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Pediatric Overpronation: Treat Or Monitor?
Point
Here the author shares his personal experience and evidence from the literature to advocate for proper and comprehensive evaluation and management of pediatric overpronation.
By Joseph C. D’Amico, DPM, DSc
The human newborn must undergo considerable developmental unwinding before it possesses all the requisites necessary for normal ambulation.1 Achievement of these requisites must take place despite the presence of significant phylogenic and ontogenic influences, osseous malalignment, osseous immaturity, neurologic immaturity, and ligamentous laxity.2-7 This early and profound developmental potential faces challenges from the accompanying resultant abnormal forces in a plastic system, rendering it readily vulnerable to the deforming effects of gravity.2-11
No child is born with perfect feet. Every infant has inherent imperfections affecting all three body planes, which, if not outgrown by age six, will result in dysfunction and deformity in the foot and related superstructure.2-7,12-20 In his lectures and articles, Richard O. Schuster, DPM refers to these atavistic traits as “evolutionary scars.”21,22 Herman R. Tax, DPM, father of podopediatrics and founder of the American College of Foot and Ankle Pediatrics, began every lecture stating that the story of the human foot is millions of years old and still being written. Consequently, “all children are born with the potential for orthopedic foot problems related to weight-bearing because of the inherent structure of man’s foot. It is these weaknesses in the foot structure of the child that are the predecessors of foot disability in the adult.”14,15,23,24 Over 80 percent of the population suffers from foot problems during their life.25 The overwhelming majority are musculoskeletal and begin in childhood.3
Contrasting The Concepts Of Prevalence And Normalcy
The assumption exists that, since most children’s feet are flat, asymptomatic, and otherwise non-deformed, they are normal. The absence of symptoms is not a criterion for optimum function nor as a determinant for intervention. In fact, the attendant malfunction, ie, excessive pronation, regardless of the underlying pathology, is the same in symptomatic and asymptomatic groups.3,5 Children, for the most part, do not complain about their feet since the bones are still soft, forgiving, and primarily cartilaginous, ligaments are loose, and body weight and the degree of stress imposed are relatively low. They may complain of leg pain, knee pain, bouts of “growing pains,” an aversion to walking, clumsiness, avoidance of sports activities, etc. The parents may note that the child cannot stand up straight no matter how often others remind them. In any event, one may not experience symptomatology due to excessive pronation until the second or third decades of life, or sooner if one imposes increased stresses on the system, as with participation in sports.
Excessive pronation affects the foot and each body segment that it supports and transports.12,13,15,24 Correspondingly, defects or deviations in the limb above affects the foot.12,13,16,17,26-28 Good posture starts with the feet, and excessive pronation precipitates, aggravates or perpetuates postural derangement in children.24 A common misconception about the child’s foot is that it is “normally pronated” up to six years of age.29-31 During this same time frame, pedal alignment and development depend upon the nature, severity, and ability to resist the deforming forces directed through it.2-11 If allowed to continue, these forces hinder ideal development, encouraging the retention of inherited neonatal deficiencies.2-5 It is interesting to note that in the established walker at one-and-one-half to two years of age, the navicular has not even begun its ossification process, and is therefore subject to deforming forces concurrent with excessive pronation.
One should never confuse revalence or commonality with “normalcy.” Normal implies “ideal,” and this is not the case in the developing foot. No matter the age of the child, excessive pronation is a poor postural position that sets the stage for future dysfunction and deformity, and according to the tenet of Tax, “if you can see it, it’s excessive.”15,20 The young child’s foot does develop in the direction of more stability and less pronation, but not zero pronation.32,33 Sobel and colleagues, in their study of 150 children between six and 16 years of age, found that the average weight-bearing rearfoot angle was four degrees of valgus. They did not find “normal” values of zero degrees plus or minus two degrees even in the oldest age group.34
Parents often receive misinformation about their child’s condition, including that it isperfectly normal, and that they’ll grow out of it. The problem is, they don’t grow out of it; they just grow up and out of the pediatrician’s practice. Another justification for treating the overpronated pediatric flatfoot lies in the long-known fact that lower extremity torsional problems are not outgrown and lead to abnormal stresses, creating compensatory pathologic adjustments in the feet, knees, and hips.35 Recent evidence reconfirms this concept.36-38
Flat Feet Versus Flattening Feet
Most children’s feet are not flat feet, but flattening feet. Virtually every child is bornwith a discernible longitudinal arch that fails to maintain its intended architecture upon weight-bearing for a host of reasons.2-5,14,15,22-24,39 The height of the arch by itself is variable, an unreliable indicator of foot and limb function, and certainly not a criterion to assess the function of the foot.39,40 Arch depression is a one-plane expression of a three-plane problem, pronation. Although both the high- and low-arched foot may function well, it is the observed degree of deviation from its intended design to the position it assumes on weight-bearing that indicates the level of dysfunction.
