PEDIATRICS Vol. 103 No. 6
June 1999,
p. e84
ELECTRONIC ARTICLE:
Flexible Flat Feet in Children: A Real Problem?
Antonio García-Rodríguez*,
Felipe Martín-Jiménez
,
Manuel Carnero-Varo*,
Enrique Gómez-Gracia*,
Jorge Gómez-Aracena*, and
Joaquín Fernández-Crehuet*
From the * Department de Medicina Preventiva y Salud
Pública, Facultad de Medicina, Universidad de Málaga,
Spain; and Servicio de Traumatología, Hospital
Clínico Universitario, Málaga, Spain.
 |
ABSTRACT |
Objectives To estimate the prevalence
of flexible flat feet in the provincial population of 4- to 13-year-old
schoolchildren and the incidence of treatments considered
unnecessary.
Setting. Province of Málaga, Spain.
Methods. We examined and graded by severity a sample of
1181 pupils taken from a total population of 198 858 primary
schoolchildren (CI: 95%; margin of error: 5%). The sample group was
separated into three 2-year age groups: 4 and 5 years, 8 and 9 years,
and 12 and 13 years. The plantar footprint was classified according to
Denis1 into three grades of flat feet: grade 1 in which
support of the lateral edge of the foot is half that of the metatarsal
support; grade 2 in which the support of the central zone and forefoot are equal; and grade 3 in which the support in the central zone of the
foot is greater than the width of the metatarsal support. The statistical analysis for the evaluation of the differences between
the groups was performed with Student's t and
2 tests as appropriate.
Results. The prevalence of flat feet was 2.7%. Of the
1181 children sampled, 168 children (14.2%) were receiving orthopedic
treatment, but only 2.7% had diagnostic criteria of flat feet. When we
inspected the sample, we found that a number of children were being
treated for flat feet with boots and arch supports. Most of them did
not have a flat plantar footprint according to the criteria that we used for this work. Furthermore, in the group of children that we
diagnosed as having flat feet, only 28.1% were being treated. We found
no significant differences between the number of children receiving
orthopedic treatments and the presence or absence of a flat plantar
footprint. Children who were overweight in the 4- and 5-year-old group
showed an increased prevalence for flat feet as diagnosed by
us.
Conclusion. The data suggest that an excessive number of
orthopedic treatments had been prescribed in the province. When
extrapolated to the 1997 population of schoolchildren within the age
groups studied the figures suggested that ~28 167 children in
Málaga province probably would have been receiving orthopedic
treatments with boots and insoles at the time of our study.
Consequently, the total expenditure on orthopedic boots and
insoles that year could be estimated as 676 008 000 pesetas
($4 447 422 in US currency).
Key words:
children,
flexible
flat feet,
treatment cost effectiveness.
Our reading of the bibliography of flat feet revealed that
the authors of recent works, such as Rao,2
Rose,3 and Staheli,4 appear to have abandoned
the classic conservative treatment of this condition advocated by
earlier authors such as Lelivre,5 Viladot,6
and Giannestras.7
Many authors doubt the effectiveness of the orthopedic treatment of
flat feet. Some authors, such as Broks,8
Fowler,9 and Volpon,10 are of the opinion
that flat feet are normal in early childhood and that the condition
resolves spontaneously without treatment. These authors state that the
feet of most children who displayed the condition as infants become
structurally normal when they are 12 or 13 years old.
The modern tendency to turn against previous established practice
stimulated our curiosity and led us to perform an epidemiologic study
of young children with flat feet in the Málaga province. The
study gave special attention to the prolonged economic burden on
parents that was created by the considerable cost of mostly unnecessary
orthopedic treatments for this condition. Our findings prompted us to
ask the question posed in the title of this work: "Flexible flat feet
in children: a real problem?"
| |
METHODS |
We obtained a representative sample and a random sample from the
total population of 198 858 Málaga schoolchildren who are receiving primary education (CI: 95%; margin of error: 5%). We examined 1181 pupils who were separated into three 2-year age groups 4 and 5 years, 8 and 9 years, and 12 and 13 years (Table
1). The children were divided also into
groups of town or country dwellers and again into another two groups
according to the type of schooling that they were receiving: private or
public.
When the different sample groups were separated clearly, we established
an experimental protocol that used several variables such as age,
height, weight, social class, etc, and other variables that are
associated directly with the foot such as plantar footprint, valgus
calcaneus, abducted forefoot, and whether or not the child had
orthopedic supports such as insoles (Tables
2 and 3).
The plantar footprint was classified according to Denis1
into three grades of flat feet: grade 1 in which the support of the
lateral edge of the foot is half of that of the metatarsal support;
grade 2 in which the support of the central zone and forefoot are
equal; and grade 3 in which the support in the central zone of the foot
is greater than the width of the metatarsal support. This is described
in detail in Fig 1.
In this study, we defined those children who displayed a second or
third degree plantar footprint as flat-footed. Children with first
degree plantar footprints were not included in this study, because they
were considered to have evolutionary foot problems without pathologic
significance according to Meary11 and
Stewart.12
| |
RESULTS |
The prevalence of flat feet in our series was 2.7%. This differs
greatly from the prevalence of 12.3% that was mentioned by Denis,1 but it is very similar to the prevalence that Gil13 reports.
