was no correlation between FPI-6 scores and knee and heel pain.

CONCLUSION

Children and adolescents between 9 and 15 years of age have neutral to slightly pronated foot morphology and an average FPI-6 score of 3.0-3.4. In addition, there was no relationship between foot morphology and knee and heel pain. This normative distribution for FPI-6 in Japanese children could serve as a reference value for future research and clinical evaluation.

Age differences in running biomechanics during footstrike between preschool children and adults

This study aimed to compare impact loading between two age groups of preschool children (3-4 and 5-6 years old) and one group of young adults representing mature level of running skill (n = 15 per group). Three-dimensional biomechanical data were collected during running barefoot, in minimalist and running shoes. A two-way mixed ANOVA was performed to assess age and footwear differences in vertical instantaneous loading rate (VILR). An interaction was found in VILR. Older (5-6) preschoolers had 30-31% lower VILR than younger (3-4) (p = 0.012, d = 1.02; p = 0.001, d = 1.18) and adults had 51-77% lower VILR than younger preschoolers (p = 0.001, d = 1.85; p = 0.001, d = 2.82) in minimalist and running shoes, respectively. Additionally, adults had lower VILR than older preschoolers in running shoes (p = 0.001, d = 2.68). No differences were found between older children and adults in barefoot and minimalist shoes. Loading decreased with increasing age, particularly in minimalist and running shoes. Unchanged cadence and running speed did not explain the decrease of VILR during preschool age. The explanation likely underlies in lower limb alignment during footstrike and developmental ontogenetic changes.

Characteristics of paediatric foot arches according to body mass among primary school students in Wrocław, Poland

Background

The purpose of this study, conducted within the framework of the project entitled ‘Let’s get the kids moving’, was to determine the associations between children’s longitudinal and transverse foot arch and their weight, gender and age.

Method

The pro-health initiative ‘Let’s get the kids moving’ was created by researchers of the Medical University and the Run for Health Foundation. A total of 655 children (51.5% boys) aged 7 to 10 years from primary schools in south-western Poland participated in the study. The mean age of the subjects was 8.7 ± 0.8 years. In all the children, we assessed anthropometric measurements (weight and height) and the longitudinal and transverse arch of the foot under the load of their weight. A two-dimensional foot scanner (Sensor Medica, Italy) was used to examine the plantar part of the children’s feet.

Results

The data collected from the 655 subjects revealed that excessive weight predisposed them to less longitudinal and transverse arching. The foot shape was not differentiated by gender or age.

Conclusions

Screening school-aged children’s footprints can detect abnormalities in the shape of children’s feet early on, which allows for early diagnosis of functional or structural flatfoot in children.

Diagnostic Accuracy of Various Radiological Measurements in the Evaluation and Differentiation of Flatfoot: A Cross-Sectional Study

Arch angle is used to indicate flatfoot, but in some cases, it is not easily defined. The presence of flatfoot deformity remains difficult to diagnose due to a lack of reliable radiographic assessment tools. Although various assessment methods for flatfoot have been proposed, there is insufficient evidence to prove the diagnostic accuracy of the various tools. The main purpose of the study was to determine the best radiographic measures for flatfoot concerning the arch angle. Fifty-two feet radiographs from thirty-two healthy young females were obtained. Five angles and one index were measured using weight-bearing lateral radiographs; including arch angle, calcaneal pitch (CP), talar-first metatarsal angle (TFM), lateral talar angle (LTA), talar inclination angle (TIA) and navicular index (NI). Receiver-operating characteristics were generated to evaluate the flatfoot diagnostic accuracy for all radiographic indicators and Matthews correlation coefficient was calculated to determine the cutoff value for each measure. The strongest correlation was between arch angle and CP angle [r = -0.91, p ≤ 0.0001, 95% confidence interval (CI) (from -0.94 to -0.84)]. Also, significant correlations were found between arch angle and NI [r = 0.62, p ≤ 0.0001, 95% CI (0.42 to 0.76)], and TFM [r = 0.50, p ≤ 0.0001, 95% CI (from 0.266 to 0.68)]. Furthermore, CP (cutoff, 12.40) had the highest accuracy level with value of 100% sensitivity and specificity followed by NI, having 82% sensitivity and 89% specificity for the cutoff value of 9.90. In conclusion, CP angle is inversely correlated with arch angle and considered a significant indicator of flatfoot. Also, the NI is easy to define radiographically and could be used to differentiate flat from normal arched foot among young adults.

Advanced practice physiotherapy in paediatrics: Implementation results

Objectives

This study aimed to evaluate the implementation of an advanced practice physiotherapist (APP) clinic in our paediatric institution and assess APP and orthopaedic surgeon satisfaction.