What Does The Evidence Reveal?
The absence of evidence is not evidence. There are no 30-to-50 year double-blind comparison studies that chronicle the effect of proper conservative management of pediatric overpronation. One should not devalue clinical sense, clinical experience, and clinical judgement. The problem with many studies of this topic is that the methodology depends on the depth, breadth, scope of knowledge, ability, licensure, level of experience, and skill of the individual or individuals performing the biomechanical evaluation. The facility, ability, and technique of the investigator to obtain a proper subtalar neutral impression of the foot also come into question. Add to this the correctness of the orthotic prescription, laboratory fabrication technique and standards, and the ability or inability of the prescriber to objectively assess patient progress, and one can readily find multiple reasons to question the validity of many of these studies.
It’s interesting to note that one of the most often quoted articles refuting the benefits of custom foot orthoses in children is a study by Wenger and colleagues.41 Closer inspection of the data reveals not only that the subjects improved with UCBL-type devices, but the more severe the pathology, the greater the improvement. There are other flaws associated with this study, as I discovered in similarly oriented articles on this subject.5,6,42 One key deficiency I have noted in these studies is that the forefoot-to-rearfoot relationship is not mentioned or was not assessed. In fact, other than an occasional “intrinsic” forefoot modification, there is no prescribed correction for forefoot (and in some cases rearfoot) deformities, relegating the device to the category of a heat-formed “custom insole” and not a functional orthosis.5 It’s also surprising that prescriptive corrections, when present, are the same from individual to individual and from right to left.5
On a positive note, some good studies indicate the benefits of intervention in the excessively pronated pediatric flatfoot, utilizing custom foot orthoses and modified ankle-foot orthoses (AFOs).43-54 In a 10-year study by Rose of 154 children with flexible pes planus treated with a modified AFO (lateral bar upright with medial “Y” strap), only six children were unable to achieve a stable position and all six of these were over six years of age at the start of the study.55 All of the other subjects were under one year of age when treatment began. Rose also stated that “because the ultimate condition can be so disabling, and the treatment so readily tolerated that some degree of overcorrection is acceptable and desirable.”55 Bordelon’s classic studies utilizing UCBL devices revealed a five-degree per year reduction of the talo-first metatarsal angle.43,44
Medicine is both a science and an art, my experience is that this is particularly true and significant in the conservative management of inherited structural imperfections of the foot and ankle. Why is it that a particular procedure is successful in the hands of one surgeon while another finds it unworkable? Why do certain practitioners have consistently excellent outcomes with conservative management of the excessively pronated foot in children (and in adults) and others do not? There is an art to performing and modifying a particular procedure to meet the needs of the individual, and there is an art in the evaluation, cast taking, prescription writing, and management of the excessively pronated child’s foot.