Some relevant results of the different variables that were studied such
as height, weight, knee valgus, internal and external rotation of hip
are shown in Table 4.
Our analysis of data aimed to determine whether the existence of flat
feet was related to the presence or absence of other independent
variables that may cause the development or evolution of flat feet. The
three variables that revealed a significant relationship
(P < .05) were age, social level or class of the family or parents, and sex. Table 5 shows
that 75% of flat feet were found in the first 2-year age group (4 and
5 years). The remaining 25% were distributed between the second and
third groups (8 and 9 years, and 12 and 13 years, respectively).
We detected a decreased prevalence of flat feet in the children of
lower and lower-middle class families, and males predominated in both
classes.
The effect of obesity on the incidence of flat feet was calculated by
using the body mass index. We found no significant differences in our
series, but when the results were adjusted by age, being overweight was
seen to increase the prevalence of flat feet diagnosed in group 1 (4 and 5 years).
At the time that we inspected the samples, 168 of the 1181 children
(14.2%) were receiving orthopedic treatment (Table
6). We considered this percentage
excessive because only 2.7% of these children had the diagnostic
criteria of flat feet. Paradoxically, we must emphasize that we found
no significant difference between the number of children who received
orthopedic treatments and the number of children who were diagnosed as
flat-footed, and this figure suggests that an excessive number of
orthopedic treatments had been prescribed. It was even more surprising
that only 9 of the 32 children who were diagnosed as having flat feet
(28.1%) were receiving orthopedic treatment.
When we extrapolated these figures to the 1997 population of
schoolchildren within these age groups, we found that ~28 167 children in the Málaga province probably would have been
receiving orthopedic treatments with boots and insoles at the time of
our study. If we take into account normal wear and tear and growth, we
can assume that each pair of orthopedic boots (12 000 pesetas; $79 in
US currency) will need changing every 6 months. Consequently, the total
expenditure on orthopedic boots and insoles that year was
~676 008 000 pesetas ($4 447 422 in US currency).
| |
DISCUSSION |
Our study of the literature revealed that there is a great
variation in the prevalence of infantile flexible flat feet reported by
different authors.2,3,13,14 In our opinion, these
differences could be explained by the fact that the authors used
different age groups or perhaps only made their diagnosis at the end of
the usual evolutionary period when additional evolution toward healthy
feet was improbable.
Rose3 states that the critical age for development of the
plantar arch is 6 years, and consequently, if the prevalence of flat
feet is evaluated before this age, the finding will overestimate the
problem.
Our figures agree with those that have been quoted previously. We found
that 75% of all the flat feet found in this present work were in the
youngest age group (4 and 5 years), our group 1. This percentage is
comparable with that of the epidemiologic studies of
Gil.13
The controversy about the treatment of flat feet arises from the
contradictory opinions expressed by different authors.
Viladot6 recommends starting treatment at 2 or 3 years of
age. Rose3 asserts that treatment should never be
undertaken after 6 years. However, Staheli15 observes that
most flat feet conditions correct themselves spontaneously and that
those that remain deformed do not benefit from orthopedic treatment,
and Smith14 states that a flat foot that does not correct
itself will not be corrected with orthopedic insoles.
The results of this study suggest that an excessive number of young
schoolchildren in the Málaga province were receiving orthopedic
treatment for flat feet and that because most of these children had
normal feet, the cost of the special footwear represented a
considerable unnecessary expense for parents and health services. Moreover, many of the children would have suffered psychologically by
having to wear ugly boots that become increasingly unacceptable as the
child grows older. A more serious consideration is the fact that
orthopedic corrective footwear confines the foot in a rigid mold that
limits the normal function of the extrinsic and intrinsic muscles of
the foot. Furthermore, the insole arch supports remove the usual
alternating stimuli that strengthen the foot muscles that maintain the
arch, and without this exercise, the muscles tend to lose tone and
weaken. In this way, unnecessary orthopedic arch supports cause twofold
damage; they initiate and then perpetuate the problem for which they
were prescribed ostensibly to correct.
If we take into account the years of treatment received by each young
school child (Table 7), the group of
children in our study received 1377 years of treatment. We assumed that each child would receive two treatments and need two replacements of
footwear per year. When we extrapolated this figure to the total
population of schoolchildren within these age groups in Málaga
province, we obtained the figure of 546 276 571 treatments during the
period of elementary schooling. After this, in disgust, we decided not
to make any more calculations; the results had revealed an embarrassing
situation that spoke more of opportunism than professionalism.
| |
CONCLUSION |
In summary, according to our study, we have noted that an
excessive number of orthopedic treatments have been prescribed
unnecessarily.
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ACKNOWLEDGMENT |
We thank D.W. Schofield for editing and translating the
manuscript.
| |
FOOTNOTES |
Received for publication May 11, 1998; accepted Jan 28, 1999.
Reprint requests to (A.G.R.) Department de Medicina Preventiva
y Salud Pública, Facultad de Medicina, Universidad de
Málaga, 29071, Málaga, Spain. E-mail: antoniogr{at}uma.es
| |
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Pediatrics (ISSN 0031 4005). Copyright ©1999 by the American Academy of Pediatrics
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