Do all paediatric flatfeet need management? My thoughts on the self professed controversial article

Recently this article was shared around facebook, close in timing to a systematic review on the effectiveness of foot orthoses for paediatric flat feet. It was shared with a statement acknowledging that it takes a controversial stance and would likely draw comment.

People that are familiar with my social media presence know I’m not one to shy away from sharing opinions that go against the grain. One of which turned into a formalised debate between myself and Robert Issacs on the topic of diagnosis, which I loved because I felt like we delved into a lot of nuance and created a learning experience for everyone, whether you agreed with me, Robert or neither of us!

So it’s worth noting, I’m not against making controversial statements. However, the widespread nature of this piece, being published in a article in well known news media publication, and therefore taking their point to the public first, has spurred me to make my thoughts known outside of a social media comment.

The core issue I have with this article is the assertion that flat feet are always painful and destructive and therefore require correction. There is no evidence to support this and evidence that doesn’t support this link wasn’t presented in this article.

I agree with the author’s that it is likely that in someone with a paediatric flatfoot, they are unlikely to suddenly develop an arch. Kids don’t grow out of flatfeet. And the biomechanics evidence they present appears to support this. I however should mention this here, am not an expert in podopaediatrics and extensively familiar with the research in this area. Cylie Williams, Alicia Jame, Angela Evans are 3 amazing clinicians and researchers who I would trust for their opinion in this area.

(Edit: It has come to my attention that there’s evidence to show that kids feet do ‘un-flatten’ in the first decade of life ref, ref)

I also agree with the author’s frustration in seeing patients who have long term pain and disability from a lack of intervention for their flat feet while a child. Anecdotally I have seen and believe there are other cases out there, where patients experience pain and disability associated with flat feet as a child, that wasn’t appropriately treated due to the misunderstanding that flatfeet are ‘normal’ in children, therefore never require treatment and don’t apply treatment when symptoms are present. Or that patients/parents aren’t given a choice in whether they wish to intervene in flatfeet, with full informed consent about what we do and don’t know.

But is that all paediatric flatfeet?

It appears that the author’s take a philosophical bias of medical reductionism. That the body operates like a machine and our role is to remove dysfunctions.

While this viewpoint has been helpful for many years and led to numerous advances in the treatment of medical conditions, this viewpoint hasn’t held up in musculoskeletal medicine and pain. We don’t see the relationships between foot posture or gait and pain (ref, ref), posture and pain in the shoulder and multiple levels of the spine (Ben Cormack’s done a nice little blog with links to the evidence here) as well as large bodies of work that illustrate that the postural-structural-biomechanical model of the human body doesn’t reflect the reality of pain and disability (ref). 

What we are learning is that there are many factors that can result in someone developing injury or pain. Bittencourt NFN et al does a review of complexity which highlights this fact (ref) and we see these same lessons in conditions such a low back pain (ref) and tendinopathy (ref) that highlight that there isn’t one factor that results in the presentation of pain and disability, but likely many different factors operating together that result in an issue arising (ref, ref)

For paediatric flat feet, or really any musculoskeletal condition, we don’t have and are unlikely to have anytime soon, a complete understanding of the pathogenesis and the factors that come together to produce this outcome, because they are likely to be highly varied, many ways that they can occur and are difficult to study in a way that removes confounding factors.

So the most likely outcome is that some paediatric flat feet need intervention, but we’re left in the dark about how we predict and discover those who need and will benefit from treatment.

One of the criticisms I’ve seen of this piece is that it uses ‘old evidence’ to support its viewpoint. There’s an opinion that because evidence is older that it somehow is completely irrelevant based on that fact alone, which was a common viewpoint when I studied both my undergrad and post-graduate degrees, which I never agreed with.

An experiment or article can hold up many years after its publication. It may be the only work or experiment in its area, or work that has never been followed-up on because of a lack of funding. We have many amazing papers on pain and the biopsychosocial model which still present relevant points to today’s practice and provide a historical perspective that show that maybe practice hasn’t moved as far forward as we think.

I think one of the concerns about older papers is that their experiments are designed and discussions written at a time before contemporary discoveries, which can mean their decisions and conclusions don’t get this benefit and may lead us astray. That we don’t get the benefit of the current context of musculoskeletal medicine and its discoveries. That’s what I think this whole article suffers from.

While presenting some incredibly valid points and highlights how we can be too quick to uptake evidence that suggest flat feet are normal and uniformly apply the principle that they don’t need intervention, it presents viewpoints and evidence that completely ignore the contemporary evidence that does exist, including the recent systematic review of the use of foot orthoses for paediatric flat feet and the wider evidence of the human body to suggest that pain and injury are more complex than just a postural dysfunction.

My conclusion from reading the evidence that I’ve had available to me, is that we should be diligent in assessing the patients with paediatric flat feet that do present to us about whether there may be reason to intervene. But we also must be equally as diligent about our biases when applying therapy, including our personal experience may be prone to survivorship bias of those who come to see us and our own personal financial gain from intervening.

My only other point is it is disappointing to see such a contentious view presented is such a reductionist and threat-invoking manner. We have a lot of evidence illustrating the link between pain and health related beliefs and increased disability and unhelpful pain related problem solving behaviour, that creates difficult scenarios for clinicians to assist patients with positive behaviour change (one link to a good review of the literature for brevity’s sake ref). 

In the absence of hard and consistent data supporting your viewpoint, I think it’s unhelpful and potentially raising to the point of harmful for some, to present information that evades the complexity of the situation and can invoke beliefs about the function of the human body and can influence patient’s belief and therefore engagement in unhelpful pain-problem solving behaviour.

So while I am very sympathetic to the legitimate issues the authors see in clinical practice and have presented in this piece, I find the lack of context and complexity presented, which influences their conclusion, concerning and why I disagree with it.

Alex Murray Podiatrist

Alex Murray is a Podiatrist working in private practice and the founder of website Making Sense in Podiatry. He's passionate about helping other clinicians make sense of evidence and clinical practice with a core philosophy of exploring the complexity of human beings, embracing the uncertainty of clinical practice, and avoiding overly reductionist thinking. In addition to his undergraduate degree from La Trobe, he also holds a Post Graduate Diploma in Sports and Exercise Medicine from the University of Otago. He has experience with both national and international athletes and has recently transitioned to focusing primarily on helping the general population and local athletes manage their pain and achieve their goals.

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