Methods

In this retrospective cohort study, all patient records from the APP clinic's second year (March 2017 to March 2018) at CHU Sainte-Justine were reviewed. These were compared with the records of patients seen by orthopaedic surgeons within the gait clinic the year before implementing the clinic. The following data were collected: demographic, professional issuing referral, reason for referral, consultation delay, clinical impression, investigation, and treatment plan. We also documented every subsequent follow-up to rule out any diagnostic change and identify surgical patients. Clinician satisfaction was assessed by the Minnesota Satisfaction and PROBES Questionnaires along with a short electronic survey.

Results

Four hundred and eighteen patients were assessed by APPs and 202 by orthopaedic surgeons. APPs managed patients independently in 92.6% of cases. Nearly 86% of patients were discharged following the initial visit, and 7.4% were referred to a physiotherapist. Only 1% of APP patients eventually required surgery compared with nearly 6% in the orthopaedic group. The mean waiting time for consultation was greater in the APP group (513.7 versus 264 days). However, there was a significant reduction in mean waiting time over the last 3 months surveyed (106.5 days).

Conclusions

The feedback from all clinicians involved was positive, with a greater mean score on the Minnesota Satisfaction and PROBES Questionnaire for APPs. The APP gait clinic appears to be an effective triage clinic.

Level of evidence

III.

Age-related changes in three-dimensional foot motion during barefoot walking in children aged between 7 and 11 years old

BACKGROUND

The biomechanical complexity of children's feet changes throughout childhood, yet kinematic development of the feet is poorly understood. Further work exploring the kinematic profile of children's feet would be beneficial to help inform our understanding of the typical development of children's feet.

RESEARCH QUESTION

Do three-dimensional segmental kinematics of the feet during gait relate to age in a sample of children age 7-11 years?

METHODS

This study was a secondary analysis of an existing database representing one hundred and twenty-one children age 7 - 11 years (90 male, 31 female; mean ± SD: age 9.57 ± , 1.17 years, height 1.37 ± 0.08 m, body mass 35.61 ± 9.33 kg). Fifteen, 9 mm retroreflective markers were attached to the right shank and foot of each participant in, line with the 3DFoot model. Multi-segmental joint kinematics were collected during barefoot walking. Sagittal, frontal, and transverse planar motion was described for the shank-calcaneus, calcaneus-midfoot, and midfoot-metatarsals segment of the right foot. Principal component analysis (PCA) was used to reduce the major modes of variation in the data to fully explore foot segment motion over the entire gait cycle. Correlations and multiple regression between PCA outputs with age, and potential confounding factors are presented.

RESULTS

Significant positive correlations were found between age and greater calcaneus, dorsiflexion, midfoot inversion and adduction, and metatarsal dorsiflexion, plantarflexion and abduction. There were no significant confounding effects of height, body mass, walking speed or gender on the relationships between age and PCA outputs.

SIGNIFICANCE

The findings from this study demonstrated a relationship between foot kinematics and age suggesting that the development of foot kinematics is ongoing until at least the age of 11 years. This work offers a comprehensive data set of inter-segmental kinematics which helps to advance understanding of the development of the pediatric foot.

Measurement of the Developing Foot in Shod and Barefoot Paediatric Populations: A Narrative Review

The theory that footwear may change foot shape dates back 100 years. Since this period, research has revealed the anatomical and functional consequences that footwear can cause to the foot. Children’s feet remain malleable as they undergo developmental changes until adolescence, which is why childhood is arguably a crucial period to understand how footwear can affect natural foot development. This review explored the development of the foot in children and adolescents and the methods used to measure the different foot structures; it comments on the key issues with some of these methods and gives direction for future research. Various internal and external factors can affect foot development; the main factors are age, gender, ethnicity, body mass index (BMI) and footwear habits. Research on how footwear can affect foot development has increased over the years and the final section of this review aimed to unpick the findings. Studies investigating the influence of footwear habits on foot length and width have established inconsistent findings. Many of the studies in the review did not control for internal and external factors that can affect foot development. There was also a limited number of studies that investigated hallux valgus angle and muscle strength differences in those with different footwear habits. Moreover, multiple studies in the final section of this review did not successfully examine the footwear habits of the participants and instead used observations or self-assessments, which is a major limitation. Future research should examine footwear behaviors and other confounding factors when investigating the development of the foot in children and adolescents. Moreover, researchers should critically evaluate the methods used to quantify the different structures of the foot to ensure valid and reliable parameters are being used.

HyProCure for Pediatric Flexible Flatfoot: What Affects the Outcome

BACKGROUND

The high success rate, minimal invasion, and safety of subtalar arthroereisis (SA) have made it a primary mode of surgical management for pediatric flexible flatfoot. The HyProCure procedure is a new surgery for SA, However, very few available studies reported the therapeutic effects of the HyProCure procedure, especially in pediatric flexible flatfoot. The main aim of the present study was to investigate the clinical and radiological outcomes of the HyProCure procedure for pediatric flexible flatfoot and analyze the risk factors for therapeutic outcomes and sinus tarsi pain.