Rationale For Early Intervention In The Asymptomatic Pediatric Flatfoot
Most experts agree that adult-acquired flatfoot almost always begins with a preexisting pediatric flatfoot.40,43,44,47,56,57 As far back as 1917, eminent New York orthopedist Royal Whitman, MD, wrote in his Treatise on Orthopedic Surgery text that pronation of the feet commonly seen in children is more likely to worsen than improve over the years.19 Justin Greisberg, MD, goes on further to state, “perhaps the most important treatment for the adult-acquired flatfoot is prevention. If the at-risk foot can be identified, early intervention might prevent the deformity.”40 Most flat feet in children are flexible and passively correctable early in life. However, the persistence of deformity as the foot grows and develops will result in structural change.58 Richard O. Schuster, DPM, states that any child with a navicular drop of 3/8-inch (nine mm) with or without pain should undergo treatment to prevent symptomatology and deformity later in life.21,22,32
Limb length discrepancy is present in over 90 percent of the pediatric and adult populations and is another untoward influence commonly present in the developing child, creating compensatory asymmetrical pronation.16,59-62 This often-neglected fact is another indication for early intervention and appropriate management. Dismissing or not identifying an asymmetry in structure or function leads to superstructural pathology in the future.16
As with most pediatric musculoskeletal pathology, the more flexible the deformity, the more favorable the outcome, and the earlier one identifies the condition and institutes treatment, the more rapid and dramatic the response.2-5,8,46,63 This is particularly true of biomechanical problems in the very young since tissues are growing rapidly, are quite malleable and receptive to applying a gentle corrective force. However, in the older child, “tissue cooperation” is not always forthcoming. As maturity and strength develop, normal limbs resist deformation, and deformed segments resist reformation.64 In my original developmental flatfoot article, I recommended intervention beginning at seven to nine months of age when the child begins to stand; however, James V Ganley DPM is his editorial commentary, stated that treatment should begin before that time “since casts and splints are truly effective in this age group.”64 Dr. Ganley considered corrective casting in the young child the “purest form of preventative medicine.”64
The greatest chance for correction in the infant’s lower extremity is due to the rapid growth rate and the cartilaginous nature of the “osseous” segments. By the end of the first year, the infant’s foot is 50 percent of its adult length.65 The legs reach 50 percent of their adult length between three and four years of age.66 Periodic observation of these excessively pronated children is a mistake in judgement due to this rapid growth phase making later treatment much more difficult.8,55,64,67,68 Another issue with merely monitoring development in the excessively pronated child’s foot is that they remain unassessed and unaddressed until symptoms emerge.
Early treatment is mandatory if one expects a successful result, with the ideal period being under six months of age.8,64 According to Lenoir, “each day that an infant foot deformity goes untreated is a day of golden opportunity lost forever.”8
One of the benefits of early intervention is the redirection of epiphyseal forces more appropriately. Application of a gentle manipulative force encourages anatomic remodeling of the deformed segment.69 Essentially, this is analogous to orthodontics in dentistry and serial plaster immobilization in orthopedics.2-11,14,15,20,30,43,44,55,67 Arthur Helfet MD, an orthopedic surgeon, designed a heel stabilizer to limit calcaneal eversion in the overpronated pediatric flatfoot.69 Dr. Helfet noted that when the calcaneus is held in a vertical position, there is the creation of a normal arch, and if the growing foot is held in this position, it will develop and function in the shape in which it was held. According to Hurrman “growth and development can be effectively used as long as the orthotic is worn faithfully and for a prolonged period of time.”67
Arthur J Trott MD, in his article on children’s foot problems, states, “if it is possible to maintain the bones of the foot in normal relationship to one another during the growing years, regardless of whether the eventual outcome is a good arch or a flatfoot, the end result should minimize arthritic changes later in life.”70
In Summary
Excessive pronation is a progressive, repetitive, self-perpetuating, potentially disabling, lifestyle limiting, static and dynamic disorder, creating compensatory abnormal stresses and postural derangement throughout the entire musculoskeletal system. It is never outgrown. In the excessively pronated pediatric flatfoot, we face the dilemma of lax ligamentous structures, an immature neuromotor system, and/or an also immature, malaligned and ill-designed musculoskeletal system. It is from this inappropriate framework that one derives their adult foot structure and function. Failure to intervene is failure to recognize the long-term consequences of excessive pronation not only in the foot but in the superstructure, as well.2-7,12
Past and present prominent podiatrists and orthopedists have advocated for early intervention or the excessively pronated pediatric foot for over a century.8,14,15,18,24,30,37,40,43,44,55,56,69-74
Based on personal clinical observation, research, and experience in a controlled patient setting I concur with these leaders that not only should the excessively pronated pediatric flatfoot be treated, but it should be treated early, aggressively, and for the appropriate length of time required to achieve correction.2-7,75 A “wait and see” attitude ignores the high percentage of adults with foot problems not cured by time. In the words of James V. Ganley, DPM, this is a “grave mistake” and disservice to the child since it allows increasing strength and maturity along with rapid growth to reinforce, retain and sustain this condition, making it recalcitrant to later intervention.8,64 Those who propose that the overpronated pediatric foot should be “given a chance to grow out of it,” would do well to reflect on this fact.
In conclusion, the child born today may live to over 100 years of age, and what will determine their quality of life when they are 70, 80, or 90 years old is the ability to walk without pain. That starts with the feet. Therefore, any action at an early age to positively influence optimum alignment and function will increase the likelihood that the children of today will have healthy feet tomorrow.
