Symptomatic pes planus in children: a synthesis of allied health professional practices

Paediatric pes planus (flat foot) is a nebulous presentation which has challenged clinicians for many years [1‐5]. Pes planus is typically described as flexible (non-osseous) or fixed (osseous) [6] and is a common presentation to clinical services [7‐9]. The flexible variant can be further characterised as asymptomatic (often referred to as physiological) or symptomatic [6]. Typical features of symptomatic pes planus include foot pain [1, 6, 10], functional impairment such as tripping and fatigue [1], proximal joint problems [11], and reduced quality of life [12, 13].Children with both asymptomatic and symptomatic pes planus frequently present to health professionals with parents reporting concerns about the physical appearance of their child’s feet [7, 14]; however opinion supports intervention for symptomatic presentations only [1, 4, 6].

Pes planus is often characterised by observable features of foot shape and position (e.g., decreased height of the medial longitudinal arch, and valgus position of the rearfoot), although there are no standardised criteria [2, 15, 16]. Given this ambiguity it is no surprise that evidence underpinning treatment effectiveness remains elusive [17]. Treatment for the symptomatic presentation is often multi-faceted and includes non-surgical [17, 18] and surgical [3, 6, 8] interventions. Common non-surgical interventions include footwear advice, stretching and strengthening exercises, and foot orthoses [6], yet there is little guidance on what an appropriate intervention is, and when, or for whom, this should be used. Research amongst Canadian physiotherapists identified a lack of consensus regarding clinical use of foot orthoses for children with gross motor delay [10]. More recent work by Dars and colleagues [1] sought consensus on diagnostic methods and interventions for children with flexible pes planus; however this only considered the perspective(s) of podiatrists. Within the UK, foot orthoses are commonly prescribed by podiatrists, physiotherapists, and orthotists [19] and therefore, further work is needed to understand how these professions approach assessment and management of children with pes planus.

The aim of this work was to explore health professional (podiatrist, physiotherapist and orthotist) perspectives on the assessment and management of symptomatic pes planus in children. Given the persistent debate about this condition, exploring current practices may help ensure consistent, evidence-based assessment and intervention strategies are delivered by health care professionals working in this area.

The findings from this survey offer a snapshot of professional approaches to assessment and management of symptomatic pes planus, and highlight common strategies adopted by the three professional groups. The results suggest that these professional groups have differing priorities for clinical assessment and demonstrate some inconsistencies with the approaches to intervention and use of outcome measures. These results might help to contribute to wider efforts seeking to better understand the working context and scope of practice of health professionals who prescribe foot orthoses [19, 24].

Assessment techniques for symptomatic pes planus varied between professions and diverged from recent recommendations advocating use of the FPI-6 and static, footprint-based measures [16]. None of the respondents reported using static footprint measures, but many included both static and dynamic assessments; this was most commonly joint range of motion and standing tip-toe, although the podiatrists also used the FPI-6. Assessment of foot shape was a priority for the podiatrists but all professions appeared to make treatment decisions based on physical presentation and (to some extent) physical function, as supported by the existing literature [1]. Further consideration of the theoretical frameworks that inform assessment choices may clarify the relationship between these approaches and the interventions that are subsequently selected. Based upon the findings from this survey, it is unclear if the assessment techniques resulted in different outcomes.

The data demonstrated that treatment options were diverse, and professionals adopted various first-line approaches. Orthoses, stretching and/or strengthening exercises, footwear advice, and complementary strategies (e.g. manipulation) were all identified as components of care and these mixed practices are broadly consistent with the existing literature [8, 17]. Foot orthoses were commonly used by all three professions, despite debate over their effectiveness [17] and robust evidence remaining elusive. As expected, the data suggested that the professional groups used orthoses in different ways (accompanied or augmented by a variety of other intervention modalities). The results also highlight some early evidence that parents have different expectations of the professional groups, which suggests that it is important to understand more about the profile of the children who are seeing the different professionals. Consistent with previous reports [1], the podiatrists in this study preferred prefabricated orthoses to bespoke devices; but there was variability across the professions. Disagreement about orthoses as a first-line intervention was most evident amongst the physiotherapists. These descriptions of intra- and inter-professional practices echo a wider discussion about the quality and consistency of orthotic service provision within musculoskeletal services [25]. It is clear that clinical approaches are multi-factorial and likely to represent a combination of geographical factors [26], sparse evidence [17], and professional preferences [27] . It is feasible that lack of knowledge and/or confidence may also impact consistency in practice [28], and further evidence to inform management strategies is needed.

The survey also sought to understand how clinicians responded to the asymptomatic children referred into their services. Consistent with previous results [7], most clinicians in this sample indicated that they would not intervene. The data suggested that various factors, most commonly foot presentation, informed clinical decision-making and this implies that some clinicians would intervene if they felt the foot presentation was “excessive” or in some way outside typical boundaries. Efforts are needed to ensure that paediatric interventions are underpinned by appropriate conceptual frameworks such as the International Classification of Functioning, Disability and Health (ICF) [29]. Respondents to this survey reported that they used few objective, standardised measures to evaluate outcomes in practice. Whilst the use of VAS and (non-specific) patient reported outcomes were common, a shift towards disease-specific assessment and consideration of functional capabilities is indicated. Efforts to adopt developmentally-appropriate [30], validated, child-centred outcome measures (such as the Oxford Ankle Foot Questionnaire) [31], which are aligned to patient goals, might complement existing measures. Ensuring that outcome measures are aligned with the ICF [29] domains, particularly the activity and participation dimensions, by emphasizing activity and participation-related outcomes rather than impairments of body structure and function could help foster a more biopsychosocial approach to intervention and facilitate integrated services for these children. This could also help erode some of the persisting (but out-dated) approaches to assessment and intervention for these children.

Whilst the results of this survey help to inform our understanding of current approaches to the assessment and management of symptomatic (flexible) pes planus, the findings must be considered in light of some limitations. We adopted an open invitation sampling approach of clinicians with the UK and this was facilitated via social media and professional networks. Inevitably, this introduced a volunteer bias and the findings may not fully represent the professions recruited into this study. Further, the sample size was moderate overall and small for orthotists, which reduces the external validity of the findings and impacts on comparison between professional groups. To the best of our knowledge, there is no publicly available workforce data which details the percentage of the professions working in paediatrics within the UK. Therefore, we are unable to define the target population or explore the extent to which the survey respondents represent paediatric specialists within each of the professions. We also acknowledge that the external validity of the work is compromised as our sampling was limited to the UK.

This survey described the approaches of a group of UK-based podiatrists, physiotherapists, and orthotists to the clinical assessment and management of symptomatic, flexible pes planus in children. The findings demonstrated variation in assessment and intervention approaches for this population, both between and within professions. Foot orthoses were a common first-line strategy adopted by all groups, although there was variability within each profession. Further work is needed to better understand clinical decision-making and evidence-informed approaches to assessment and treatment of pes planus. More consistent, evidence-based strategies underpinned by a child-centred biopsychosocial approach to intervention may help improve outcomes for this group of children.