METHODS

In this retrospective cohort study, 69 pediatric flexible flatfoot patients (107 feet) who underwent the HyProCure procedure were included between July 2015 and September 2020. All patients underwent the HyProCure procedure with or without gastrocnemius recession. The Maryland foot score (MFS), visual analog scale (VAS), radiographic data, and complications were assessed at a minimum 1-year follow-up and statistically analyzed.

RESULTS

The mean follow-up was 35.9 months (range, 13-73 months). At the last follow-up, VAS (0.64 ± 1.16) was significantly lower than the preoperative VAS (4.06 ± 1.43) (p < 0.001); MFS (90.39 ± 12.10) was significantly higher than the preoperative MFS (71.36 ± 10.25) (p < 0.001). The AP talar-second metatarsal angle (T2MT angle) significantly decreased from 17.0 ± 5.4° preoperatively to 11.4 ± 5.2° at the last follow-up (p < 0.001). The lateral talar-first metatarsal angle (Meary's angle) significantly decreased from 13.8 ± 6.4° preoperatively to 6.3 ± 5.0° at the last follow-up (p < 0.001). The calcaneal declination angle (Pitch angle) significantly increased from 13.5 ± 4.9° preoperatively to 14.8 ± 4.4° at the last follow-up (p < 0.001). Logistic regression analysis indicated that patients with a longer distance from the tail end of the implant exceeding the longitudinal talar bisection line had 275.8% greater odds of MFS < 90. Yet, no risk factors were found in connection with sinus tarsi pain.

CONCLUSIONS

The HyProCure procedure for pediatric flexible flatfoot achieved satisfactory curative effects with a low complication rate; implant depth was associated with unsatisfactory postoperative outcome.

An association between excessive valgus hindfoot alignment and postural stability during single-leg standing in adolescent athletes

BACKGROUND

Diminished balance is associated with the incidence of ankle and lower extremity injuries in adolescents. Although flexible flatfoot is a common foot condition in pediatric and adolescent populations, the association between balance control and foot morphology remain unclear in adolescent athletes.

METHODS

Rearfoot angle in the double-limb standing position, body mass index (BMI), and isometric muscle strength related to the knee joint were retrospectively reviewed in 101 adolescent athletes (75 boys and 26 girls) with a mean age of 14.0 years (range 12-17). Postural stability during single-leg standing on static and dynamic platforms was investigated using Balance System SD in 119 feet without functional ankle instability. The participants were divided according to their rearfoot angle into control (less than 7°) and valgus (greater than or equal to 7°) groups. The measured parameters were compared between the control and valgus groups using Welch's t-test, and P values < 0.05 were considered statistically significant. Multiple regression analysis was conducted to identify the factors that significantly influenced postural control.

RESULTS

The average rearfoot angle was 4.6° in all participants. An excessive valgus rearfoot angle was detected in 53 feet (26.2%). No significant difference was found between the groups in terms of BMI and isometric knee muscle strength. Although no statistical differences were observed in postural stability on the static platform between the control and valgus groups, the valgus group demonstrated poorer postural stability for single-leg standing on the dynamic platform. Multiple regression analysis revealed that BMI and rearfoot angle were significantly associated with a poor postural control on the dynamic platform.

CONCLUSIONS

Our findings suggest that excessive rearfoot valgus specifically contributes to the deterioration of postural stability in adolescent athletes, and that rearfoot alignment should be evaluated for the adolescent population to prevent sports-related lower extremity injury.

The typically developing pediatric foot - The data of the 1744 children in China

BACKGROUND

The medial longitudinal arch (MLA) improves with age in childhood. However, it still causes parents to worry that children have flat feet. Due to the lack of a standard to quantitatively assess the arch development in kids at certain age, the pediatricians judge the flat feet by experience, causing many cases to be overtreated. The aim of this study was to plot the distribution of MLA parameters in children.

METHODS

Children without lower limb deformity and lower limb pain were recruited from 12 primary schools and kindergartens in Chongqing province-level city. Foot length (FL) and navicular height (NH) was measured manually, arch index (AI) and arch volume (AV) were measured with the Foot Plantar Scanner. Each parameter was measured in both weight-bearing and non-weight-bearing positions. Significant differences were also compared between the measurements of consecutive years.

RESULTS

This study was the first to use a three-dimensional laser surface scanner to measure the MLA parameters of children aged 3-12 years in China. 1744 children (871 girls, 873 boys) participated in this study. FL, NH, AI and AV varied significantly with age in both the weight-bearing and non-weight-bearing positions. These parameters have significant differences between the weighted and non-weighted positions (p < 0.05).

CONCLUSIONS

The age distribution characteristics of these parameters indicated that the MLA improves with age. The establishment of a developmental scale for the children's MLA is necessary.

