THE ASYMPTOMATIC FLEXIBLE FLAT FOOT

Lithuanian University of Health Sciences Faculty of Medicine

Department of Pediatric Orthopedics

Masterthesis:

THE ASYMPTOMATIC FLEXIBLE FLAT FOOT

Author:

Boghdan Tanos

Supervisor :

KAUNAS 2019/2020

TABLE OF CONTENTS

1. SUMMARY ...3

2.SANTRAUKA...8

3. CONFLICTS OF INTEREST ...9

4. ETHICS COMMITTEE APPROVAL ...10

5. LIST OF ABBREVIATIONS ...11

6. CHAPTER 1: INTRODUCTION ...12

7. CHAPTER 2: AIM AND OBJECTIVES ...12

8. CHAPTER 3: LITERATURE REVIEW ...16

What is flatfoot?... Functional Anatomy... Foot and Flatfoot development... Etiology And Predisposing Factors... Diagnosis... 9. CHAPTER 4: RESEARCH METHODOLOGY ...26

10. CHAPTER 5: RESULTS ...29 11. CHAPTER 6: DISCUSSION ...34 12.CHAPTER 7: CONCLUSION...36 13. CHAPTER 8: LIMITATIONS ...39 14. REFERENCES ...40

SUMMARY

Name of Author: Boghdan Tanos

Research Title: The Asymptomatic Flexible Flat Foot

ABSTRACT :

In childhood, the most commonly diagnosed foot deflection – asymptomatic flexible flatfoot.It is known that all children with normal development are born with a flexible flat-foot, but During the first decade of life the foot develops - the longitudinal foot arch develops, and its convex form develops. Although it is understood that all born children are flat-footed – there is no consensus in the literature asto how flat the foot should be flat. Also, age stages, leg axial deformities, obesity and flat foot development stages of a particular age are not taken into account. Different dimensions are used to define a literary flat-foot, but the common, well-defined, flat-denominator in clinical practice is unknown. Therefore, there is a debate in the literature about what the child "s feet" are considered to be "normal" in a different age of the child, and how the "normal" steps of the foot passes as a flat foot. Also, increasing associations between increased body mass index and a flatter foot have been

demonstrated in the literature.

AIM :

To Evaluate the commonly used Diagnostic tools and Criteria of an asymptomatic flexible flatfoot and typical foot posture of a growing child in separate age.

Objectives:

1. To determine the parameters most commonly used in the literature for an asymptomatic flexible flat foot in children.

2. To evaluate the developmental stages of the growing child‘s foot by age.

3. To assess the transition period of an asymptomatic flexible flat foot to a healthy foot.

Methods:

A systematic Literature Review Was Conducted in accordance with PRISMA criteria ( Possible Citation )[63], by searching different electronic databases including (Pubmed, Cochrane, Web of Science,Sciencedirect ,orthopedic journals) With search terms for key words including '' Foot and Child' ,''measurements'',''Diagnosis'' , ''Pediatric Flexible flatfoot' ,'' epidemiology' , ''growth and development'' , '' Pes Planus'' And ''Pes Planovalgus'' . Initial selection was made based of ''Year of published article''( 70% of articled published in the last 10 years) , The Relevance of Abstract's Content and Title.After reviewing a large number of Articles the most Relevant ones to the

objectives were selected. Epidemiological Appraisal instrument (EAI ) was used to assess Risk of Bias

RESULT:

33 articles pertaining to the development of pediatric foot and flatfoot were assessed.

16 different posture measures were Identified on which footprint measured were based on and outcomes reported, with 3 methods being the most reliable these include: Chippaux-Smirak index, Steheli arch index and FPI-6 .other than that the only consensus that can be derived is related to physical observation of FFF meaning the collapse of MLA when the child is in weight-bearing position,followed by its restoration when the child is not in weight-bearing position the terms of FFF and Asx FF are used interchangeably in as there appears to be no clear definitive separation between the two is the only consensus is reached. 3-D foot imagining is also another technique for

anthropometric assessment of foot dimension .Despite lack of a unified definition of FFF there seems to be a clear agreement that factors such as Age, BMI , and occasionally sex do correlate to the

prevalence of FFF.

