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Pediatric Pes Planus: A State-

of-the-Art Review
James B. Carr II, MD, Scott Yang, MD, Leigh Ann Lather, MD

Flatfoot (pes planus) is common in infants and children and often resolves abstract
by adolescence. Thus, flatfoot is described as physiologic because it
is usually flexible, painless, and of no functional consequence. In rare
instances, flatfoot can become painful or rigid, which may be a sign of
underlying foot pathology, including arthritis or tarsal coalition. Despite
its prevalence, there is no standard definition for pediatric flatfoot.
Furthermore, there are no large, prospective studies that compare the
natural history of idiopathic, flexible flat feet throughout development in
response to various treatments. The available literature does not elucidate
which patients are at risk for developing pain and disability as young adults.
Current evidence suggests that it is safe and appropriate to simply observe
an asymptomatic child with flat feet. Painful flexible flatfoot may benefit
from orthopedic intervention, such as physical therapy, bracing, or even
a surgical procedure. Orthotics, although generally unproven to alter the
course of flexible flatfoot, may provide relief of pain when present. Surgical
procedures include Achilles tendon lengthening, bone-cutting procedures
that rearrange the alignment of the foot (osteotomies), fusion of joints
(arthrodesis), or insertion of a silicone or metal cap into the sinus tarsi to
establish a medial foot arch (arthroereisis). It is important for a general
pediatrician to know when a referral to an orthopedic specialist is indicated
and which treatments may be offered to the patient. Updated awareness
of the current evidence regarding pediatric flatfoot helps the provider
confidently and appropriately counsel patients and families.

The development of the medial serious underlying pathology, such as


longitudinal foot arch can occur over tarsal coalition or a neuromuscular
several years with a broad spectrum of process. The vast majority of patients
Department of Orthopaedic Surgery, University of Virginia,
normal variations. The presence of pes with neuromuscular flatfoot will Charlottesville, Virginia
planus (flat feet) in older children and have rigid flatfoot. Management of
Dr Carr performed a signicant portion of the
adults lies within the acceptable range neuromuscular flatfoot differs from
literature review and drafted nearly all of the initial
of normal development. Pediatric pes management of idiopathic, flexible manuscript; Dr Yang assisted with the literature
planus can be empirically divided into flatfoot because neuromuscular review and helped with the initial draft; Dr Lather
flexible flatfoot and rigid flatfoot. A flatfoot merits prompt orthopedic conceptualized the structure and content of the
medial longitudinal foot arch that is referral. Patients with pes cavus manuscript, extensively edited the manuscript,
and provided clinical photographs for gures;
present while sitting yet disappears (high arched feet) also merit a and all authors approved the nal manuscript as
with weight bearing is considered neuromuscular workup and an submitted.
a flexible flat foot. Flexible flatfoot orthopedic referral. Although less DOI: 10.1542/peds.2015-1230
is physiologic and comprises 95% common, patients with painless,
of cases. Rigid flatfoot is defined by idiopathic rigid flat feet should be
significant restriction of subtalar joint treated with reassurance, just like To cite: Carr JB, Yang S, Lather LA. Pediatric
Pes Planus: A State-of-the-Art Review. Pediatrics.
motion. It is nonphysiologic and is other patients who do not have foot
2016;137(3):e20151230
often associated with pain and a more pain. The main focus of this article is

