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Original Research
PAGE NO.
13-20
10.37547/tajmspr/Volume07Issue03-03
OPEN ACCESS
SUBMITED
02 January 2025
ACCEPTED
03 February 2025
PUBLISHED
07 March 2025
VOLUME
Vol.07 Issue03 2025
CITATION
Bianca Gabriella de Oliveira, Gihad Reda Khalil, Hussien Ali Mustapha,
André Luís Matos Caetano, Vanderson Reis de Sousa Brito, & Marcella
Rodrigues Costa Simões. (2025). Therapeutic update of pediatric flatfoot:
a systematic review with meta-analysis. The American Journal of Medical
Sciences and Pharmaceutical Research, 7(03), 13
–
20.
https://doi.org/10.37547/tajmspr/Volume07Issue03-03
COPYRIGHT
© 2025 Original content from this work may be used under the terms
of the creative commons attributes 4.0 License.
Therapeutic update of
pediatric flatfoot: a
systematic review with
meta-analysis
Bianca Gabriella de Oliveira
Salvador, BA, Brasil
Gihad Reda Khalil
Médico residente em Ortopedia e Traumatologia do Hospital Municipal
Padre Germano Lauck, Foz do Iguaçu, PR
Hussien Ali Mustapha
Médico residente em Ortopedia e Traumatologia da Fundação Municipal
de Foz do Iguaçu, Foz do Iguaçu, PR
André Luís Matos Caetano
Médico residente em Ortopedia e Traumatologia do Hospital Municipal
Padre Germano Lauck, Foz do Iguaçu, PR
Vanderson Reis de Sousa Brito
Médico pelo Centro universitário Tiradentes, Maceió, AL
Marcella Rodrigues Costa Simões
Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil
Corresponding author
: Bianca Gabriella de Oliveira. Rua araçari,
número 18, bairro Muchila 2 (dois), Feira de Santana - Bahia, CEP
44005756
Abstract:
Objectives: The aim of this systematic review
is to evaluate the effectiveness of the use of orthoses in
the treatment of pediatric flatfoot.
Methodology: A systematic review was carried out in
the online databases Cochrane Library, EMBASE,
CINAHL, Medline and PubMed, using the following
terms: flatfoot AND pediatric AND Orthotic
Devices. There were no limitations on gender, date or
language. All results up to
February 1, 2024 were included.
Results: 213 patients under the age of 18 were included
in this study. The use of medial arch support insoles
proved to be effective in the treatment of flat feet in
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children, with an improvement in ankle internal
rotation angles and knee internal and external
rotation.
Conclusion: The use of orthoses has shown good
results and is a reproducible and reliable approach,
especially in pre- school patients who have been using
them for more than 12 months, with improvements in
gait, alignment and coordination of the lower limbs.
Keywords:
Flatfoot;
Pediatrics;
Orthopedic
procedures.
Introduction:
Flat feet result from loss of the medial
longitudinal arch, abduction of the forefoot and
excessive subtalar subtalar eversion, divided into rigid
or flexible. The pathology itself is marked by the rigid
form with etiologies such as genetic, neurological,
inflammatory, rheumatological, traumatic and/or
bone abnormalities.1,2 As it is mostly asymptomatic,
flexible flatfoot is classified as idiopathic, with no
apparent cause. It is one of the most common diseases
affecting pediatric health, as of 2006 the high
prevalence of flexible flatfoot in children aged three to
six was 44%, but the prevalence of pathological flatfoot
was less than 1%. It is a frequently reported disease.
1,2
The discussion of treatment and monitoring of
asymptomatic and symptomatic flat feet remains
heated in the orthopedic population, however the
main goals of treatment of flat feet are the relief of
pain or disability and the prevention of future
disabilities. Therapeutic options are diverse and
include rest, physical therapy, orthoses and the use of
anti-inflammatory drugs. 1,3
–
5 Surgical intervention is
uncommon, however, in the event of failure of
conservative treatment, the approach is indicated. 3
–
5
Surgical options and techniques include: soft tissue
procedures, realignment osteotomies and limiting
motion techniques without joint fusion. It is worth
noting that the latter is not recommended in the
pediatric population. 1,2,5
It is known that the progressive increase in the number
of obese children in the population is a relevant
epidemiological fact. Faced with mechanical overload,
these children report greater complaints of
musculoskeletal pain than eutrophic children,
therefore, obese children have a higher prevalence of
flat feet. The association between div weight and flat
feet in children shows a variation in the prevalence of
flat feet between 14% and 67%. Almost all studies have
indicated an increase in flat feet in children with
increasing weight.
Due to the different methodologies, the lack of
consensus regarding the definition of flat feet, the
scarcity of research on pain/complications and the few
existing studies, more research is needed to determine
a relationship between children's div weight, flat feet
and the associated effects on pain and function. The aim
of this systematic review is to evaluate the effectiveness
of the use of orthoses in the treatment of pediatric
flatfoot.