CONCLUSION :

Flatfoot is a very frequent cause for both parents worry and visitation to the Orthopedic specialists . the only constant definition that can be agreed upon from various studies is the visual assessment in which FFF is the loss of arch when the child is standing and it's restoration when child is sitting or undergoes plantar flexion, failure of arch to restore is relaxed postion would indicate that we are dealing with RFF.The Prevalence of flatfoot varies due to many factors including the fact that there is no single standardized definition of flatfoot. The Flatfoot can be divided into ''flexible'‘ and'' Rigid'' as well as ''Symptomatic and Asymptomatic'' . Common assessment is done using visual inspection,footprint parameters, anthropometric methods,and radiological assessment ,and although

these vary greatly at times the 3 foot postures studied which have shown most although not perfect reliability are : FPI-6, Stehali Arch index, and Chippaux-smirak index. Majority of Flatfoot asymptomatic cases are considered physiological requiring no intervention beyond follow up .the small number of cases that are symptomatic do warrant treatment starting with conservative methods . there is no clear parameters that would separate FFF from Asymptomatic Flatfoot which are considered totally '' Normal'' physiological findings in children up to 10 years old.The Transition of FFF (normal for Child) to what is considered adult version of foot happens on a spectrum from around 6-10 years old. In any case persistence of FFF beyond the age of 10 although perhaps anomalous should not be considered a pathology because there isnt enough evidence to point to the fact that it may become symptomatic or lead to deformity later.

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Keywords:

''Foot and Child' ,''measurments'',''Diagnosis'' , ''Pediatric Flexible flatfoot' ,''epidemiology' , ''growth and development'' , '' Pes Planus'' And ''Pes Planovalgus''

Santrauka

Darbo autorius: Boghdan Tanos

Darbo pavadinimas: Mobili besimptomė plokščiapėdystė

SANTRAUKA:

Besimptomė mobili plokščiapėdystė yra dažniausia vaikystėje diagnozuojama pėdos skliauto patologija.Žinoma, jog visi normaliai besivystantys vaikai gimsta su mobilia plokščiapėdyste, kuri pranyksta per pirmą gyvenimo dešimtmetį – išsivysto išilginis pėdos skliautas ir jo išgaubta

forma.Nors tai, jog visi vaikai gimsta su plokščiapėdyste yra žinoma, literatūroje nėra konsensuso dėl pėdos ploštumo laipsnių.Taip pat nėra atsižvelgiama į amžiaus stadijas, kojos ašies deformacijas, nutukimą ir plokščiapėdystės vystymosi stadijas skirtingame amžiuje.Randama daug skirtingų plokščiapėdystės apibrėžimų, tačiau vis dar nėra vieno sutarto, paplitusio, bei naudojamo klinikinėje praktikoje. Todėl literatūroje yra prieštaravimų dėl pėdos plokštumo normų skirtingose vaiko

amžiausstadijose. Be to, šaltiniuose randama vis stipresnė sąsaja tarp ploščiapėdystės ir didesnio kūno masės indekso.

DARBO TIKSLAS:

Įvertinti dažniausiai naudojamas priemones ir kriterijus besimptomės mobilios plokščiapėdystės diagnostikai ir įprastą skirtingų amžiaus grupių vaikų pėdos padėtį.

DARBO UŽDAVINIAI:

1. Apibrėžti dažniausiai literatūroje aprašomus vaikams būdingos besimptomės mobilios plokščiapėdystės parametrus.

2. Įvertinti augančio vaiko pėdos vystymosi stadijas pagal amžių.

3. Nustatyti besimptomės mobilios plokščiapėdystės perėjimo į sveiką pėdą laikotarpį. 4. Palyginti skirtingų šalių vaikų besimptomės mobilios plokščiapėdystės formą.

Tyrimo metodai:

Nagrinėjant skirtingas elektronines duomenų bazes (Pubmed, Cochrane, Web of

Science,Sciencedirect, Orthopedic journals) pagal tam tikrus raktinius žodžius („Foot and Child“, „measurements“, „Diagnosis“, „Pediatric Flexible flatfoot“, „epidemiology“, „growth and

development“, „Pes Planus“ir„Pes Planovalgus“), atlikta metodiška literatūros apžvalga laikantis PRISMA kriterijų. Pradinė atranka buvo atliekama atsižvelgiant į straipsnio paskelbimo datą (70%

straipsnių buvo paskelbti per paskutiniuosius 10 metų), santraukos turinio aktualumą ir pavadinimą. Po didelio skaičiaus straipsnių apžvalgos buvo pasirinkti uždaviniams tinkamiausi straipsniai.Šališkumo rizika buvo įvertinta su epidemiologinio vertinimo priemone (EAI ).