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PEDIATRICS Volume 137, number 3, March 2016:e20151230 STATE-OF-THE-ART REVIEW ARTICLE
the diagnosis, treatment, and current arch that is visible when sitting. also associated with a higher risk
trends in management of pediatric This arch may collapse with weight of having flatfoot in children aged
non-neuromuscular, flexible flatfoot. bearing, producing the appearance 7 to 8 years. Other studies confirm
of flat feet. Flexible flatfoot usually that obesity is associated with the
Despite widespread prevalence, pes
resolves by the age of 10, yet in some persistence of flat feet in older
planus is often a misunderstood
patients it persists into adolescence children.1316 There are no studies
topic. Lack of high-level evidence
and adulthood. It is uncertain that have investigated which factors
to guide indications for treatment
whether this should be considered increase the risk of developing
perpetuates some confusion.
a normal variant or a deformity that symptomatic flatfoot, and this is a
Furthermore, there is no universally
may lead to future pathology. In the potential area of future research.
accepted classification system
absence of symptoms, most authors
or definition of pediatric flatfoot.
agree that flatfoot is a normal variant
Various studies have suggested a PATHOGENESIS
foot shape throughout life.3,12
definition based on footprints,14
heel-to-arch width ratio,5 subjective No single factor has been identified
assessment,6,7 or radiographic as the root cause of pediatric flexible
EPIDEMIOLOGY flatfoot. Two classic theories have
measurements.810 Classically, the
diagnosis of flatfoot is assigned Cross-sectional epidemiologic been described for its etiology.
to patients who appear to have a studies have shown that flatfoot One theory suggests that flexible
collapsed medial arch, yet this is a is the normal foot shape in the flatfoot is the result of decreased
subjective measure that neglects first few years of life. In children 2 foot muscle strength.1719 Another
etiology or specific anatomic years or younger, Morley5 found theory proposes that the arch is
considerations. Therefore, parental a 97% prevalence of flatfoot, as mainly created by the shape and
concern and physician preference defined by the heel-to-arch width strength of the osseous-ligamentous
tend to drive the evaluation and ratio. The prevalence drastically complex.2023 The latter is supported
subsequent management of flatfoot.11 decreased with age so that only by the observation that incompetence
This can lead to unnecessary 4% of patients had flat feet by the of the spring ligament is a common
treatment and spending for a age of 10. This supports the belief link in the loss of a normal medial
condition that usually does not need that most pediatric flatfoot resolves arch during weight bearing.
intervention.2 spontaneously throughout the first Current opinion generally accepts
Occasionally patients with decade of development. In a study that the osseous and ligamentous
previously pain-free flat feet become analyzing footprints in >800 patients, structures are most important in
symptomatic. Their pain can be Staheli et al3 found a similar trend maintaining the medial foot arch,
persistent and debilitating, limiting with 54% of 3-year-old children although this is still a debated
participation in sports, recreation, having flat feet. The prevalence topic. The intrinsic muscles of the
and even normal daily activities. decreased to only 26% of 6-year-old foot contribute more to strength,
These patients often benefit from patients, suggesting that ages 3 to 6 stabilization of the foot during
an orthopedic referral. We review years may be a critical time period ambulation, and protection of the
the potential risk factors for flat for the development of the medial ligamentous structures, rather than
feet, physical examination findings, longitudinal arch.3 This same study the actual shape of the foot.20,21
and current nonsurgical and also analyzed footprints in patients Mann and Inman24 demonstrated
surgical options for treatment of up to 80 years old and discovered that individuals with flat feet require
symptomatic, flexible flat feet. that flatfoot is within normal limits greater intrinsic muscle activity
for adults. during ambulation to stabilize the
foot. This may be an explanation
Recent articles have analyzed factors
DEVELOPMENT that may predispose children to
for muscle pain experienced in
symptomatic flatfoot.
Infants are usually born with flexible the development and persistence
flat feet. At the time of birth, a fat pad of flatfoot. A study by Chen et al6 In support of the muscle weakness
is the dominant visible structure in discovered that higher joint laxity, theory, Vittore et al25 recently
the region of the medial plantar arch. W-sitting, male gender, obesity, and investigated activation of the
During the first decade of life, the younger age were all associated extensor muscle groups in patients
medial longitudinal arch develops with a higher risk of having flatfoot with flexible flatfoot. They used
along with the bones, muscles, and in preschool children aged 3 to 6 superficial electromyographic
ligaments within the foot. By the age years. Similarly, Chang et al1 found testing to discover that patients
of 2, a child usually develops a medial that male gender and obesity were with flexible flatfoot demonstrate