Effect of Plano-Valgus Foot on Lower-Extremity Kinematics and Spatiotemporal Gait Parameters in Children of Age 5–9

Aim of the study was to see how a definition of the flexible flat foot (FFF) influences the results of gait evaluation in a group of 49 children with clinically established FFF. Objective gait analysis was performed using VICON system with Kistler force platforms. The gait parameters were compared between healthy feet and FFF using two classifications: in static and dynamic conditions. In static condition, the ink footprints with Clarke’s graphics were used for classification, and in dynamic condition, the Arch Index from Emed pedobarograph while walking was used for classification. When the type of the foot was based on Clarke’s graphics, no statistically significant differences were found. When the division was done according to the Arch Index, statistically significant differences between flat feet and normal feet groups were found for normalized gait speed, normalized cadence, pelvic rotation, ankle range of motion in sagittal plane, range of motion of foot progression, and two parameters of a vertical component of the ground reaction force: FZ2 (middle of stance phase) and FZ3 (push-off). Some statically flat feet function well during walking due to dynamic correction mechanisms.

Characteristics of inhomogeneous lower extremity growth and development in early childhood: a cross-sectional study

BACKGROUND

Early childhood is a transferring stage between the two accelerated growth periods (infant and adolescent). Body dimensions are related to physical growth and development. The purpose of this study was to investigate physical growth in terms of anthropometry, muscle growth of the lower extremity, and functional development over early childhood.

METHODS

A cross-sectional study was carried out on 29 preschool children (PS: 3-5 years), 21 school children (SC: 6-8 years), and 22 adults (AD: 20-35 years). Lower extremity characteristics (segmental dimensions, muscle and adipose tissue thicknesses of the thigh and lower leg), and voluntary joint torque (knee and ankle) were measured. Correlations between parameters and group comparisons were performed.

RESULTS

All the parameters except for body mass index (BMI) and subcutaneous adipose tissue thickness were correlated with age for PS and SC combined (r = 0.479-0.920, p < 0.01). Relative thigh and shank lengths to body height were greatest in AD and smallest in PS (p < 0.05) but the relative foot dimensions were significantly larger in PS and SC than in AD (p < 0.05). Relative subcutaneous adipose tissue thickness was largest in PS and lowest in AD. Muscle thickness and the muscle volume measure (estimated from muscle thickness and limb length) were significantly larger in older age groups (p < 0.05). All groups showed comparable muscle thickness when normalized to limb length. Joint torque normalized to estimated muscle volume was greatest for AD, followed by SC and PS (p < 0.05).

CONCLUSIONS

Relative lower extremity lengths increase with age, except for the foot dimensions. Muscle size increases with age in proportion to the limb length, while relative adiposity decreases. Torque-producing capacity is highly variable in children and rapidly develops toward adulthood. This cross-sectional study suggests that children are not a small scale version of adults, neither morphologically nor functionally.

Non-radiographic validity and reliability measures for assessing foot types: A systematic review

BACKGROUND

Foot type classification is well recognized in clinical practice and orthopedic literature, a universally accepted classification or standardized measures to determine foot types are lacking. The objective of this study was to identify which non-radiographic assessment methods are considered valid and/or reliable for the classification of foot types.

METHOD

A systematic database search was performed. Only cross-sectional studies that performed reliability and/or validity analysis of non-radiographic methods were included. To evaluate the risk of bias, the Critical Appraisal Tool (CAT) was used to evaluate the measurement properties of objective clinical methods.

RESULTS

Twenty-six studies were included. The results of reliability and validity, in general, demonstrated high scores, but, inconsistencies were related to the variability of the measurements, heterogeneity of the methods used to determine reliability and validity, and lack of parameters for classifying foot types, which resulted in few elements to determine which method of foot type evaluation is valid and reliable.

CONCLUSION

Given the Intraclass Correlation Coefficient and CAT results and the presence of normative values, the static measurements of the "Arch Height Index", "Foot Posture Index", and "Staheli Arch Index" can be suggested to classify foot types.

Bony Procedures for Correction of the Flexible Pediatric Flatfoot Deformity

The pediatric flexible flatfoot is a common foot shape that is most often asymptomatic and may be a physiologic variant of normal. Surgery is only indicated when nonoperative interventions have failed to resolve symptoms. The goal of surgery is to alleviate symptoms by improving hindfoot alignment and restoring the medial arch while preserving joint mobility. This article focuses on the common bony techniques for surgical correction of the pediatric flexible flatfoot that has failed nonoperative management, including calcaneal, midfoot, and supramalleolar osteotomies and distal tibial hemiepiphyseodesis.

Ilizarov Technique in Severe Pediatric Foot Disorders

The treatment of foot disorders in pediatric age with Ilizarov method is reserved for complex cases, cases in which it is not possible to perform acute corrections or cases that need bone and soft-tissue lengthening. Ilizarov method permits to correct any deformity. Correction can be achieved progressively with a closed procedure or combining the external fixator with a treatment involving soft or bone tissues. Complications are frequent; however, most of them do not affect the outcome of the treatment.