Dr. D’Amico is a Professor and Past Chairman in the Division of Orthopedics at the New York College of Podiatric Medicine and the Department of Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University. He is a Diplomate of the American Board of Podiatric Medicine and a Fellow of the American Academy of Foot and Ankle Pediatrics. Dr. D’Amico is in private practice (limited to gait-related disorders) in New York City.
Counterpoint
Here the author encourages readers to consider key questions and thought processes in determining the benefits and risks of treating pediatric overpronation, including definitions, planal dominance, classification, and true benefit.
By Edwin J. Harris, Jr., DPM, FACFAS
Before beginning this discussion on whether it is appropriate to initially treat or monitor overpronation, I must make several crucial points. First, monitoring a disease does not equate with “do not treat.” Instead, it allows the treating physician to decide whether treatment is indicated or determine the best time to start. Second, there is no consensus about the definitions of pronation and overpronation.1 Diagnostic criteria, including radiographic interpretation, is challenging in the child because of incomplete skeletal maturity and the possibility of spontaneous improvement with advancing age.2 Third, is the pronated foot necessarily pathologic? At what point does the pronated foot cease being physiologic and become either pathologic pronation or overpronated?
Fourth, pronation is not a disease, but is one of several possible anatomical lesions or clinical findings. There are many different variations based on severity, rigidity, dominance on an anatomical plane, and the presence or absence of subjective symptoms such as night pain, pain after activity, vague leg pains, decreased endurance, and vague arch pain, to name a few. Fifth, all clinical problems have a natural history, whether treated or left untreated. Sixth, other issues may influence treatment options or determine whether treatment is necessary or even advisable. Seventh, operative and non-operative treatments are not equal or interchangeable. Eighth, should treatment be empirical rather than data-based? Ninth, one must direct treatment to realizable, scientifically demonstrated goals and objectives. Tenth, is there an unrecognized financial bias for those who provide orthoses directly to patients? This includes not only podiatrists, but chiropractors, physical therapists, and orthotists, to name a few.
Management of the pronated and overpronated foot, just like the treatment of any other medical condition, must be based on objective and reproducible data demonstrated to a reasonable degree that specific treatment goals are reasonable, realistic, and achievable. Ideally, these treatments should result in permanent anatomic change for the better that will remain after treatment ceases; otherwise, they must be considered palliative. Additionally, there should be clear, irrefutable data to support the contention that pronated feet in toddlers and children cause adult foot, ankle, knee, hip, and back problems.
Considering The Role Of Planal Dominance
The default position of the subtalar joint is pronated. However, we must also include the talo-calcaneo-navicular complex (acetabulum pedis) in our consideration, since none of these individual articulations can function independently and must act as a functional unit.3 One must also take planal dominance into consideration, as well as failure of the medial column at multiple points along its length.3-7 Conceptually, planal dominance does not mean that the pronation deformity is limited solely to one of the anatomical planes. Rather, it is more pronounced in one of the planes.
In my experience, excessive heel eversion indicates that the deformity dominates on the frontal or coronal plane and may indicate an abnormal calcaneal shape. In some cases, it is a triplane deformity with all three planes having an almost equal impact. Heel eversion within normal limits with near-normal sagittal alignment, but a wide divergence of talonavicular alignment in the transverse plane indicates transverse plane dominance. Failure of the medial column in the sagittal plane is the hallmark of sagittal plane dominance. Medial column failure could present at the talonavicular, cuneonavicular, or metatarsocuneiform levels, or a combination of two or all three. Ankle equinus is almost always associated (and possible etiologic) with dominance on this plane. Understanding the concept of planal dominance helps in the development of appropriate treatment.
What Other Factors Come Into Play When Creating A Plan For Pediatric Overpronation?
Multiple attempts at classifying pronation exist,8-12 and often, only add to confusion.13 I participated in one such study, and I can attest to the difficulty in arriving at a consensus even among experts in the field. At best, we encounter limited agreement about classifying flexible versus rigid.1 The definition of a flexible flatfoot is a normal arch off weight-bearing and flattening on standing.14 Rigid forms are less controversial, and I agree that they will require some form of treatment. These include, but are not limited to, congenital convex pes valgus and various forms of tarsal coalition. Other than that, there are no universally agreed-on definitions of non-rigid forms of pronated feet.