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2 CARR et al
poor extensor muscle activity during
the heel-contact phase of the gait
cycle. Weakness was also present in
patients with flatfoot when at rest
compared with patients without
flatfoot. Furthermore, the amount
of extensor muscle weakness
was directly proportional to the
severity of medial arch collapse.
The authors suggest that extensor
muscle weakness causes an overall
imbalance among the foot muscles.
They propose that this is the sentinel
event leading to the development and
persistence of flatfoot.
Another recent study by Singh et al26
analyzed rotational bony alignment
in children with flexible flat feet. They
found that increased tibial torsion
and increased hindfoot malalignment,
as measured by the foot-bimalleolar
angle, were directly correlated with
the presence and severity of medial
arch collapse. Patients with more FIGURE 1
severe bony malalignment were also Rotational prole of the pediatric hips. External and internal hip rotation is best measured with
the patient prone. The legs can be used as a goniometer relative to a vertical line. A, Assessment of
less likely to respond favorably to external rotation. B, Assessment of internal rotation. C, Assessment of thigh foot angle.
conservative treatments. Benedetti
et al27 also analyzed limb alignment history of painful feet or special shoe to as miserable malalignment)
in 53 patients with flexible flatfoot. wear, as several studies suggest warrants ongoing surveillance
They discovered that internal knee that pes planus may have a familial due to potential risk of developing
rotation was the most common limb link.28,29 Obtaining a developmental symptomatic flat feet.
malalignment in this population,
and previous medical history
as seen in 43.6% of patients. The The shape of the foot is the sum
may give clues to the presence of
presence of internal knee rotation of multiple interactions among a
syndromes with musculoskeletal
significantly correlated with variety of joints, muscles, ligaments,
manifestations.
the presence of foot symptoms, and tendons. The hindfoot, midfoot,
further linking positional limb and forefoot are interrelated and
The physical examination starts
abnormalities with the development affect the overall position of the foot.
with a generalized musculoskeletal
of symptomatic flat feet. Patients with flat feet often have
examination, which should always
a valgus hindfoot, dorsiflexed and
The development of flatfoot is include rotational profiles of the legs.
abducted midfoot, and pronated or
certainly multifactorial. The This is best assessed by measuring
externally rotated forefoot (Fig 2).
relationship between bones, internal and external rotation of
This combination in sum leads to loss
ligaments and muscles of the foot, the hips along with the thigh-foot
of the medial foot arch.
along with overall limb alignment angle while the patient is prone (Fig
and comorbid medical conditions, 1). An examination for generalized Examination should include
all play a role in the development of laxity using the 9-point Beighton inspection of the feet in both the
flatfoot. score is also useful in detecting standing and sitting positions and
hypermobility. A score 5 may during gait. The physician should
indicate a hypermobility disorder in examine the feet from the front and
CLINICAL FEATURES children >5 years old.30 The presence the rear while the patient stands. The
Flat feet are usually painless, and of generalized ligamentous laxity rear view may reveal a valgus heel,
most children present for evaluation or external tibial torsion, especially or too many toes sign. Normally the
because of parental concern.11 It is if coupled with excessive femoral examiner should be able to see only
often useful to inquire about a family anteversion (sometimes referred the fifth and half of the fourth toe

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PEDIATRICS Volume 137, number 3, March 2016 3
FIGURE 2
Examples of common foot characteristics seen in pediatric feet. A, Pediatric pes planus results in
hindfoot valgus, as dened by the angle formed by the leg and heel. B, Abduction of the midfoot and
pronation of the forefoot is also seen with inward collapse of the ankle joint, resulting in rotation of
the forefoot away from the center axis. C, Pes cavus results in a high medial longitudinal arch, best
seen from the sagittal view. D, Normal pediatric foot with maintained medial longitudinal arch while
standing.