REZULTATAI:

Buvo išanalizuoti 33 straipsniai susiję su vaikų kojos vystymusi ir plokščiapėdyste. Identifikuota 16 skirtingų pėdos padėties matavimo būdų, iš jų 3 buvo dažniausiai naudojami ir patikimiausi: FPI-6, Staheli skliauto indeksas ir Chippaux-Smirak indeksas. Kitas atrastas konsensusas susijęs su fizine mobilios plokščiapėdystės apžiūra –vidinio išilginio skliauto sumažėjimas ar išnykimas krūvio metu, jo atsistatymas ramybės metu.Sąvokos „mobili plokščiapėdystė“ ir „besimptomė plokščiapėdystė“ vartojamos pakaitomis, be jokio aiškaus skirtumo tarp jų.Dar kitas pėdos matmenų antropometrinio ištyrimo būdas – pėdos 3D vaizdų gavimas. Nors standartizuoto mobilios plokščiapėdystės apibrėžimo nėra, dauguma tyrėjų sutaria, jog su mobilios plokščiapėdystės paplitimu koreliuoja tokie faktoriai kaip amžius, KMI ir kartais lytis.

IŠVADOS:

Plokščiapėdystė yra dažna tėvų susirūpinimo ir apsilankymo pas ortopedą priežastis.Vienintelis pastovus, skirtinguose moksliniuose darbuose sutinkamas mobilios ploščiapėdystės apibrėžimas yra toks: matomas pėdos skliauto sumažėjimas atsistojus ir pėdos skliauto atsistatymas į normalią padėtį vaikui sėdint ar lenkiant pėdą; jeigu pėdos skliautas į normalią padėtį neatsistatoįtariama rigidiška plokščiapėdystė. Plokščiapėdystės paplitimas priklauso nuo daugelio veiksnių, ypač nuo to, jog nėra standartizuoto plokščiapėdystės apibrėžimo. Plokščiapėdystė gali būti skirstoma į mobilią ir rigidišką, taip pat į simptomus turinčią ir besimptomę. Bendros apžiūros metu tiriamas klinikinis vaizdas, pėdsako parametrai, naudojami antropometriniai metodai ir radiologiniai tyrimai. Pastebėti3 labiausiai patikimi pėdos padėties matavimo būdai: FPI-6, Stehali skliauto indeksas ir Chippaux-Smirak indeksas.Dauguma besimptomės plokščiapėdystės atvejų yra laikomi fiziologiniais ir nereikalauja jokios intervencijos, išskyrus tolimesnį stebėjimą. Tik maža dalis atvejų yra simptomus turinti plokščiapėdystė, kuriai reikalingas gydymaspradedant nuo konservatyvių metodų. Nėra išskiriami aiškūs parametrai, leidžiantys diferencijuoti mobilią plokščiapėdystę ir besimptomę plokščiapėdystę, kuri vaikams iki 10 metų yra normalus fiziologinis radinys. Vaikams įprastos plokščiapėdystės išsivystymasį suaugusio žmogaus pėdą įvyksta vaikui esant 6-10 metų. Bet kuriuo atveju mobilios plokščiapėdystės užsitęsimas, nors ir anomalija, neturėtų būti laikomas patologiniu procesu, dėl įrodymų trūkumo, kurie rodytų vėlesnį deformacijų atsiradimą ar vėliau atsirandančius simptomus.

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Raktiniai žodžiai:

„Pėda ir vaikas“ , „Matavimai“, „Diagnozė“,„Pediatrinė mobili plokščiapėdystė“, „Epidemiologija“, „Augimas ir vystymasis“, „Pes Planus“ ir „Pes Planovalgus“.

CONFLICTS OF INTERESTS

I Boghdan Tanos Report No Conflict of Interest

Ethics Approval committee!:

No Real Patient data was involved in this study

TERMS:

FFF: Flexible Flat Foot

AP : anteroposterior

FPI-6 : foot posture index – 6 item

LAF : longitudinal axis of foot

MLA : medial longitudinal arch

ND : No Data

RFF: Rigid Flat Foot

CHAPTER 1: INTRODUCTION

Flexible Flatfoot is a dated Phenomonen which is also known by other terms such as FF is also known by other names such as Pes planus, Pes Planovalgus,calcaneo-vlagus[1]. Despite our

advancements in understanding Foot development it children it still perplexes medical specialist and leaves a lot of question unanswered , From what is the exact Definition of Flexible Flatfoot exactly, how ''FLAT'' is FF , to what is the best Dx Crtieria or method as well as When or What Intervention is Required .

Despite FF being a very regular occurrence it is still one of the most common reasons due to which worried parents come to visit orthopedic specialist [4,7], And Despite many attempts at clarification and standardization there is still no universal consensus on what exact definitively Constitutes FF (article 35,65) proper classification or even radiological criteria [5], instead there is hallmark of Characteristics which aims to describe this phenomenon which views it as a condition where there is a Collapse of MLA with or without rearfoot eversion [2]. other descriptions go more into detailed and view FF as the Loss Of Longitudinal arch of foot along with the following segmental deformities such as : hindfoot valgus/eversion, forefoot supination , midfoot abduction , ankle Equinus [9], excessive pronation of subtalar joint , valgus postion when the Child in in weight bearing position [1,36], as well as 'Too many toe signs' when assessed from the the back[1,5].

