Flatfoot in Children and Adolescents (Pes Plano Vagus)
Overview
Pes plano valgus (PPV) is the medical term for the condition commonly known as flatfoot. We use the term to describe a foot with an abnormally low or flattened arch that causes the ankle to roll inward and the heel to roll outward. These position changes are called pronation of the foot.
The arch of your child’s foot does not develop until he or she is 3 to 5 years old. Your child may simply have a low arch, without additional symptoms. If your child has PPV, the condition is not usually painful, but you may notice that your child complains of sore feet and ankles after playing sports or walking.
There are 2 types of PPV. The most common is the flexible type, in which the joints of the foot and ankle are mobile. A relatively uncommon form can be caused by a condition called tarsal coalition, which limits joint movement.
We usually recommend treatment if the foot is painful or if the abnormal arch is affecting the overall alignment of your child’s foot. Surgery is not commonly recommended and often reserved for children over age 5 or adolescents who have continuing symptoms (pain) despite a nonsurgical care program.
Symptoms
PPV does not always cause symptoms. When your child is sitting down, you may not notice anything unusual about the foot at all. Possible symptoms of PPV include:
- Foot and leg fatigue. Younger children may complain of tired feet or legs. You may notice that your child asks to be carried after only a short walk or is reluctant to participate in sports.
- Foot or leg pain. Older children and adolescents may complain of knee, shin, heel, ankle, or arch pain during sports activities. When the foot pronates excessively, the knee tilts inward as well. If this movement is excessive, it can cause knee pain due to the uneven weight distribution at the knee joint. Similarly, the hip and lower back may also become painful as a result of abnormal function of the foot.
- Foot conditions. A pronating foot places excessive force on other joints of the foot, stretching them. Over time, this hypermobility can permanently affect the alignment of the joints in the foot, causing bunions, hammertoes, and heel pain.
Causes
In most cases, PPV is caused by an associated hereditary condition. Examples include the following:
- Irregular bone and joint alignment.
- Hyperflexible joints. In flexible PPV, the ligaments in the foot that hold the bones together are too loose, allowing the joints to move excessively. In response to this hyperflexibility, the structures of the foot and ankle have to work harder to keep the foot in correct alignment. Over time, this extra effort weakens the foot, leading to a sagging of the arch.
- Tight calf muscles. Most cases of flexible flatfoot in children are associated with a very tight calf muscle.
- Excess weight. Carrying excess weight can put pressure on a child’s foot that causes symptoms similar to PPV. However, it does not cause PPV. Losing the weight will usually fix the symptoms.
- Congenital flatfeet. There are 2 uncommon congenital (present at birth) conditions that cause flatfeet: vertical talus (not flexible) and calcaneovalgus (flexible). Since these conditions are usually identified at birth and treated differently from the more common PPV, they will not be discussed here.
Diagnosis
We can often diagnose PPV based on a physical examination of your child’s feet and posture. We will also ask you about your child’s medical and family history to determine if other family members also have the condition or other foot-related problems.
We will ask your child to stand in bare feet while we look at the feet from all angles. We may ask him or her to lift the toes and to stand on tiptoe. We will usually examine the calf muscles and Achilles tendon to see if tightness in these areas may be affecting the arch. Sometimes looking at patterns of wear on the child’s shoes as well as any calluses on the feet can help confirm the diagnosis.
Non-surgical Treatments
Nonsurgical Treatment
Typically, we recommend treating PPV if your child is experiencing pain, or if the condition is harming the correct alignment of the foot. We rarely recommend surgery unless nonsurgical treatments have proven to be ineffective and pain is continuing.
We will discuss treatment options with you and your child. The goals of treatment are to eliminate pain and other symptoms and to enable your child to regain full comfortable use of the feet and legs. Nonsurgical treatments cannot raise the arch or permanently correct the structure of the foot.
Nonsurgical treatment options include the following:
Appropriate footwear. Choose supportive shoes that have a sturdy heel counter. Boots or hightop shoes are preferable, as they provide more support than standard footwear. We recommend that your child avoid wearing sandals or going barefoot. It is important to replace shoes that show signs of wearing out in the sole or heel.