when the standing patient is viewed ambulation. The arch also may be
from the rear, including during gait. reconstituted in flexible flatfoot by
In the presence of flatfoot, more toes the toe raising test, in which the
are seen due to the global external examiner dorsiflexes the great toe
rotation and abduction in the flat while the patient stands, allowing
foot (Fig 3). It is easy to use the the plantar fascia to tighten and FIGURE 3
number of toes seen from behind as secondarily reconstitute an arch (Fig Characteristic physical examination ndings
an objective measure to document 3). Each of these simple tests can be of a patient with physiologic, exible atfoot. A,
progression or resolution of flatfoot. quite reassuring when shown to a Rear view examination of the heel revealing a
valgus alignment and too many toes sign. B,
Angular or rotational deformities at concerned parent. If these findings Reconstitution of the medial foot arch is seen
the hips, knees, ankles, or feet may are not present, the patient has a on toe raise. C, Reconstitution of the medial
appear worse during gait and this rigid flat foot, which remains flat arch is also seen with forced dorsiexion of the
can help explain the presence of great toe during the jack test.
during sitting, tip-toe standing, and
painful symptoms. Documenting the the toe raise test due to the relative
foot progression angle during gait immobility of the subtalar joint. more urgent causes of foot pain, such
is another way to track change over as infection or neoplasm.
time (Fig 4). It is important to determine the Last, it is important to examine
A medial longitudinal foot arch that is location of any foot pain. Usually the the Achilles tendon complex when
present while sitting yet disappears pain is in the medial midfoot from assessing a child with flatfoot
with weight bearing is characteristic localized pressure on the collapsed because this may have important
of a flexible flat foot. The medial talar head where callus formation implications for treatment.28,31 This is
arch should also reform when a may be evident. Pain also can be best assessed using the Silfverskiold
patient goes from standing to tip- located in the lateral foot at the test. With the knee held in flexion,
toe standing (Fig 3). Observation of sinus tarsi due to impingement from the foot is held in an inverted
the foot position in single leg stance excessive subtalar joint eversion. position and then dorsiflexed. The
may reveal arch collapse that is not Pain that has a sudden onset, is worse amount of dorsiflexion is measured
seen in 2-leg standing and is more at night, or is associated with a fever between the lateral border of the
indicative of the foot position during should prompt a workup for other, foot and the anterior border of the

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4 CARR et al
Treatment options for symptomatic who were >6 years old (mean age
patients include physical therapy, 10) and were treated with custom
shoe wear modification, orthotics, rigid foot orthoses. After 2-year
and, occasionally, surgery. follow-up, multiple radiographic
measurements had improved,
Asymptomatic Flexible Flatfoot suggesting development of the
In the absence of pain, neither medial longitudinal arch.39 However,
operative nor nonoperative this study lacked both a control
management is superior to observing group and clinical assessments to
the patient. In fact, a recent meta- evaluate any improved function of
analysis in 2012 concluded that there the feet. It still remains to be proven
is a lack of quality evidence to guide whether orthotic use can change
management of pediatric flatfoot.32 the natural course of flatfoot in any
Physicians must be mindful of this pediatric age group.
when they are making management
FIGURE 4
Foot progression angle (FPA) is a rough decisions for patients with flatfoot. Overall, unnecessary treatment of
measurement obtained during gait by asymptomatic pediatric flat foot can
A major debate in the management of
observing the angle of the foot off of the line be expensive, with no evidence of
of progression. By convention, in-toeing is a patients with asymptomatic flexible
negative value (eg, 20) and out-toeing is a flatfoot has been the role of accessory change in the patients outcome.11
positive value (eg, +20). shoe supports and orthotics. A A study by Pfeiffer et al14 found
variety of supportive devices that nearly 10% of patients with
distal tibia. This is then performed have been investigated, including pediatric flatfoot wear some form of
with the knee held out in extension. heel cups, heel wedges, silicone orthotics, despite only 2% reporting
Less than 10 degrees of dorsiflexion shoe inserts, and custom shoe pain. Many physicians justify orthotic
above plantigrade with both the knee orthotics.3336 A prospective study use in asymptomatic children by
flexed and extended implies that the performed by Wenger et al37 studied assuming that there is no harm.
entire Achilles tendon is tightened. the efficacy of shoe modifications However, studies have suggested that
Less than 10 degrees of dorsiflexion in altering the development of the unnecessary orthotic use can lead to
with the knee extended only implies longitudinal arch of the foot in 129 dependency on orthotics36 and even
isolated gastrocnemius tightness. patients aged 3 to 5 years. They long-term negative psychological
This is an important distinction for an were unable to show any significant effects as an adult.40
orthopedic surgeon when developing difference in foot development
a treatment plan. between patients with shoe wear A notable area of concern is
modifications compared with healthy whether persistent pediatric flatfoot
controls after at least 3 years of predisposes patients to chronic foot
TREATMENT follow-up. Whitford and Esterman38 pain or other pathology as an adult.
compared generic orthoses, custom If a patient has painless flexible
The decision to simply observe
orthoses, and a control group in flatfoot, then it is generally believed
versus treat a child with pes planus
children aged 7 to 11 with flat feet. that there is a low likelihood the
is based on the patients symptoms
There were no significant differences condition will evolve into painful
and physical examination findings.
between the groups in reported flatfoot. However, Kosashvili et al41
Lack of flexibility is often a sign
pain, gross motor proficiency, self- discovered that adolescents with
of underlying foot pathology, and
perception, or exercise efficiency. moderate to severe flatfoot had
referral for further workup is
indicated. These conditions often There are a few studies that have nearly double the rate of anterior
require operative intervention. For reported correction of flatfoot knee pain and intermittent low-back
patients with pain-free, flexible flat with the use of over-the-counter pain. The authors suggested that
feet, there is no concrete evidence arch supports, heel wedges, and prophylactic treatment of severe,
that any available intervention orthotics33,34; however, these studies persistent flatfoot deformity may
can alter the natural course of foot were greatly limited by the absence prevent future joint pain, although
shape development. Observation of matched controls. Any correction this has not been proven. As of
is the best course. Referral to an may be due to the natural history of now, further evidence is necessary
orthopedist is encouraged for resolution with age. A recent study before prophylactic treatment of
patients with pain, fatigue, or investigated radiographic features asymptomatic flexible flatfoot can be
concerns regarding malalignment. in children with flexible flatfoot recommended.