Althought FF is a very common Reason why parents visit the Orthorpedic Specialist there is a doubt on whether it should be a cause of concern at all ,although Most Cases are Painless and do Not Lead to Disability, Many parents are still concerned as it may lead that FF will lead to future deformity or Gait disorder later in life [3,36,37,A24] , Perhaps instead of pathologizing the Idea of FF we need to Consider children feet as developing structures and absence of arch is Just a normal part of the process instead of the foot being viewed as '' Flat'' maybe it should be viewed as highly compliant and plastic structure which is under influence of external ( shoes ,exercise) and internal factors(Genetics) and the Pathologization of FF is complete Nonsense [23].

There seems to be no clear demarcation on what is to be considered FFF and what is Asx FF so long as the there are no Sx or functional deformities.

A flattened MLA is common finding for both children and adult patients with FF(article 3). FF is normal in toddlers due to Fat pads present under the MLA, these Fat pads resolve around the age of 2-5 as Fat gives way to Arch formation![3 ,38] Additionally to Fat Pads in children‘s other contributors to FF are intrinsic ligament laxity and lack of neuromuscular control result in foot being flat when in weight bearing position [3,39], nearly 100% of children <2Yo are flatfooted while only 4% remain so after the age of 10 [9].

Arches Progressively Resolve starting from 2-5 YO(article 3) and may Become less fat from ages 7-9 [12],althought the exact prevalence is estimated to range from 0.6-77.9% with reduces prevalence as age increases . This Wide gap is due to the Fact that Lack of consensus on what consistitutes FF and how it is to be measured! [10] ,the Prevalence of FF is related to 3 key factors: age, gender and weight inverse proportional, with age boys are twice more likely FF ,obese children also showed significant prevalance [13,17,37] and time when child starts to wear shoes wear all predispose for FF [4,45] Generally the FF Tends to decrease with age , specifically during the First Decade , more specifically the Prevalence of FF decreases between 6-7 due to development of MLA and reduction of rear

footangle [16]. This occurs via several mechanism: the neuromuscular development improves balance and motor control of distal muscle of lower limbs, physiological joint laxity which peaks a 2-3 YO decreases!, and ossification of foot occurs giving it greater rigidity(article 6).The FF can be Categories into:flexible Flatfoot( FFF ) and Rigid flatfoot( RFF) ,As well as Sx and Asx FF [8] To Distinguishing feature between FFF and RFF, is that in FFF when the foot is in non-weight bearing position the Arch Reappears( reconstruction of medial arch with dorsiflexion) while in RFF the foot remains flat even in nonweight-bearing position [3,8,40]. FFF can be differentiated from FFF by simple toe Raising Test also known as ''jacks Test'' [2]. While RFF remain Flat in both Weight and non weight bearing

position(Article 5) . unlike FFF which generally warrants only follow up , Rigid FF can be linked with other conditions such as Genetic disorder/ CT disorder/ neurological , Ligaments laity or muscular abnormalities![3], Sx FF Renders Tx starting with conservative and possibly Surgery which is left for Cases of Sx FF when conservative Tx failed as as cases of FF with short Achilles Tendon[9]

Unfortunately there us Still no Universal Diagnostic Technique for FFF[8].

Rather the focuses is on plethora of things such as : Clinical examination, Static foot measurement, footprint analysis,[7] Radiological Studies are Not Necessary for DX of FFF [2].However it can be used for precise assessment of Pain location , Asses cause of decrease flexibility and surgical

planning[24] , There are different Indexes for foot posture measurement however the one that proved to be more precise and reliable are : Chippaux-Smirak index, Staheli arch index, And FPI-6 [7] .FPI-6 is advanced update on Pediatric Flat foot proforma (pFFP) developed evidence based tool for

evaluating the types of FF which is Based on a Checklist if items such as arch shape, Range of motion, tenderness, Fait and Diagnostic examination [22] .

-Although there are some evidence and believes that FF will cause disability in the future [1].There isn't enough Evidence that FFF will lead to disability and pain in the Future hence Tx is unnecessary however monitoring is advisable [9,46] .Asx FFF Treatment is Avoided [1,3] On the other hand the Sx FFF is require Tx [33]Starting with Conservative methods Such as : Education ,Footwear selection ,Foot orthoses,exercise , NSAID's ,When Conservative Methods Fail then Surgery may be

considered[5,33] other examples of conservative Tx are : weight reduction, FO's,Stretching exercise and serial casting![9].

This Systemic Literature Reviews Seeks to find the common basics surrounding this controversial and confusing topic ,From a commonality between various FF Definitions, Various FFF

Parameters,measurement ,tool & Dx methods .it also seeks to cover the Stages of Child foot

development and how it related to Foot flatness! , to try to find the transitional line between Asx and FF as well as determine the different FF developmental aspects in Relation Different Geographical Areas.