Orthoses. When you buy new shoes for your child, replace the insoles with an orthotic insert that provides additional arch support and prevents further stretching of loose ligaments and tendons. You can buy over-the-counter or custom-made orthotic inserts at our medical offices.
- Over-the-counter inserts. Because children grow quickly and custom-made orthotic inserts are expensive, we recommend that you try noncustom inserts first. We can recommend the most appropriate orthotic inserts for your child’s feet. We stock specific over-the-counter brands that we feel provide the best support and quality. If you are buying inserts from a non-Kaiser Permanente pharmacy, please ask us about the best type to buy.
- Custom-made foot orthoses. If your child still has pain or fatigue, or the alignment of the foot is threatened, we may suggest that you try custom orthotic inserts. This is a good idea when your child’s feet have finished growing, usually at around 14 to 16 years of age. We make a plaster cast of your child’s foot that is used to build the orthotic inserts. Custom foot orthoses are not a covered benefit of the Kaiser Permanente Health Plan, but they are available on a fee-for-service basis.
- Calf-stretching exercises. Sometimes a tight calf muscle can cause or contribute to PPV. We recommend that your child practice calf-stretching exercises for 30 to 60 seconds on each leg at least 2 times per day. Teach your child this technique: Stand an arm’s length away from a wall, facing the wall. Lean into the wall, stepping forward with one leg, leaving the other leg planted back. The leg remaining back is the one being stretched. The leg being stretched should have the knee straight (locked) and the toes pointed straight at the wall. Stretch forward until you feel tightness in the calf. Hold this position without bouncing for a count of 30 to 60 seconds. Repeat the stretch for the opposite leg.
- Weight management, if necessary. Losing weight can reduce stress on the feet and improve symptoms.
If your child has a flare-up of PPV symptoms, we recommend following these steps:
- Modify activities. Encourage children to decrease the amount of time they spend on their feet during physical education class, sports, and play. When the feet are painful, we recommend that your child switch to nonimpact forms of exercise such as cycling, swimming, and pool running.
- Ice the area. Use ice on the painful area for 15 to 20 minutes at least 2 to 3 times a day. You can fill a Styrofoam or paper cup with water and freeze it. Peel back the leading edge of the cup before application. Massage the affected area for 15 to 20 minutes. Or apply an ice pack for 15 to 20 minutes. Avoid using ice if your child has circulation or sensation problems.
- Use oral anti-inflammatory medication. Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, can help manage pain or discomfort. Ask us about the recommended dosage for your child. The correct dosage will depend on your child’s weight and age.
Surgical Treatment
Most children and adolescents with PPV will not need surgery. We rarely recommend surgery for children under 5 years of age, because the arch may not yet be fully developed. Sometimes, if your child has a family history of severe PPV, we may discuss surgery as an option. People who have surgery for PPV may still occasionally need foot orthoses to support their surgically corrected alignment.
Typically, we recommend surgery when:
- We have tried other treatments for an extended period of time, and they are not working.
- The alignment of the foot is abnormal as a result of PPV. This increases the risk that other foot problems will develop.
- Factors causing PPV are not responding to treatment and are likely to respond to surgery. An example would be a tight calf muscle.
Surgical procedures
We can use a variety of different surgical procedures to correct PPV. We may combine several approaches. The exact combination of procedures we recommend will be influenced by your child’s age and the source of the alignment abnormalities. Surgeries of this nature typically require general anesthesia. Your child may need to stay in the hospital overnight. Full recovery generally takes 4 to 12 months.
Techniques include:
- Calf muscle lengthening. Lengthening the calf muscle and/or tightening a tendon can adjust the positioning of the foot and increase the arch height.
- Implant procedure. In very rare cases, we can surgically place an implant to increase the height of the arch.
- Repositioning of the heel. We may consider lengthening the heel bone with a bone graft in order to raise the arch.
Surgical risks
All surgeries involve some level of risk. The risks of PPV surgery include:
- Infection
- Nerve injury or entrapment
- Delayed healing/recovery
- Wound or scar problems
- Incomplete relief of pain
- Worsened pain
- Calf atrophy
- Weakness
- Rejection of implants
Additional References
Disclaimer
If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following: (1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder.
This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.