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PEDIATRICS Volume 137, number 3, March 2016 5
TABLE 1 Surgical Treatment Options for the Management of Pediatric Flexible Flatfoot With Their Associated Descriptions, Pros and Cons
Procedure Description Pros Cons
1. Soft tissue Achilles lengthening to improve ankle range of motion May be used as adjunct with other Less efcacy when performed in
procedures Tendon transfers to realign muscular forces across the foot procedures isolation
2. Osteotomy Cutting and realigning bones to correct pathologic alignment A powerful surgery that offers large Relies on bone healing to
corrective capabilities maintain correction
Reliable outcomes when performed Possibility of overcorrection
correctly
3. Arthrodesis Fusion of joint to reduce motion and maintain joint alignment Provides denitive correction Irreversible elimination of joint
movement
Very powerful correction Degeneration of adjacent joints
Only used as last resort for
children with physiologic
atfoot
4. Arthroereisis Insertion of metal, silicone, or biodegradable implant into Minimally invasive True long-term corrective ability
talocalcaneal joint unknown
Implant may be removed
Does not alter bony or muscle
anatomy

Symptomatic Flatfoot reduction. In patients with a tight Surgery is rarely indicated in flexible
heel cord, the talus remains plantar- flatfoot except in the presence of
The hindfoot in normal foot persistent pain despite a period
flexed, and orthotics may increase
mechanics inverts and provides a of observation and nonsurgical
pain due to pressure against the talar
rigid lever arm for propulsion during management. The general goal
head.28 A home physical therapy
push-off in gait. In flexible flatfoot, of surgery is to provide durable
program consisting of Achilles
especially with associated Achilles reduction of symptoms throughout
tendon stretching and calf muscle
tendon contracture, the hindfoot the childs growth into adulthood.
strengthening should be the initial
may lack the necessary inversion There are several surgical methods
recommendation. A recent study by
needed to create a rigid lever arm to achieve this broad goal of altering
Blitz et al42 showed that stretching
for propulsion. Inefficient push-off foot mechanics and shape. These
of the Achilles tendon may help
during gait may lead to lower-leg include soft tissue reconstruction
counteract an equinus deformity, but
pain and foot muscle fatigue. (eg, tendon transfers), realignment
there is still no definitive evidence to
Symptomatic flatfoot includes a prove that physical therapy alters the osteotomies, and nonfusion motion-
constellation of complaints, such as clinical symptoms or structure of flat limiting techniques (eg, arthroereisis)
activity-related pain, fatigue of the feet. Nonetheless, it is a reasonable (Table 1).
foot muscles, calluses to the medial starting point for management. Isolated soft tissue surgical options
foot, and rapid shoe breakdown. include medial foot capsular-
Patients may also experience When a patient has symptomatic tightening procedures, peroneus
recurrent ankle sprains, especially flatfoot without a tight heel cord, the brevis lengthening, or Achilles
while wearing shoes or inserts that physician may consider orthotics tendon lengthening. In general,
provide substantial arch support. as the initial treatment of choice. these have had very poor results
This is because the ankle has a Contrary to asymptomatic flexible with high failure rates because the
tendency to invert with less contact flatfoot, generic orthotic use can underlying structural anatomy of the
between the foot and the ground as reduce pain in symptomatic flexible foot is not altered.31 Therefore, these
the heel is neutralized by the special procedures are usually performed
flat feet for some patients.33,34,43