The Relationship between Foot Status and Motor Status in Preschool Children: A Simple, Comparative Observational Study

Background: The research objective of the study is to determine the differences in the manifestation of the motor status of normally fed preschool test subjects, classified into groups according to foot status. Methods: This is a simple, comparative observational study. Preschool children included in this study have been subjected to anthropometric measurements in order to determine BMI, tests for motor skills assessment (running at 20 m from a high start, standing broad jump, backwards polygon, rectangular seated forward bend, plate tapping, sit-ups for 60 s, and bent arm hang), and a determination of foot status. The total sample was comprised of 202 test subjects who attended a regular sports program, aged 3.9 to 6.5 years of decimal age (M = 141; Age = 5.3 ± 0.74; Height = 117.3 ± 7.1; Weight = 22 ± 3.7; F = 61; Age = 5.1 ± 0.73; Height = 114.9 ± 7.4; Weight = 21.2 ± 3.8), of which 153 (75.7%) were normally fed, 6 (3%) were undernourished, 30 were overweight (14.9%), and 13 were obese (6.4%). Results: In the total sample, 30 (14.9%) subjects had normal arch feet, 90 (44.6%) high arched feet, and 41 (20.3%) flat feet. We found 41 (20.3%) subjects who had different left and right foot statuses within this sample. The data were processed by means of nonparametric tests (the Kruskal–Wallis and Mann–Whitney U tests) at a significance level p ≤ 0.05. Conclusion: The results show that there is a statistically significant difference between groups of subjects with different foot statuses in the manifestation of motor status in most tests, with a significance level of p ≤ 0.01, and in tests of sit-ups for 60 s and the bent arm hang, there is a statistically significant difference, the level of which is p ≤ 0.05. It is only in the inclination test of rectangular seated forward bend that no statistically significant difference was displayed.

Foot orthoses use for pediatric flexible flatfoot: comparative evaluation of quality of life for children and parents

This study aimed to comparatively evaluate the quality of life scores of patients with pediatric flexible flatfoot (PFF) according to the use of foot orthoses. We also aimed to compare quality of life scores of children and their parents. Nonobese children aged between 5 and 10 years old who were diagnosed as PFF according to physical and radiological examinations were included in this cross-sectional comparative study. All children and their parents completed the Turkish translation of Oxford ankle foot questionnaire (OxAFQ) which contains four domains (physical, school and play, emotional, and footwear). Patients were grouped according to the use of foot orthoses (group I: no foot orthoses group and group II: foot orthoses group). Comparison of OxAFQ scores demonstrated no significant differences between the two groups. However, the mean emotional scores of parents were significantly lower in group II (P = 0.007). In group I, the mean emotional score of children was significantly lower compared to their parents' scores (P = 0.001). In group II, the mean physical score of children was significantly lower compared to their parents' scores (P = 0.003). According to our results, we observed no significant difference in terms of quality of life scores between children using foot orthoses and not using foot orthoses. However, we observed significantly lower emotional scores in parents whose children were using foot orthoses. We recommend that physicians should be aware of low physical scores in children with PFF and should inform parents about this situation rather than considering foot orthoses to relieve parents' concern about foot deformity.

Comparison of multiple flatfoot indicators in 5-8-year-old children

Background

The foot posture is age dependent. The purpose of this study was to investigate the relationship between the 6-item version of the foot posture index (FPI) and other clinical, foot anthropometric, radiological measurements for the foot position in 5–8-year-old children.

Methods

A total of 301 participants with a mean age of 6.4  ±  1.14 years were enrolled in the study. Children were examined physically, clinically, and radiologically to measure the FPI and navicular drop (ND) test, resting calcaneal stance position (RCSP) angle, Chippaux–Smirak index (CSI), Staheli index (SI), calcaneal pitch (CP) angle, talocalcaneal angle (TCA), and the first lateral metatarsal angle. Tibial torsions, internal rotation of the hip as an indirect method of femoral anteversion, and Beighton scale were analyzed for factors associated with flatfoot prevalence.

Results

The study included children with normal and flexible flatfeet. Statistical analysis showed a significant FPI score correlation with other parameters (SI, CSI, RCSP, ND, CP, TMA, and TCA showed strong and moderate correlations, p < 0.001). Overall, the strongest associates are CSI (β = 0.34) and ND (β = 0.28). Other indicators have relatively small relationships with the FPI.

Conclusion

A positive correlation was observed between FPI-6 and ND test, CSI in 5–8-year-old children. All three prominent foot posture indicators (FPI-6, ND, and CSI) might be used as a primary or preferred tool in clinical practice.

Lateral Ankle Sprains and Their Association with Physical Function in Young Soccer Players

Purpose

Lateral ankle sprain (LAS) in childhood can result in lateral malleolus avulsion fractures; additionally, bone nonunion may occur. Physical maturity relates to the development of bone morphology and physical functionality. It is unknown how changes in physical functionality attributable to physical maturity affect young soccer players with abnormal lateral malleolus (ALM) morphology. Hence, the present study aimed to investigate the bone morphology of the lateral malleolus in young soccer players and to examine its relationship with physical functionality at different maturity levels.