CHAPTER 2 AIM AND OBJECTIVES:

AIM :

To Evaluate the commonly used Diagnostic tools and Criteria of a asymptomatic flexible flatfoot and typical foot posture of a growing child in separate age.

Objectives:

1. To determine the parameters most commonly used in the literature for the asymptomatic flexible flat foot in children.

2. To evaluate the developmental stages of the growing child‘s foot by age.

3. To assess the transition period of a asymptomatic flexible flat foot to a healthy foot.

4. To compare the changes in the asymptomatic flexible flatfoot shape of children in different nations

CHAPTER 3 : LITERATURE REVIEW

• What is Flatfoot?

Flatfoot ,also knows by other names Such as pes planus, pes planovalgus, is a debatable Condition where the Central commonality is the collapse of the Medial Longitudinal arch[2,65,72], and the hyper pronation that results as the Result of that[Article 1,34], in simple words it is the inability to see a normal arch in the weight-bearing(Standing) position.

• Functional anatomy:

The Medial Longitudinal Arch is Supported by both Dynamic and Static Stabilizer .

The Static stabilizers consist of several part such as deltoid ligament, Plantar Fascia,Talocalcnaeal interosseus Ligament, naviculocuneiform joints!, but the Spring Ligament is the main one ,whose main function is to maintain foot shape during stance The Dyanamic stabilizers consist of : Posterior Tibial tendon(PTT) whose main function is heel rise and not fire during stance[9]. Insufficiency of the PTT may be associated with Sx FF.The windlass function (Static Stabilizer) of the foot is performed by the Plantar fascia which does so in order to reduce the flatfoot, it does so by forming Tie-Rods structures that run from the calcaneus to the phalanges and ends up wrapping around the metatarsal head, this Results in the Longtiduinal arches being elevated while the toe are extended![6] . Reasons for Children to have FF may including Ligament laxity , neuromuscular problem or number of other reasons and that unless the condition is not Sx is it considered normal , the problem arises in Sx FF where patients were patients have demonstrated reduced velocity and poorer performance when it comes to lower limb tasks(65)

• Foot and Flatfoot Development:

The Lower Limbs develop at around 3-5 week of the embryonic state, the foot develops from condensed mesenchymal cell , the embryonic tissue different from several components

Cartiglagenous,osseous, vascular, as well as neutral component of foot the average foot length at the age if gestation is 7.6 cm, which keeps on radily growing up to age then slows down progressively due to skeletal maturity in girls at around the age of 12 and in boys at around the age of 14![4] .The complete ossification of feet occurs at around first decade of life , however the centers of ossification emerge at around 4 YO, while the closure of ossification and epiphyseal plate occur between the age

15 , The the rate of growth starts at 24mm in the first 3 years of life, then slows down to 12 mm in the next 2 years , from age 5 to 10 the growth drops at around 8-10mm per year .it finally stop in girls at around age of 12-13 and in boys at around 13-15! . the major part of foot growth occurs within 3-5 years ,as the child is 3yo it has achieved 2/3 of its maximal length! up to 3 YO the foot increases at average of 2mm /month between 3-% YO this changes to 1mm/month at age 5 the growth slows down considerably to become around 0.8-1cm per year with the boys foot being an average 2 mm longer then that of girls. at 12 YO the girls foot Stop growing while the boy‘s continues for around another 2 years to stop at around 13-15 [19] .Muscle tendons, Fatty CT are differentiated in newborns however their stiffness and resistance only reaches its peak in adulthood as tendons and ligament undergo formation more cross link collagen which increases mechanical rigidity, while the consolidation of dense Soft tissue start at 2-4 YO it is only completed in adulthood [19].

A Study Done in USA which included 111 children aiming to measure MLA is developing children and what factors may affect it found that on average the Arch index in boys decreased more ( Higher arch ) when compared to girls , and that from age 7-9 th MLA remained stable since the fastest growth of MLA occurres till age of 6 , with factors such as sex and footwear playing a role ,as boys were found to have decreased arch index compared to girls of same age, and children who wore slippers as toddlers had flatter arch later in children when compared to those who wore sandals!(Article 14) Another study concerning the MLA development was done in Taiwan where 40 children aged 2-6 were recruited with their feet being studied by 2 methodologies 2-D navicular height measurements and 3-D scanner which uses Vn and Vf parameters. the study found that foot arch correlated with navicular height.and that the NH as well as Vf and Vn all increased progressively between the ages of 2-6 with the arches becoming more rigid .with the highest increase occurring between the ages of 3-4 and then slowing down between 4-5 which suggest that the arch develops the fastest sometime around 3-4 years old with development continuing but subsiding in pace (76)