inserts. In the presence of these in conjunction with osteotomies,
Custom orthotics have not been
symptoms, a referral to an orthopedic which entail cutting bones and
proven to be superior to over-the-
surgeon is recommended. repositioning them in a more
counter orthotics, so it is logical
to recommend the least expensive anatomic position to help restore
The initial treatment of painful-but-
orthotic first.44 Only 1 study normal foot anatomy.
flexible flatfoot is nonoperative.
Conservative treatment modalities, has quantitatively proven pain Although a mainstay in treatment
such as rest, activity modification, reduction with the use of custom- of painful adult flatfoot deformity,
icing, massage, and nonsteroidal made orthoses in patients who fusion of selected joints in the foot
anti-inflammatory medication, are had concomitant chronic juvenile is not recommended in the pediatric
the initial interventions for pain arthritis and flatfoot.45 population unless a neuromuscular

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6 CARR et al
foot deformity is present. Fusion
is irreversible and ultimately
leads to increased stress in the
adjacent midfoot and ankle joints
due to lack of mobility of the fused
joints.46,47 It is best to preserve as
much functional range of motion as
possible in a pediatric patient, so
fusion is generally avoided in the
treatment of the common, flexible
flatfoot. However, in adolescents or
adult patients with neuromuscular
flatfoot, fusion is a viable option, as it
can provide definitive treatment with
reliable results in patients who are
minimally ambulatory at baseline.

Osteotomies address the underlying


deformities in flexible flatfoot.
These surgeries include the medial
displacement calcaneal osteotomy,
the lateral calcaneal lengthening
osteotomy (eg, modified Evans
osteotomy), and the Triple-C
(calcaneus, medial cuneiform,
cuboid) osteotomy. The medial
displacement calcaneal osteotomy
effectively compensates for a valgus
heel by shifting the heel medially,
allowing for a more medial and
inversion-producing vector of the
Achilles tendon.48 Postsurgical
series have demonstrated significant
improvement of foot shape along
with improvements in fatigue
symptoms in 89.5% of patients
studied after medial displacement
calcaneal osteotomy.49 The lateral
calcaneal lengthening osteotomy
is a powerful osteotomy that
FIGURE 5
lengthens the anterior process of the A, Preoperative lateral radiograph of an adolescent patient with severe right atfoot. B, Intraoperative
calcaneus, and simultaneously can uoroscopic radiograph after insertion of arthroereisis capsule, anteroposterior and lateral
correct hindfoot valgus and forefoot views. C, Postoperative lateral radiograph revealing stable placement of arthroereisis capsule and
improved medial foot arch
abduction. Mosca50 demonstrated
a good or excellent clinical result
in 93.5% of cases. After lateral without the support of a control outcome score at mean 5.2 years
calcaneal lengthening osteotomy, group.52,53 after certain osteotomy procedures.
patients demonstrated significant Importantly, a return to sport
biomechanical plantar pressure Overall, positive outcomes after activities was accomplished in 15
measurement improvements as surgical management are possible of 16 patients, and all patients were
well.51 The postsurgical results of a when performed on the appropriate satisfied that they underwent the
Triple-C osteotomy also have been patient. A recent study by Oh et procedure. Akimau and Flowers55
overall favorable from a clinical and al54 demonstrated a significantly also demonstrated favorable patient
radiographic evaluation, although increased mean American Orthopedic outcome scores in children with
these results have been observational Foot and Ankle Society clinical flexible flatfoot after mean 5.6 years