Subjects and Methods

Two hundred and ninety young soccer players aged 6–15 years were included. The presence of ALM was assessed using ultrasonography. The subjects were allocated to three groups based on physical maturity (Pre-, Mid-, and Post-peak height velocity age [PHVA]). The prevalence of ALM and the relationship between ALM and physical maturity were examined for body composition, foot pressure distribution, foot alignment, ankle mobility, and single-leg balance.

Results

The prevalence of ALM was 17.6%. For physical maturity, the post-PHVA group showed a decrease in ankle dorsiflexion and eversion and an increase in one-leg hop distance compared to the Pre-PHVA group (P < 0.05). In the ALM group, the center of pressure during heel raising was distributed laterally in the Post-PHVA (P < 0.01), and the weight-bearing dorsiflexion angle was decreased in the Mid- and Post-PHVA (P < 0.05).

Conclusion

In the Post-PHVA young soccer players, decreased ankle dorsiflexion and eversion and increased one-leg hop distance were observed. The ALM group exhibited lateral loading during heel raising in the Post-PHVA group and decreased weight-bearing ankle dorsiflexion angle in the Mid- and Post-PHVA groups. The findings indicate the importance of secondary prevention of LAS and ultrasonography. Prospective studies of LAS in young athletes are required in the future.

Is it possible to define reference values for radiographic parameters evaluating juvenile flatfoot deformity? A case-control study

Background

Numerous radiographic parameters are described to evaluate juvenile flexible flatfeet. Reference values for these measurements are based on few studies. The purpose of this study was to determine boundary values among the most widely used radiographic measurements to evaluate juvenile flatfeet.

Methods

Twenty-two patients with normal hind-, midfoot configuration (group A: control group; 22 ft, mean age: 12,1 years) and 19 patients with flatfoot deformity (group B: study group; 22 ft, mean age: 12,4 years) were retrospectively analyzed. Nine radiographic parameters were measured (Talocalcaneal-angles, Calcaneal-pitch-angle, Costa-Bartani-angle, Talo-metatarsal-I-angles, Talo-first-metatarsal-base-angle, Talo-navicular-coverage, Calcaneus-fifth-metatarsal-angle). ROC curve analysis was used to calculate optimal differentiating thresholds of each parameter.

Results

Four out of nine parameters (TC-dp, TC-lat, Calc-MTV, Calc-P) were not statistically different between the groups and their ability to distinct between normal foot and flatfoot was low (AUC values = 0,660 - 0,819). Calculation of reference values for these parameters was not performed due to threshold ranges between the groups of > 10°. Reference values could be defined only for three parameters: TMTInd >(−)31°, TMTIB >(−)7,5°, TMT-lat > (−)13,5°. The TMTInd was shown to be a very reliable and valid combination of two measurements (TMTIB and TMT-lat) in the differentiation of normal feet and flatfeet (AUC = 0,998).

Conclusion

The calculation of reference values for established radiographic parameters used to evaluate juvenile flatfeet is difficult for most parameters. The TMTInd as a combination of TMTIB and TMT-lat has been shown to be reliable and valuable to distinct normal feet from flatfeet.

Flat foot at 5 to 6-year-old and history of delayed walking

  Background Flat foot, also known as pes planus, is a common problem in daily pediatric practice. For most children, this physiologic condition gradually disappears with age. However, flat foot that persists after the age of four might have developmental coordination disorder in the future and it may relate to the history of delayed walking . Objective To determine the prevalence of delayed walking in children with pes planus compared to children with normal foot curvature and to assess for a possible association between flat foot and history of delayed walking. Methods This cross-sectional study was done in 120 children aged 5-6 years. Foot curvature was evaluated by wet footprint test. Inclusion criteria include children in 3 playgroups in Tangerang from January to August 2018, in children aged 5-6 years. Children with history of neurologic diseases, genetic disorders, chronic diseases, disorders of the lower extremities except pes planus, and obesity were excluded. Grading of pes planus refers to Olivier et al. criteria and evaluation of delayed walking at 18-month-old was done through history taking from their parents. Results Of 120 children, 41 (34.2%) had pes planus while 11 (9.2%) had a history of delayed walking. Of those 11 children, 9 had pes planus. Most children with pes planus had grade I (78%). There was a significant association between pes planus and delayed walking (OR=10.8; 95%CI 2.2 to 52,9; P=0.001;). Conclusion In 5-6-year-old children, there is a significant association between pes planus grade 2 & 3 and history of delayed walking early in life. Wet footprint test screening for children with a history or signs of delayed walking may be used to identify pes planus in order to implement treatment in a timely manner.

Flatfoot and associated factors among Ethiopian school children aged 11 to 15 years: A school-based study

BACKGROUND

The Foot health of a child plays a pivotal role in their participation in play, locomotive activities, healthy lifestyle, somatic development, and weight management. The burden of flatfoot among children in Ethiopia is not known. The objective of this study was to analyze the structure of the medial foot arch using Staheli plantar arch index and investigate its associated factors among larger sample school children, aged 11-15 years in Ethiopia.