METHODOLOGY
Method
This systematic review was conducted in accordance
with the PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analysis) guidelines.6
Search strategy
The online databases Cochrane Library, EMBASE,
CINAHL, Medline and PubMed were searched using the
following terms: flatfoot AND pediatric AND Orthotic
Devices. The search was repeated using several
alternative spellings for flatfoot. No limitations were
imposed on gender or language.
All results up to 1 February 2024 were included. The
SPICE strategy was used to identify the most relevant
studies.
- Setting: Patients under 18 years of age diagnosed with
flatfoot.
- Perspective: Individuals undergoing a non-surgical
approach using orthoses for the treatment of flatfoot in
children.
- Intervention: Non-surgical treatment.
- Comparison: patients undergoing flatfoot treatment
using orthoses compared to the placebo group.
- Evaluation: effectiveness of non-surgical treatment.
Inclusion and exclusion criteria
The following were included: (1) studies with patients
under 18 years of age (2) studies with an approach to
patients diagnosed with flatfoot treated with the use of
orthoses (3) studies published between 2009-2024 (5)
original studies, preferably randomized studies.
Exclusion: (1) studies that evaluated surgical techniques
for the treatment of flatfoot (2) studies published more
than 15 years ago (3) non-original studies.
This systematic review has the registry code of the
successful ID CRD42024519348.
RESULTS
Initially, 201 articles were selected, 72 of which were
excluded because they had been published more than
15 years ago, leaving 15 articles. After evaluating the
titles and abstracts, 35 were excluded, leaving 27 for full
reading. These articles were analyzed and only 04 were
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randomized clinical trials related to the treatment of flexible flatfoot (Figure 1).
Figure 1 - Studies selected according to PRISMA parameters.
The 04 selected articles presented children diagnosed
with flatfoot who underwent treatment with orthoses.
An analysis of the functional evaluation, correction of
the deformity and associated pain was performed in
those studies that involved these variables. In total,
213 patients under 18 years of age were included in
this study.
Table 1 presents the selected studies and their
outcomes. 7,8,9,10
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Table 1. Results obtained by the selected studies.
Table 2 contains the analysis of treatments for correction of flat feet in children. 7,8,9,10
Table 2- Analysis of the studies selected to evaluate the efficacy of treating flexible flat feet in children.
The randomized clinical trial by Liebau et al evaluated
the efficacy of support and sensorimotor insoles in
relation to a control group. An evaluation of the
muscular activity of the tibialis anterior and peroneus
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longus muscles was performed as a parameter in the
treatment of flat feet. The comparison, in relation to
the mean, of the activity of the tibialis anterior muscle
with the support insoles (p: 0.757), sensorimotor
insoles (p: 0.971) and placebo (p: 0.046). While the
muscular activity of the peroneus longus for the
support insoles (p: 0.180), sensorimotor insoles (p:
0.057) and placebo (p: 0.600). The valgus index, which
assesses rearfoot alignment, varied from 31.7 to 34.1
in the placebo group, 32.2 to 33.7 in the sensorimotor
insole group, and 32.5 to 32.0 in the support insole.
The foot and ankle disability index (FADI) changed from
95.8 versus 98.9 in the placebo group, 90.7 versus 96.3
in the sensorimotor group, and 94.8 versus 94.0 in the
support insole. There were no significant variations in
pain between groups.7
Jafarnezhadgero et al presented a randomized clinical
trial that compared the use of support insoles with
placebo insoles. The mean time of use of support
insoles was 6.8±3.8 hours and 7.0±3.7 hours per day
for placebo. The use of support insoles was related to
significant improvement in walking kinematics with
evolution of the results of internal rotation angles of
the ankle (5.2° +- 0.8 versus 3.3° +- 1.2) and internal
rotation (8° +- 2.5 versus 4.8° +- 0.6) and external
rotation (-12.7° +- 0.9 versus -10.7 +- 0.7) of the knee.