⦁ Functional development And Biomechanical Aspects:

As the foot shift from being an organ for ''grabbing'' to an organ for weight-bearing , the changes that occur are that there is reduction of bone Numbers, while the remaining bone undergo fusion and becomes stronger! .The MLA grows fastest till age of 6 ,and then it becomes less aparent[51, 14 ]. radiological analysis shows that MLA keep developing through the first decade of life[2] the Development of FF is a multifactorial event which is influenced by internal as well as external program[19] , the main theory FF development suggest that extensor muscle weakness causes overall imbalance among foot muscle leading to collapse of the MLA.[5]the main muscle involved is the excessive tension of tricep surae which leads to its fatigue[49]. In Childhood intrinsic and extrinsic

muscle are strengthed by walking and without their regular use (Sedentary lifestyle) they will become weak (Arictle 18 )

There are 3 arches in the foot medial , longitudinal and transverse , The function of the medial is absorb weight[13] In the end too little support of the MLA or conversely to much arch flattening will cause it to Collapse , Resulting in FF. This is Articles gave an overview about the Development of Foot in General and some theories about FF

In A Study Done in Japan which included 619 children using Toe grip strength dynamometric measures it was determined that the Childer with FF had weaker grip when compared to those with normal Feet , the toe grip reflects foot posture which is related to the function of hallucis longus and flexor digitorum longus.it was shown the toe grip strenth is related to foot arch height , in childen with FFF the toe flexor is stretched hence preventing it from contracting at its maximal strength (73) In Clinical aspect, there is little evidence that FF will lead to Symtpoms in the future however in studies focusing on biomechanics there such as the study in UK when 95 children ages 8-15 YO some of which had FF and some normal hypothesized that because most weight-bearing activities require close chained coupling of foot/ankle/knee and hip it likely that change in foot posture ( such as the case in FF) would lead to change in posture and motion of proximal joints. the results of this study found a significant association between reduced AHI ( arch heigh index) and Knee Sx with 37 (39%) children having knee Sx and 33 (35%) having back and hip symptoms which proves the idea that a reduced AHI such as in FF tends to lead to abnormal lower limb biomechanics and hence possible Symptoms ,however the mechanism of why this happens is not yet clear ( 25).however this study suggests that ASx FFF may lead to Sx in other parts of the body is rather an exception and needs to be be expanded.

when it comes to Rearfoot angle development , a study in US including 150 children focused on studying the development of rearfoot angle in children with relationship to age, gender and weight, the rearfoot angle is the weight-bearing angle formed between bisection of achilles tendon and posterior aspect of heel and is used to determine valgus heel!. when heel valgus is Greater then 5 degrees it is thought to disrupt the normal axis and be a source of pain.In childen everted calcaneal position reduced with age starting with 5 to 10 years the degree of valgus decreases to normal size by age 7 (4 degrees) . the study concluded that the average angle size was around 4 degrees with no significant difference between the feet or gender ,rearfoot angle had also no relation to heigh or weight and the valgus rearfoot didn't change on weight-bearing , age as well had no effect on the rearfoot angle after the age of 6-7.(67)This study was consistent with previous studies which measured the healthy valgus heel to be around 3 to 7 degrees!.

A South Korea study which included 13 children with pes planus, with the focused on measurements and 3-D gait analysis on children with pes planus. in this study the pes planus was considered a foot with >4degree Talometatrsal angle on the weight-bearing radiograph . the study focused on internal and external rotations , thigh foot angle( FA) , resting calcaneal angle(RCSP) and Tali-calcaneal angle (TCA) . the study found the average Calcneal valgus angle to be 4 degrees in children aged 6-16 with the range being 0-9 degrees,tibial torsion in with children 2-10 years old with FFF was 25 degrees , TCA which corresponds to larger internal tibial rotation in static position is the only parameters related to transverse rotation o the knee joints.The conclusion was that there is clear correlation between TMA and RCSP as well as between TMA and TCA , the calcaneal pitch showed little correlation with either TMA or RCA ,the larger the TCA leads to decrease in maximal external rotation and increased maximal internal rotation in gait cycle .the Clinical finding did not correlate with gait pattern of patients with Pes planus, hence Static measurements were limited to their ability to predict 3-D movement of Pes plus foot during walking.(69 )

In conclusion it is safe to say that the evidence points to clear difference in biomechanics when it comes to normal vs FF however the degree of that difference and its potential effect on future of child is debatable.!