METHODS

A school-based cross-sectional study was conducted among children aged 11-15 years from eleven randomly selected primary schools. The sample size was determined proportionally across school strength and governmental and private schools to ensure variety within the sample. Data collection consisted of physical measurements, footprint-based measures whilst full weight-bearing, and a structured questionnaire on foot pain, footwear type, and physical activity. Data were analyzed descriptively and through uni- and multivariate logistic regression model.

RESULTS

A total of 823 children participated. The overall prevalence of flatfoot was 17.6% with a significant difference between age, gender, type of school, BMI, and type of footwear. Being younger (OR 3.3, 95% CI 1.6-6.7), male (OR 1.6, 95% CI 1.0-2.4), experiencing foot pain (OR 1.9, 95% CI 1.0-3.5), wearing closed shoe (OR 4.4, 95% CI 1.6-11.9), overweight (OR 3.8, 95% CI 1.2-8.7), obese (OR 4.2, 95% CI 2.5-10.9), and low level of physical activity (OR 2.1, 95% CI 1.0-4.6) were significantly associated with flatfoot. Children who were overweight, obese, and also experiencing foot pain have a 2.8 (95% CI 1.62-5.94) and 4.1 (95% CI 2.85-8.31) times greater chance of having flatfoot respectively. The prevalence of flatfoot among 560 normal weight children was 17.5%.

CONCLUSIONS

The findings of this study demonstrated that the overall prevalence and the prevalence of flatfoot among normal-weight children are almost the same. There is a definite need to develop a screening algorithm for diagnosis and treatment indication for this children's lower extremity disorder.

Functional and Radiological Outcomes Following Calcaneo-Cuboid-Cuneiform Osteotomy for the Treatment of Planovalgus Feet: A Short-Term Analysis

INTRODUCTION

Flexible flatfoot refers to the loss of the medial longitudinal arch of the foot on weight bearing and is associated with excessive heel eversion or forefoot abduction. Unless symptomatic, flexible flatfeet are best managed non-operatively. The calcaneo-cuboid-cuneiform osteotomy is a procedure that restores the anatomical shape of the foot without arthrodesis of the joints. Our study aims to evaluate the functional and radiological outcomes of patients treated with calcaneo-cuboid-cuneiform osteotomy in patients with planovalgus feet.

METHODOLOGY

A retrospective review of records and radiographs of patients with symptomatic flexible planovalgus feet, who were operated with the calcaneo-cuboid-cuneiform osteotomy by a single senior surgeon in a time period between April 2016 and July 2017 was done. The clinical and radiological outcomes were evaluated in 12 feet in 8 children.

RESULTS

A total of 12 feet in 8 children were operated (6 males and 2 females). Average age of patients was 11 ± 1.27 years; average follow up was 14.7 months ± 2.7 months. Two patients had planovalgus feet secondary to spastic diplegia and 6 had idiopathic planovalgus feet. There was a statistically significant improvement in the pain score as well as the radiographic parameters in all the operated patients.

CONCLUSION

The calcaneo-cuboid-cuneiform osteotomy has potential to give good results for symptomatic planovalgus feet with minimal complications.

Effectiveness of therapeutic footwear for children: A systematic review

BACKGROUND

It is estimated that 2% of the global childhood population is living with some form of mobility impairment. Although footwear interventions are proposed to aid ambulation, there appears to be a paucity in the understanding of the effects of therapeutic footwear. This review aims to explore the effectiveness of footwear as an intervention for mobility impairment in children.

METHODS

A systematic search of MEDLINE, CINAHL, PubMed, SPORTdiscus and Scopus databases were performed. Studies which focused on children with some form of mobility impairment, age of 9 months to 18 years, therapeutic footwear that allowed walking, and outcome measures that had explored biomechanical or skeletal geometry or psychosocial aspects were included in this review. Modified Downs and Black quality assessment index of randomised and non-randomised studies were used to assess the methodologies of included papers.

RESULTS

Out of 5003 articles sourced, 13 met the inclusion criteria for this review. These were grouped into two titled "corrective and "functional" based on the types of footwear used for intervention. Studies within the corrective footwear group included participants aged 11 months to 5 years with moderate congenital talipes equino varus or mobile pes planus. While using skeletal geometry as an outcome, there was a limited fair quality (level II) evidence that corrective footwear has no significant effect on the development of pes planus but may assist in the reduction of deformity in congenital talipes equino varus. The functional footwear group included participants aged 3 to 17 years, predominantly with mobile pes planus or cerebral palsy. Based on biomechanical measures as an outcome, there was a limited fair quality (level III) evidence that functional footwear alters biomechanical parameters in mobile pes planus (spatiotemporal) and cerebral palsy (spatiotemporal, kinematic). Although psychosocial outcomes were considered within two studies, the analysis was limited.

CONCLUSION

Only a limited number of studies have explored the effects of therapeutic footwear and only in a narrow range of mobility impairments. Further high-quality research is required to improve the evidence base for the effectiveness of therapeutic footwear. This should include a wide range of mobility impairments and should focus both on physical and psychosocial outcomes.