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PEDIATRICS Volume 137, number 3, March 2016 7
of surgical follow-up. In summary, One of the main concerns regarding understanding of the natural history
osteotomies appear to provide this procedure is its high reported of asymptomatic flatfoot into
reliable improvement in pain and complication rate in 4% to 18% of adulthood needs to be elucidated. It
symptoms. More research is needed cases in a recent literature review.57 is well known that there is a subset of
regarding long-term outcomes into Frequently reported complications adults with pes planus who develop
adulthood. include malpositioning of the disabling pain, posterior tibial
Arthroereisis is a nonfusion type implant, improper correction of the tendon dysfunction, and subsequent
of procedure in which the motion deformity, extrusion of the implant progressive arthritis of the ankle
of a joint is restricted though not from the sinus tarsi, foreign body and subtalar joint. It is not clear
fully eliminated. First introduced reaction to the implant, peroneal whether there is a link between
in the mid-1900s, this procedure spasm, and persistent foot pain. pediatric flexible flatfoot and the
entails placing a metal or bio- These complications are generally development of posterior tibial
absorbable implant into the sinus managed by implant removal. More tendon dysfunction in adults or
tarsi of the foot (Fig 5). This blocks serious complications include talar whether the altered biomechanics of
excessive eversion of the subtalar neck fracture and the development the pediatric flatfoot predisposes to
joint, subsequently preventing arch of subtalar fusion.61,62 Although tendon failure.
collapse. Some find this procedure most of the available case series Prophylactic treatment of an
attractive because it is less invasive on arthroereisis provide favorable asymptomatic, painless flatfoot
as no osteotomy is involved. In radiographic results and improved with expensive orthotics or surgery
addition to pain relief, the goal foot alignment,57,60 the complication is not justified until the natural
of this procedure is to prevent loss rate is high and long-term results into history of flatfoot is more thoroughly
of posterior tibial tendon function, adulthood are lacking. investigated. A validated outcomes
thereby minimizing the need for measure for pediatric foot and ankle
future reconstructive conditions needs to be standardized
CONCLUSIONS AND FUTURE
foot surgery. Studies have so that reported outcomes on all
DIRECTIONS
demonstrated increased ankle interventions for symptomatic
dorsiflexion, decreased foot pain, Based on current literature, flatfoot can be more clearly and
improvement of radiographic treatment of flexible pes planus in objectively understood.
features, and even improvement children is indicated only for those
in foot printing after this who have painful symptoms. Both
procedure.5659 A recent case orthotic and surgical treatments can ACKNOWLEDGMENTS
series has also demonstrated the improve pain levels and function, Thank you to Dr Mark Abel and Dr
potential for maintenance of the foot although the literature clearly lacks Mark Romness for their review of the
in a corrected position even after rigorous comparative studies for manuscript and provision of surgical
subsequent implant removal.60 each intervention. An improved radiographs.

Accepted for publication Jul 23, 2015


Address correspondence to Leigh Ann Lather, MD, University of Virginia Childrens Hospital, 1204 W. Main St, Charlottesville, VA 22908-0159. E-mail: lac7c@virginia.
edu
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright 2016 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have no nancial relationships relevant to this article to disclose.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conicts of interest to disclose.

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10 CARR et al
Pediatric Pes Planus: A State-of-the-Art Review
James B. Carr II, Scott Yang and Leigh Ann Lather
Pediatrics 2016;137;; originally published online February 17, 2016;
DOI: 10.1542/peds.2015-1230
Updated Information & including high resolution figures, can be found at:
Services /content/137/3/e20151230.full.html
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2016 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Pediatric Pes Planus: A State-of-the-Art Review
James B. Carr II, Scott Yang and Leigh Ann Lather
Pediatrics 2016;137;; originally published online February 17, 2016;
DOI: 10.1542/peds.2015-1230

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/137/3/e20151230.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2016 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from by guest on August 25, 2016