There was no association between an improvement in
walking speed and leg length adjustment; the support
insole group presented pre-treatment values of
2.43±0.37 m/m/s and post-treatment values of
2.42±0.35 m/m/s, while the placebo group was
associated with 2.44±0.38 m/m/s and post-test values
of 2.43±0.34 m/m/s.8
Sinha et al, through a randomized clinical trial,
analyzed the effectiveness of using a medial arch
support insole in relation to placebo. The orthosis
group had a shorter follow-up time than the control
group, median of 9 vs. 19 p=0.003. The use of the
support insole was related to a significant
improvement in the AOFAS scores of the forefoot,
midfoot and hindfoot, values before and after
treatment: 56+- 15 versus 68+- 12; 63 +- 10 versus 66
+- 12 and 66 +- 10 versus 77 +- 13, respectively. For the
control group, only the forefoot and hindfoot scores
showed improvement: 54 + -10 versus 58 + -10 and 63
+ -10 versus 67 + -11, respectively. When comparing
the changes in foot angles in the two groups, there
were significant differences in the lateral angle of the
first metatarsal of the left foot (p = 0.004), lateral angle
of the talocalcaneal of both feet (p < 0.001), and
inclination angle of the calcaneus of the left foot (p =
0.016).9
The randomized clinical trial by Hsieh et al also
evaluated the use of medial arch support insoles in the
treatment of flexible flatfoot. The parameters evaluated
demonstrated better results in the group using support
insoles compared to placebo: physical health (10.3% vs
−38.9%, P = 0.035 PedsQL and P < 0.001 by ANCOVA);
pain (30.4% vs −7.7%, P = 0
.048 and P < .008 by
ANCOVA), mobility (65.9% vs 20.7%, P = 0.042 and P <
0.005 by ANCOVA) and physical function (21.6% vs
−33.3%, P = 0.016 and P < 0.001 by ANCOVA).10
DISCUSSION
The muscle activity of the lower leg, assessed in the
study by Liebau et al, was greatly influenced by the use
of support and sensory motor insoles, with no
significant functional differences between the two. The
use of medial arch support insoles proved to be effective
in treating flat feet in children, improving ankle internal
rotation angles, internal and external knee rotation,
providing functional results in walking kinematics, as
well as improving pain, limb mobility and physical
function.7,8,9,10
There is a wide range of treatments for flexible flatfoot,
although it is still a much debated and controversial
subject,
which
involves
issues
ranging
from
differentiating between physiological and pathological,
how to make the diagnosis, when to start treatment,
what is the best therapeutic option and when to advise
surgical intervention or whether not to approach it and
allow the physiological evolution to continue11,12,13..
For this reason, the choice of the therapeutic approach
often depends on the individual doctor14. However, the
factors that are taken into account when establishing an
intervention are age, flexibility, the symptoms
presented, the equinus position, the severity of the
deformity and suitable footwear15.
The most commonly used conservative treatments are
foot orthoses (FOs), physiotherapy with joint
manipulation, the Mulligan method, corrective
footwear and
physical exercise. 14,16-23 The surgical approach
includes procedures such as subtalar arthrolysis 24,
indicated for feet with severe deformity, rigid flat feet
or without clinical improvement and persistence of
symptoms even with the conservative approach. 25
The earlier effective treatment is started, the less
damage will occur to other parts of the div.
Furthermore, they added that conservative treatment
should be carried out rather than invasive
treatment19,26. Therefore, since untreated flexible
flatfoot can trigger problems in the foot itself or in other
structures, it is necessary to demonstrate the
effectiveness of OP as a conservative therapy to reduce
clinical symptoms and improve the quality of life of
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patients8,25,27-3
A recent study showed that OP has a positive impact
on pain, gait, posture and foot function.1 Although
there is no agreement on the ideal type of orthosis,
they all have a high degree of longitudinal support of
the medial arch and are made of different materials,
but always rigid or semi-rigid25. The use of factory-
made orthoses has been proven to be better than
prefabricated orthoses, as they promote better foot
adaptation and pressure distribution32. There is also a
relationship between the hardness of the OP and the
effectiveness of the treatment, but this increase is
related to soft tissue damage33.
As for the time of use, studies specify that it should be
used every day, for a period of between 3 months and
6 years8,34,35,36. However, there is no agreement on
this time, however three months are considered an
insufficient period for therapy37,38. Its use can have
an immediate effect and modify the children's feet, but
it is after 12 months that more changes and
improvements are observed, such as in gait kinematics,
alignment and coordination of lower limbs8,34,39.
Regarding age, some argue that the best results and
evolution of treatment is before the age of six and
others after the age of six40,41. The study published
by
Lee et al.42 found that FO should be offered to children
under the age of six, given that in their study of
children aged between 1 and 12, the best results were
in preschoolers, and that children over the age of 7
showed minimal correction.However, it should also be
pointed out that the natural development of the foot
occurs before the age of 6-743,44,45. Furthermore, it
is not known whether gender influences the
prevalence of flat feet, although it does show a higher
incidence in male children46,47,48.
As for the negative effects of this therapy, they report
skin irritation, increased pain, intolerance or
discomfort after using the orthosis and problems with
the fit of the shoe49. Some scholars state that the use
of footwear is part of the treatment to ensure the
effectiveness of the OP39. However, only one group of
scholars have advised patients on a specific type of
footwear8,34.
CONCLUSION
It can be concluded that this pediatric pathology needs
to be further discussed and studied, since there is no
agreement as to its definition, diagnosis, therapeutic
management and onset. The use of orthoses has
shown good results, being a reproducible and reliable
approach, especially in pre-school patients who use
them for more than 12 months, with improvements in
gait, alignment and coordination of the lower limbs.
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