• Etiology and predisposing factors:

-FFF Can be Congenital or acquired[13] FF are divided into several categories : FFF vs RFF , Sx vs Asx , with each group having its own unique etiology .The FFF is distinguished from RFF in that in FFF the arch is restored when the foot it not in a weight-bearing position[5, 8 ] . Predisposing factors for FF : Age, Sex , Body Composition, Familial Hx, Footwear, the onset of footwear, Ligament laxity [ 3,16]

I-Age

-Several studies have been done to see if there is any prevalence of age with respect to FFF.

In Nigerian study which included 474 children aged 6-10 YO , indicates that children under 6 YO are more prevalent to have FF ( 46.3%) to 7.1% at 10 years old , with 22.4 for the years children between the years 6-10[ 17] . Another study was done involving children with Px FF from 7-14 YO showed same tendency of FF decreasing with from 19% at age 7 to 6% at age 14.[20] Which proves the theory

that FF is just normal part of childs development and most case will resolve with the progression of time at around the end of first decade!

(Another study showed that FF decreased with age from 54% at 3 YO to 24% at 6 YO and to 17% from 6-12 YO !) .

A Colombian Study which studied 940 children in 2 cities found that the prevalence of FF decreased with age in both cities esp after the age of 5 where in City 1 ( Bogota) the incidence fell from 38.3% to 17.2 and in City (2) Barranquilla the incidence fell from 17.3 to just 4.5% after the age of 5!.(70). A Greek Study used 5866 children ages 6-17 YO and found that High and Low MLA( Type I and II ) decreased with age which the normal types( III and IV) increased with aged which indicated that significant development of MLA rends to occurs in the preschool years however it also points out that the MLA still continues to develop throughout the school years.[19].

With the articles presented it is possible to assume that incidence of FF decreases with age as MLA acquires structure and maturity although the exact age is unclear it is safe to say that it happens before then end of first decade of child‘s life

II-Sex:

There has been various studies that linked male sex with being more prevalence for having FF. An Iranian study which included 1158 children encompassing age 6-18 Found that boys had a

significantly higher prevalence of FF then in girls (17.5% vs 14.5% ) mainly prevalent in younger age group however this can be attributed to smaller bone and less bulky muscle (Aritcle 14).Yet another Iranian study Found that the prevalence for both types of FF increased in girls aged 14-18 with FFF prevalence being 2 for males and 11 for females , and RFF being 4 for males and 6 for females [14]. Another Nigerian study of 474 children 253 girls and 221 boys ,ages 6-10 years old found that males were more prevalent to have pes planus then females 64 (40.8% )vs42 ( 19.9%) of all Flatfooted which were considered plantar arch index >1.15 [16].

In a study on MLA development according to sex showed no significant difference between Boys and girls and arch index decrease with age( Higher arch) was the only MLA parameter of significant change[12]. however , Despite the MLA development this study did conclude that by age 7 boys displayed Flatter foot compared to girls at age 7 [12] .Another study had same conclusion where 421 high school student were investigated and boys were significantly more prevalent to have FF then girl 17.5% boys o 14.5% girls when it comes to FFF[13] .Third study that was included was done on 288 children from grade 4% and showed no Relationship difference when it came to sex among male and female and the prevalence of FF[17].When it came to Px FF however sex showed no prevalence according to sex[20]. the evidence concerning the prevalence of FFF with respect to sex is

inconclusive however it is unlikely to be significant with that being said.the Pathological FF also does not show any indication for sex prevalence!

III-BMI & Obesity:

-Several studies have linked BMI to correlate with weight in this particular study in Iran of 1168 school children( 653 boys and 505 girls) from 6 to 18 YO grouped in 3 groups( 6-10, 11-13,14-19) with the mean age being 11.95 ± 3.57 years the incidence of FF increase proportionally to increase in weight , underweight population (13.6%) , Normal weight (16.1%) and overweight (26.9%) while obese (30.8%) .The theory behind this is that increase in weight puts extra weight pressure on the lower limb which in turn put excess load on the ligament and soft tissues of foot resulting in deformity[13].Although the evidence was presented concrete and easy to understand manner there was no information on how each age group did seperatly independent from the other so that we could asses to what Extent the BMI correlates to FF in each age group!. That is an important Factor as another study also conducted in iran using 400(157 boys and 244 girls) ages 14-18 found no

significant Relationship between BMI and FF at these ages[14]. Which could be due to that fact that most FF have evolved into more mature variant and hence the BMI does not have that much effect on the arch as it might have in younger ages! Another Nigerian Study included which included 474 student aged 6-10 Years old .the prevalence of FF in Obese children as 53.4% ,overweight (26.4%) , Normal weight (14.9 %) 13.1% in underweight [16].This Shows that BMI does have a role in FF incidence in children even if its only to a certain age which the foot is undergoing development!. Pne more iranain study included is in Iran which included 667 children ages 7-14 but here specifically Pathological FF was assesed the incidence of FF in normal weight was 7.9% while is was 16.1 in overweight and 36.1% in obese patients -another point is Ligament laxity which is also related to FF also decreases with age [20] explanation could be that increased BMi is associated with heel valgus and restriction of ankle dorsiflecion , which restricts the motion of the rearfoot exerting the mechanical load on the midfoot which has weather supporting ligament structures which cases strains and