Since one should consider pronated feet anatomic lesions or symptoms, we must place additional diagnoses and comorbidities into context. Consider Duchenne Muscular Dystrophy; many of these boys undergo treatment for pronated feet for a considerable time before receiving the muscular diagnosis. Since the natural history of this disease is progression to cavus and equinus, does the pronated foot benefit from treatment? As another example, my personal experience is that children with a diagnosis of Charcot-Marie-Tooth Syndrome-IA are pronated until the middle of the first decade of life, when they develop cavus feet. In both conditions, the correct diagnosis may be delayed for years. Since treatment of pronation in these two groups has no realizable goals and objectives, the usefulness of such treatment becomes moot.
Other issues need to be weighed. These include obesity, hypotonia and hypertonia, ligamentous laxity, underlying neurological and muscular diseases, tibia varum and genu valgum, heel cord contracture, heredity, and the known or proposed natural history of pronated feet.15 With respect to the last, a number of citations in recent literature suggest that the flexible forms of pronation are normal variants,16 and spontaneously improve with time.13,14,18 These issues may or may not be modifiable or impact the success or failure of treatment.
There are a number of diverse treatment options for overpronation. They include activity modification, appropriate shoes, orthoses, exercise, medications, addressing obesity and ligamentous laxity,10 and surgical intervention (including arthroeresis, lateral column lengthening, medial column osteotomy, and medial calcaneal displacement osteotomy). The consensus is that surgical intervention should involve joint-sparing procedures.3,18
I believe that the central element of this discussion revolves around the issue of early intervention with orthoses. The question about whether orthoses can result in a positive anatomical change, positively influence potential long-term disability, or simply act as a palliative treatment remains unanswered. On the other hand, anecdotal benefits reported by physicians suggest that subjective complaints such as leg pains, decreased endurance, and arch pain may be relieved with even the simplest forms of orthoses. This raises the question of whether these devices exert a physiologic effect or are merely an example of a placebo. It does not mean that these treatments are inappropriate.
In Summary
We lack a clear definition of what constitutes relevantly pronated and overpronated feet. This is a long-overdue challenge. Without this, we run the risk of treating large numbers of children who may not benefit immediately or in the long-term by treatment. Along the same lines, we need a better understanding of the natural history of the pronated foot in children, emphasizing whether they do indeed improve and/or correct with time. We also need to understand the urgency of “treatment” and the effectiveness of orthosis therapy in toddlers and very young children. We need data on the effectiveness of orthotic control in small children with short lever arms within the foot that can make realignment of the foot mechanically difficult or impossible.
Additionally, we need data on the proper age to begin any non-surgical or surgical treatment. Unfortunately, much of these needed data are not obtainable. Although orthosis therapy carries no potential morbidity and potential for harm, there is the cost factor to consider. Additionally, since obtaining such data requires human experimentation, I feel it is unlikely that any study design would clear an institutional review board.
Monitoring this condition does not mean “do not treat.” Rather, it allows us to fully assess the patient, evaluate co-morbidities, determine whether treatment will have any benefit and what form of treatment is suitable for each unique patient.
Dr. Harris is a Clinical Associate Professor of Foot and Ankle Surgery at Loyola University Medical Center in Westchester and Maywood, Ill. He is a Diplomate of the American Board of Foot and Ankle Surgery and an Instructor in the Department of Podiatric Surgery and Applied Biomechanics at the Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science.
Point References
1. D’Amico JC, Valmassy RL, Smith L. Lower extremity examination of the normal infant. [film] San Francisco:Calif College Podiatr Med Educational Media Services;1976.
2. D’Amico JC. Developmental flatfoot. Clin Podiatry. 1984;1(3):535-546.
3. D’Amico JC. Developmental flatfoot. In: Thompson P, Volpe RL, (eds.). Introduction to Podopediatrics, 2nd ed. Churchill Livingstone;2001:269-272.
