Childhood foot problems can have both immediate and long-term effects.
During growth, the normal development of the pelvis and the spine will suffer if there is a foot imbalance. A budding athlete’s skill level—even running at recess—can be significantly affected.1
Later on, foot problems from childhood can interfere with adolescent (or adult) spinal function, which can result in poor biomechanics and accelerated degenerative changes in the knees, hips and spine. With a relatively quick screening of your younger patients, you can identify those who need early intervention, and then provide them with proper custom-made orthotic support.
During early development, and especially when beginning to walk, a person’s lower extremities change significantly. The legs undergo rotation to allow the feet to align with the knees and hips for smooth gait. The arches slowly become more obvious and increase in height as gait improves.
The foot grows faster than the rest of the body; it achieves three quarters of its mature length by the time a child is 7 years old.2 Most problems arise when the feet and legs do not align properly (in-toeing or out-toeing), or when the main longitudinal arch does not develop fully (flatfoot).
In-toeing and out-toeing: Shoe modifications such as wedges, special lasts, and corrective orthotics have no significant predictable effect on children with in-toeing or out-toeing.3,4 Exercising the involved external (or internal) rotation muscles (to accelerate or stabilize the normal developmental rotation of the leg) may be useful, but has not been reliably tested. At this point, the best recommendation for most kids is to wear good shoes, and to focus on sports and activities that develop balanced leg muscles. When there is a family history of poor foot-leg alignment, custom-made orthotics may be of some benefit, primarily in improving biomechanical function and coordination during sports performance.
Flatfoot: The longitudinal arch normally develops during the first six to 10 years of growth. The reduced incidence of flatfoot seen in studies of barefoot populations suggests that muscle strength and mobility are important factors in the normal development of the arches.5-8 This means that a child is more likely to develop a flexible, strong arch when going barefoot. Wearing orthopedic shoes or arch inserts does not seem to influence the development of normal arches.9 Parents should be encouraged to let children go barefoot whenever it is safe, and to select shoes based on function, not just on style or cost.
Screening exam for orthotics
A very quick method for checking kids for the need for orthotics follows. This lower extremity screening examination fits well into standard chiropractic examination procedures, and can be performed easily on children down to ages 5 or 6. When several red flags are present, you will have to discuss the findings and the probable need for orthotics with the parents (see table).
Observe the child’s gait. By studying a few normal, relaxed paces, several abnormal gait findings can be distinguished. With young patients, the most common fault is in-toeing, followed closely by excessive out-toeing (foot flare). This can be identified by looking at the alignment of the foot with the lower leg as your patient walks. An angle that is less than 5 degrees or greater than 15 degrees is a red flag for excessive rotational torque stresses into the knees, sacroiliac joints, and spine.
Knee-to-foot alignment: Look at the lower legs of the child from the front. Mentally drop a straight line down from the mid-point of each kneecap to the foot. This imaginary plumb line should strike the foot over the first two metatarsals. If the knees point out or in when the feet are straight ahead, or if there is a valgus angulation (knock-knees), another red flag is raised.
Is the Achilles tendon straight? When you see a patient’s heel cord bowing inward (medially), you have a red flag that indicates probable instability of the calcaneus. When the heel does not align with the Achilles tendon, the child will develop into an over-pronator, and this biomechanical fault will interfere with knee, hip, and spinal function over the decades.
Check the medial arches. If you cannot get your finger under the medial longitudinal arch, the child is not developing normal arches. While palpating the arch, take a moment to push upwards into the plantar fascia. Even a brief palpation will tell you if the connective tissue that supports the arch is intact or under excessive strain. If this is painful to the child, it is possibly a sign of early plantar fasciitis, which is likely to still be at a stage where conservative biomechanical treatment will be rapidly helpful.
Toe-raise test for flexibility: If there is a lack of development of the medial arch, ask the child to do a toe raise. By standing on up on the toes, the plantar fascia is put under tension, creating a temporary arch in patients with a flexible flat foot. If the foot remains flat (or becomes convex) in this position, it is likely that the child has a rigid flat foot. This is due to an anatomical fixation, such as a tarsal coalition or an equinus foot.
Check for subluxations: Palpate and adjust any parts of the foot that are not functioning normally. Ask the child to walk around the room a few times, and then re-check. If the extremity subluxations that were just adjusted have returned, it demonstrates an underlying biomechanical problem that will need external support.
Examine shoes: Take a moment to inspect the wear pattern on the child’s shoes. Parents may need to bring in a worn pair for better analysis. Look to see if there are any excessive or abnormal wear patterns present, either at the heels or in the upper, softer portions of the shoes. A red flag is any asymmetrical, excessive, or lateral wearing down of a heel, or a bulging or tearing of the shoe’s upper material.
The need for kids orthotics
Children do not normally need custom orthotics until about the age of six years. If at that point a child is still not developing a normal arch, or if in-toeing persists, orthotics may be needed.
This is particularly true when the child is involved in athletics and sports activities. In these cases, custom-made orthotic support for the arches can significantly improve gait and running performance. Otherwise, most children are well-served by wearing sensible, flexible shoes.
When there is a family history of flat feet or in-toeing, a more aggressive use of orthotics is appropriate. Parents will need to be informed of the need to regularly refit the orthotics as the child’s foot grows.
1 Lin CJ, Lai KA, Kuan TS, Chou YL. Correlating factors and clinical significance of flexible flatfoot in preschool children. J Pediatr Orthop. 2001;21(3):378-382.
2 Staheli L. Corrective shoes for children: are they really necessary? J Musculoskel Med. 1996;13:11-15.
3 Knittle G, Staheli LT. The effectiveness of shoe modifications for intoeing. Orthop Clin North Am. 1976;7:1019-1025.
4 Toenges F. Shoe therapy: past and present treatments. Clin Podiatr Med & Surg. 1997;14:209-214.
5 Hoffman P. Conclusions drawn from a comparative study of the feet of barefooted and shoe-wearing peoples. Am J Orthop Surg. 1905;3:105-136.
6 Engle ET, Morton DJ. Notes on foot disorders among natives of the Belgian Congo. J Bone Joint Surg. 1931;13:311-318.
7 James CS. Footprints and feet of natives of the Solomon Islands. Lancet. 1939;2:1390-1393.
8 Sim-Fook L, Hodgson A. A comparison of foot forms among the non-shoe and shoe-wearing Chinese population. J Bone Joint Surg. 1958;40A:1058-1062.
9. Wenger DR, et al. Corrective shoes and inserts as treatment for flexible flatfoot in infants and children. J Bone Joint Surg. 1989;71-A:800-810.