Adult Acquired Flatfoot Deformity: Anatomy, Biomechanics, Staging, and Imaging Findings

Adult acquired flatfoot deformity (AAFD) is a common disorder that typically affects middle-aged and elderly women, resulting in foot pain, malalignment, and loss of function. The disorder is initiated most commonly by degeneration of the posterior tibialis tendon (PTT), which normally functions to maintain the talonavicular joint at the apex of the three arches of the foot. PTT degeneration encompasses tenosynovitis, tendinosis, tendon elongation, and tendon tearing. The malaligned foot is initially flexible but becomes rigid and constant as the disorder progresses. Tendon dysfunction commonly leads to secondary damage of the spring ligament and talocalcaneal ligaments and may be associated with injury to the deltoid ligament, plantar fascia, and other soft-tissue structures. Failure of multiple stabilizers appears to be necessary for development of the characteristic planovalgus deformity of AAFD, with a depressed plantar-flexed talus bone, hindfoot and/or midfoot valgus, and an everted flattened forefoot. AAFD also leads to gait dysfunction as the foot is unable to change shape and function adequately to accommodate the various phases of gait, which require multiple rapid transitions in foot position and tone for effective ambulation. The four-tier staging system for AAFD emphasizes physical examination findings and metrics of foot malalignment. Mild disease is managed conservatively, but surgical procedures directed at the soft tissues and/or bones become necessary and progressively more invasive as the disease progresses. Although much has been written about the imaging findings of AAFD, this article emphasizes the anatomy and function of the foot's stabilizing structures to help the radiologist better understand this disabling disorder. Online supplemental material is available for this article. ^©RSNA, 2019.

Three-dimensional foot shape analysis in children: a pilot analysis using three-dimensional shape descriptors

BACKGROUND

Existing clinical measures to describe foot morphology are limited in that they are commonly two-dimensional, low in resolution and accuracy, and do not accurately represent the multi-planar and complex changes during development across childhood. Using three-dimensional (3D) scanner technology provides the opportunity to understand more about morphological changes throughout childhood with higher resolution and potentially more relevant 3D shape measures. This is important to advance the prevailing arguments about the typical development of children's feet and inform the development of appropriate clinical measures. 3D shape descriptors derived from 3D scanning can be used to quantify changes in shape at each point of the 3D surface. The aim of this study was to determine whether 3D shape descriptors derived from 3D scanning data can identify differences in foot morphology between children of different ages.

METHODS

Fifteen children were recruited from three age groups (2, 5, and 7 years of age). Both feet were scanned in bipedal stance, using the Artec Eva (Artec Group, Luxembourg, Luxembourg) hand-held scanner. Three dimensional shape descriptors were extracted from the 3D scans of the right foot, to create histograms for each age group and heat maps of representative participants for comparison.

RESULTS

There were changes to the dorsal, medial and lateral surfaces of the feet with age. The surfaces became less round along with an increase in indented areas. This is supported by the heat maps which demonstrated that the surfaces of the anatomical landmarks (e.g. the malleoli and navicular tuberosity) became more rounded and protruding, with indented surfaces appearing around these landmarks. On the plantar surface, the concavity of the midfoot was evident and this concavity extended into the midfoot from the medial aspect as age increased.

CONCLUSIONS

The findings of this study indicated that with increasing age the foot becomes thinner in 3D, with bony architecture emerging, and the medial longitudinal arch (MLA) increases in area and concavity. Three-dimensional shape descriptors have shown good potential for locating and quantifying changes in foot structure across childhood. Three-dimensional shape descriptor data will be beneficial for understanding more about foot development and quantifying changes over time.

Development of a quantitative measurement system for three-dimensional analysis of foot morphology using a smartphone

Existing techniques for measuring foot morphology are invasive or cumbersome. A new technique was developed using a smartphone, which can measure foot morphology to within 1 mm. This is shown to be applicable to the prediction of hallux valgus, which allows for early intervention.

Factors affecting foot posture in young adults: a cross sectional study

OBJECTIVE

Age, Body Mass Index (BMI) and flexibility are factors affecting foot posture, which is poorly understood in young adults. The objective of this study is to discover the relationships among these factors.

METHODS

252 healthy participants (106 males, 146 females) between the ages of 18 and 25 were selected. BMI and the Foot Posture Index - 6 item version (FPI-6) were assessed, a Beighton score was obtained for each participant, and a lunge test was conducted.

RESULTS

Pronated feet (indicated by an FPI-6 score of 6+ (had a weak positive correlation with Beighton score (r=0.25, p= 0.05, 95% CI [0.01 to 0.47]) and a weak negative correlation with BMI (r=0.31, p = 0.01, 95% CI [-0.52 to -0.07]). Females had a higher prevalence of pronated feet (81.75%) than males (18.75%).

CONCLUSION

There is a mild relationship between ligament laxity and foot pronation, and females are more prone to have pronated feet than males. No correlation was found between body weight and pronated feet.