4. D’Amico JC. Developmental Flatfoot. Part I. Podiatry Management. 2018:9;155-163.
5. D’Amico JC. Developmental Flatfoot. Part II. Podiatry Management. 2018;10:120-128.
6. D’Amico JC. Pediatric Orthoses: An Overview. Part I. Podiatry Management. 2019;4:147-155.
7. D’Amico JC Pediatric Orthoses: An Overview. Part II. Pod Management. 2019;5:147-155.
8. Ganley JV. Corrective casting in infants. Clin Podiatry.1984:1(3):501-516.
9. Arkin AM, Katz TF. The effect of pressure on epiphyseal growth J Bone Joint Surg. 1956;38(A5):1056-1076.
10. Wolff J. The Law of Bone Remodelling. New York;Springer:1986.
11. Davis HG. Conservative Surgery. New York;Appleton:1867.
12. D’Amico JC. The postural complex. J Am Podiatry Assoc. 1976;66(8):568-574.
13. D’Amico JC. Lower extremity functional dynamics. Clin Podiatr Med Surg. 1988;5(3):521- 530.
14. Tax HR. An introduction to the study of children’s feet. J Nat Assoc Chiropodists. 1944:9-13.
15. Tax HR. Flexible flatfoot in children. J Am Podiatry Assoc. 1977;67(9):616-619.
16. Kosashvili Y, Fridman T, Backstein D, Safir O, Bar Ziv Y. The correlation between pes planus and anterior knee or intermittent low back pain. Foot Ankle Int. 2008;29(9):910-913.
17. Dananberg H, Giuliano M. Low back pain and its response to custom foot Orthoses. J Am Podiatr Med Assoc. 1999;89(3):109-117.
18. Whitman RA. The classic: a study of the weak foot with reference to its causes, its diagnosis and its cure;with an analysis of a thousand cases of so-called flat-foot. 1896. Clin Orthop Rel Res. 2010;468(4):925-939. www.podiatrytoday.com • December 2021 • Podiatry Today® 37
19. Whitman RA. Treatise on Orthopaedic Surgery, 5th ed. Lea & Febiger;1917.
20. Kirby KA, Green DR. Evaluation and management of the pes valgus foot. In: DeValentine SJ (ed). Foot and Ankle Disorders in Children. New York;Churchill Livingstone:1992;295.
21. D’Amico JC. Richard O. Schuster, DPM: A biomechanical icon. Podiatry Management. 2013:129- 137.
22. Schuster RO. Origins and implications of frontal plane imbalances of the leg. In: Yearbook of Podiatric Medicine and Surgery. Mt. Kisco, NY:Futura;1981.
23. Tax HR. Podopediatrics. Baltimore:Williams and Wilkins;1980.
24. Tax HR Excessively pronated feet: a health hazard to developing children. Chil Adol Soc Work J. 1993;10;431-440.
25. Day NR. Foot Owner’s Manual. Daly City, CA:PAS Publishing;1983.
26. Khamis S, Yizhar Z. The effect of feet hyperpronation on pelvic alignment in a standing position. Gait Posture. 2007;25(1):127-134.
27. D’Amico JC, Rubin M. The influence of foot orthoses on the quadriceps angle. J Amer Podiatr Med Assoc.1986;76(6):337-340.
28. Molgaard C, Rathleff MS, Simonsen O. Patelllofemoral pain and its association with hip, ankle and foot function in 16–18-year-old high school students: a single-blind case control study. J Am Podiatr Med Assoc. 2011;101(3):215-222.
29. Carr JB, Yang S, Lather A. Pediatric pes planus: A state-of-the-art review. Pediatrics. 2016;137(3):1- 10.
30. Bresnahan P. Flatfoot deformity pathogenesis: a trilogy. Clin in Podiatr Med Surg. 2000;(17)3:505- 512.
31. Blount WP. Fractures in children. Huntington, NY:Krieger;1977:185.
32. Schuster RO, Skliar JD. Outgrowing trends in the lower extremities in children. J Am Podiatr Med Assoc. 1991;81(3):131-139.
33. Altman MI. Sagittal plane angles of the talus and calcaneus in the developing foot. J Am Podiatry Assoc. 1968;58:463.
34. Sobel E, Levitz S, Caselli M, Brentnall Z, Tran MQ. Natural history of the rearfoot angle: preliminary values in 150 children. Foot Ankle Int. 1999;20(2):119-125.
35. Sommerville EW. Persistent fetal alignment. J Bone Joint Surg. 1953;39(B):106.
36. Benedetti MG, Ceccarelli F, Berti L, et al. Diagnosis of flatfoot in children: a systematic clinical approach. Orthopedics. 2011;34(2):94.
37. Volpe RL. Commentary on Evans AM Paediatric Flatfeet: a 2020 Guide for Clinicians to Identify the “Boomerangs” J Am Podiatr Med Assoc. 2021. [In Press]
38. Singh A, Kumar A, Kumar S, Srivastava RN, Gupta OP. Analysis of ankle alignment abnormalities as a risk factor for pediatric flexible flat foot. Internet J Med Update. 2010;5(1):25-28.
