Using the new Paediatric foot posture Ready Reckoner
The recent publication of international normative data for paediatric foot posture collated the foot posture (Foot Posture Index: FPI-6) from over 3000 healthy children (https://bmjopen.bmj.com/content/9/4/e023341).
Normative reference data is helpful for clinicians, as it allows comparison of an individual with a relevant group or population.
Paediatric foot posture, and especially the flatfoot, has been confused for too long. Often ‘overdiagnosed’, asymptomatic children have been treated ‘just in case’ or with the misguided impression that all flatfeet are problematic.
For clinicians, the data from this study has been translated as a Ready Reckoner, to aid clinicians in shared discussions with parents, children and other medical and health professionals [download Ready Reckoner HERE – https://angelaevanspodiatrists.com.au/evidence-essentials-blog-7-may-2019/]
Notable ‘benchmarks’ include:
- The average FPI score across childhood is +4, with standard deviation of +3.
- Translated for the clinic, this means the normal FPI range is +1 to +7, in approximately 2/3 healthy children.
- No relationship was found between heavier children and ‘flatter’ feet.
How might this help you in your practice?
Case example 1 – age 9
The parents of an asymptomatic healthy 9 year old girl prented with query about their child’s foot posture. It just seemed to look flatter than ‘seemed right’.
Developmental and growth history was unremarkable, with independent bipedal gait from 12 months. Regular activity included swimming, school PE, gym, and family bushwalks. Family history sparked parent’s concerns with the maternal grandmother having ‘bad feet’ and mother using customised foot orthoses to alleviate her ankle pain.
Assessment revealed FPI of +6. Referring to the Ready Reckoner, it was reassuring for the parents to see their daughter’s foot posture in the expected range, along with approximately 2/3 of same age children.
Assessment also revealed ligament laxity (Beighton score 8/9) which prompted a “ah, that’s like me, and like your Grandma”, from the mother, with reference to her ankle symptoms.
Footwear was poor – slip on, soft loafer style – which actually increased the pronated foot posture and less propulsive gait, than when barefoot. Better footwear was purchased, which reduced gait angle abduction and improved toe off.
It was agreed to review progress with growth in 12-18 months, or if symptoms arose. The contribution of familial hypermobility was discussed, and the importance of foot strength, footwear, regular physical activity and normal BMI.
Case example 2 – age 11
A healthy 11 year old girl and her mother presented with concern about the girl’s foot posture and increasing ankle pain episodes over the previous six months. A physiotherapist had previously been consulted regarding knee pain, and had suggested a podiatry consult. There was no clear injury history, growth had been rapid in the last 12 months, with tight hamstrings aggravating knee symptoms.
Netball and dance were the dominant sports, and non-organised activity level described by the mother as “very!”. Developmental, family history and general health were unremarkable.
Gait revealed a consistent limp with consistent R ankle pain, despite good shoe support. The ankle was not swollen or bruised, but sore with end-range foot eversion. In stance the talo-navicular region protruded medially. The tarsal tunnel was tender, with a mild Tinel’s sign. Posterior tibialis strength was good, and the navicular tuberosity not palpably sore. Sagittal ankle range was reduced – weight-bearing lunge at 25 degrees (gastroc). There was no pain at night.
Assessment revealed FPI of +9. Referring to the Ready Reckoner, it was clear for both the girl and her mother, that foot posture was outside that expected for an 11 year old, being on the ‘edge’ of 95% of 11 year old’s expected foot posture.
Regardless of foot posture, the ongoing ankle pain directed intervention, with the added challenge of a netball semi-final in three days time.
Initial treatment included: tape (Figure 6 and reverse), ice, calf stretches, pre-fabricated foot orthoses/posted to increased midfoot stability, with the advice of a half game for the final.
The netball final was managed (full game) without worsening the ankle pain, which then improved rapidly once netball load reduced, and the ‘strained’ foot posture addressed.
From these two very regular cases:
- It is clear that painful presentations take priority, as triaged by the ‘Three Quick Questions’ – 3QQ (https://onlinelibrary.wiley.com/doi/epdf/10.1111/jpc.13761)
- Foot posture > mean +1SD, and especially when > mean +2SD, should heighten clinical suspicion, so that wider diagnostic factors are considered.
The Ready Reckoner is really useful for clinicians in making clear and shared decisions with paediatric patients and their parents/acrers.
Thank you for viewing this Evidence Essentials blog.
Dr Angela Evans AM
PhD, FFPM RCPS(Glasg)