39. D’Amico JC Emerging insights on the collapsible cavus. Podiatry Today. 2017:30(2):42-51.
40. Greisberg J. Adult acquired flatfoot. In: DiGiovanni C, Gresiberg J. Core Knowledge in Orthopaedics: Foot and Ankle. Maryland Heights, MO:Mosby;2007.
41. Wenger DR, Mauldin M, Speck G, Morgan D, Lieber RL. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg Am. 1989;71(6):800-810.
42. Whitford D, Esterman A. A randomized controlled trial of two types of inshoe orthoses in children with flexible excess pronation of the feet. Foot Ankle Int. 2007;28(6a):715-723.
43. Bordelon RL. Hypermobile flatfoot in children. Clin Orthop. 1983;181:7.
44. Bordelon RL. Correction of hypermobile flatfoot in children by inserts. Foot Ankle. 1980;1:143.
45. Bleck EE, Berzins VJ. Conservative management of pes valgus with plantarflexed talus, flexible. Clin Orthop Rel Res. 1977;122:85-94.
46. Coleman SS. Complex Foot Deformity in Children. Lea & Febiger; 1983:194.
47. Connolly J, Regan E. Pigeon-toe and flatfeet. Ped Clin N Amer. 1970;17(2):291-307.
48. Donohue BK, Kulnell KA, Strenk ML. Rehabilitation of congenital and developmental conditions in children. In: Samarco GJ. Rehabilitation of the Foot and Ankle. St. Louis:Mosby;1995:181-182.
49. Basta NW, Mital MA, Bonadio O, Johnson A, Kang SY, O’Connor J. A conservative study of the roles of shoes, arch supports and navicular cookies in the management of symptomatic mobile flatfeet in children. Int Orthop. 1977;1:143- 148.
50. Duffin A, Kidd R, Chan A, Donaghue KC. High plantar pressure and callus in diabetic adolescents, incidence and treatment. J Am Podiatr Med Assoc. 2003;93(3):214-220.
51. Mereday C, Dolan C, Luskin R. Evaluation of the UCBL shoe insert in flexible pes planus. Clin Orthop. 1972;(82):45-58.
52. Asami T, Kodama K, Akiyama N, et al. Orthotic treatment using she inserts for talipes planovalgus in children. Presented at: International Society of Prosthetics and Orthotics 2013 World Congress, Hyderabad, India, February 2013.
53. Powell M, Seid M, Szer IS. Efficacy of custom foot orthotics in improving pain and functional status in children with idiopathic arthritis: a randomized trial. J Rheumatol. 2005;32(5):943-950.
54. Jafarnezhadegro AA, Mousavi SH, Madadi-Shad M, Hijmans JM. Quantifying lower limb inter-joint coordination and coordination variability after four-month wearing arch support foot orthoses in children with flexible flat feet Hum Mov Sci. 2020;70:102593.
55. Rose GK. Pes planus. In: Jhass MH. Disorders of the Foot. Philadelphia:WB Saunders;1982:486-520.
56. Scherer PR. Pediatric flexible flatfoot and functional orthoses. Recent advances in orthotic therapy. Lower Extrem Rev. 2011:69-87
57. Gould N, Moreland M, Alvarez R, Trevino S, Fenwick J. Development of the child’s arch. Foot Ankle Int. 1989;9(5):241-245.
58. Miller GR. Hypermobile flatfoot in children. Clin Orthop. 1977;122:9.
59. Blustein SM, D’Amico JC. Limb length discrepancy: identification, clinical significance and management. J Am Podiatr Med Assoc. 1985;75:200.
60. D’Amico JC. Keys to recognizing and treating limb length discrepancy. Podiatry Today. 2014;27(5):66-75.
61. D’Amico JC, Dinowitz HD. Limb length discrepancy: An electrodynographic analysis. J Am Podiatr Med Assoc. 1985;75:639-643.
62. Khamis S, Yizhar Z. The effect of feet hyperpronation on pelvic alignment in a standing position. Gait Posture. 2007;25:127.
63. Swanson AB, Greene PW, Allis HD. Rotational deformities of the lower extremity in children and their clinical significance Clin Orthop. 1963;27:157.
64. Ganley JV. Podopediatrics. Clinics in Podiatry. Philadelphia:WB Saunders;1984;445, 727.
65. Anderson M, Blais-Messmer M, Green W. Distribution of lengths of thenormal femur and tibia in children from 1 to 18 years of age. J Bone Joint Surg (Am). 1964;46:1194.
66. Blais MM, Green WT, Anderson M. Lengths of the growing foot. J Bone Joint Surg. 1956;39(A):998.
67. Hurrman WW. Congenital foot deformities. In: Mann RA. Surgery of the Foot. St. Louis:Mosby;1986:542, 545.
68. Rose GK. Correction of the pronated foot. J Bone Joint Surg. 1962;44B:642.
69. Helfet AJ. A new way of treating flatfoot in children. Lancet. 1956;1:262.
70. Trott AA. Children’s foot problems. Orthop Clin North Am. 1982;13(3):641-654.
71. Sgarlato T. Compendium of Podiatric Biomechanics. San Francisco:California College of Podiatric Medicine;1971.
72. Whitman R. Observations on seventy-five cases of flat feet. Reprinted from the Transactions of the American Orthopaedic Assoc, Vol 1. Boston;LP Kellogg and Son;1889.
73. Schuster OF. Foot Orthopaedics. New York;First Institute of Podiatry:1927.
74. Jay RM Schoenhaus HD, Seymour C, Gamble S. The dynamic stabilizing innersole system (DSIS): the management of hyperpronation in children. J Foot Ankle Surg. 1995;34(2):124-141.
75. D’Amico JC. Letters to the editor: The flat-footed child-to treat or not to treat? J Am Podiatr Med Assoc. 2009;99(3):267-268.
Counterpoint References
1. Bauer K, Mosca VS, Zionts, LE. What’s new in pediatric flatfoot? Pediatr Orthop. 2016;36(8):865-869.
2. Ueki Y, Sakuma E, Wada I. Pathology and management of flexible flat foot in children. J Orhop Sci. 2019;24(1):9-13.
3. Blitz NM, Stabile RJ, Giorgini RJ, DiDimenico L. Flexible pediatric and adolescent pes planovalgus: Conservative and surgical treatment options. Clin Podiatr Med Surg. 2010;27(1):59- 77.
4. Borrelli AH. Planar dominance. A major determinant in flatfoot stabilization. Clin Podiatr Med Surg. 2010;27(1):59-77.
5. Green DR, Carol A. Planal dominance. J Am Podiatry Assoc. 1984;74(2):98-103.
6. Maxwell JR, Carro A, Sun C. Use of the Maxwell-Brancheau arthroeresis implant forr the correction of posterior tibial tendon dysfunction. Clin Podiatr Med Surg. 1999;16(3):479-489.
7. Spinner SM, Chussid F, Long DH. Criteria for combined procedure selection in the surgical correction of the acquired flatfoot. Clin Podiatr Med Surg. 1989;6(3):561-575.
8. Evans AM. The flat-footed child—to treat or not to treat what is the clinician to do? J Am Podiatr Med Assoc. 2008;98(5):386-393.
9. Harris EJ, Vanore JV, Thomas JC, et al. Diagnosis and treatment of pediatric flatfoot. J Foot Ankle Surg. 2004;43(6):341-373.
10. Halabchi F, Mazaheri R, Mizhahi M, Abbasian L. Pediatric flexible flatfoot: clinical aspects and algorithmic approach. Iran J Pediatr. 2013;23(3):247-260.
11. Agnew PS, Raducanu Y. An algorithmic approach to evaluation of the flatfoot. Avoidance of pitfalls. Clin Podiatr Med Surg. 2000;17(3):383- 396.
12. Labovitz JM. The algorithmic approach to pediatric flexible pes planovalgus. Clin Podiatr Med Surg. 2006;23(1):57-76.
13. Evans AM, Rome K. A Cochrane review of the evidence for non-surgical intervention for flexible pediatric flat foot. Eur J Phys Rehabil Med. 2011;47(1):69-89.
14. Michaulet C, Edenfield KM. Nicolette GW, Carek PJ. Foot and Ankle Conditions: Pes Planus. FP Essent. 2018;465:18-23
15. Napolitano C, Walsh S, Mahoney L, McCrea J. Risk factors that may modify the natural history of the pediatric pronated foot. Clin Podiatr Med Surg. 2000;17(3):397-417.
16. Bouchard M, Mosca VS. Flatfoot deformity in children and adolescents: surgical indications and treatment. J Am Acad Orthop Surg. 2014;22(10):623-632.
17. Ford SE, Scannell BP. Pediatric Flatfoot: Pearls and Pitfalls. Foot Ankle Clin. 2017;22(3):643- 656.
18. Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop. 2010;4(2):107- 121.