subsequent pain of the MLA in children with higher BMI[52].A Big Polish Study of 6992 children ( 2476 boys and 3516 girls aged 8-12 YO were assessed for Lower extremity disorder what was found that BMI played big lower limb defect ( including the FF) as Obese children had 90.2% chance when compare to 25.7% of normal weight population! and 15.1 % for underweight population!. the study showed that increase in1 unit of BMI increased the chances of lower limb defect by 2%![71]

.However BMI increase does not only affect the FF it also leads to Biomechanical differences such as weaker walking stability because of the FF pattern a a Chinese study which studied 100 children 50 obese and 50 non obese aimed at studying the plantar pressure distribution in both groups , Fond that there was no significant difference during heel-strike phase between obese and non-obese groups

,obese children had some difference such as :A- midstance phase was longer in obese. B-as well as obese children having higher peak pressure under the metarsal head. C-Obese children had significant increase in foot axis angle. On average the obese children had flatter foot pattern and larger foot angle difference on dynamic plantar pressure when compared to non-obese children[77] .With all those studies present it is safe to assume a presence of link between increase in weight and prevalence of FF

• Diagnosis part:

First important factor to consider is the age of the patient since it is known that Longitiudinal arch develops in first years of life and FF inversely correlation with age [3,5], determining History such as the reason for visit is it (pain , deformity m parental concern) it is important to also inquire about the family History of FF or condition such as (familial hyperlaxity ) , asking about shoes that child wears as well is pain is present and if so where is its location/duration / onet .it is vital to get as much

information from parents as sometimes it is hard for the child to explain [24] .2nd important thing is to determine if the FF is Flexible or Rigid. This can be separate in that the arch of the FFF is only

collapsed in weight-bearing position but is restored in plantarflexion (Tip Toe Test) in RFF the arch remains collapsed in both the weight and the non-weight bearing position. A good way to distinguish them is the Jack's Toe Test , as you see in the picture the arch is restored in FFF while it remains flat in RFF [2,3 5] .The RFF is related to PX condition such as Trauma, connective tissue problems , or even neurological conditions and requires a follow up[3,14,33] .Existing assessment exist these include : Visual inspect (Physical examination) .Anthropometric, foot measurements and in certain cases Radiological assessment[22]

• Other Factors:

Others factors which may affect FF prevalence such as Family history and geographical Location . According the the Iranian Study the Family history made no significant Different for eith FFF or RFF since that number of student who indicated ''NO'' for Family Hx for had FFF then RFF groups that Said ''YES'' To Family History(A15). And in a Colombian which included 940 children aged 3-10 ,study done between 2 cities The Capital Bogota (High Altitude) and Barranquilla ( Coastal city) is was found that Bogota had higher incidence when compared to Barranquilla when it came to FFF in ages 3-5 38.3% and 30.9% respectively and when comparing in all ages it was 20.8 % for Bogotta and 7.9 %For Barranquilla , this could be be due to geographical but also culture difference as Braanquilla being more rural and decrease prevalence of footwear[70] . With that Being the evidence to support

that either History or Definitive geographical factors which affect the prevalence of FF is yet to be determined.

• Visual Assessment / Physical examination:

Most Articles agreed that first of all we need to focus on finding out whether the FF is FFF or RFF through Jack toe test or simple plantar flexion, but further more other

things should be considered these include Foot shape in weight and non weight bearing position [2 3] ankle ,knee and hip internal and external rotation,Tenderness of palpation,Achilles tightness which can be be assed by silferskiold test which asses the dosriflexion with the knee in both flexed and extented position (if we have < 10 degree of ankle dorsiflexion with knee in flexion and extension then the ankle is likely contracted) (if >10 degree in flexion and cannot go beyond 10 degrees with knee extension , then Gastrocneumuis is affected) . Then there is need to detemine the flexibility , the heel will typically be in valgus position and when the patient plantar felxes the MLA will elevate and the hindfoot will change from valgus to varus position in FFF not least of all if the important of gait assessment during walking to check for any unsteadiness, instability ,asymmetry , ataxia(A35 A 5 ,A23) .In recent years there has also been an update when it comes to Pediatric Flat foot pathway (FFP ) which has been update to pediatric flat foot performa be reducing the elements which showed low reliability such as Arch morphology, presence of absence of Sx , heel position the updated version has proved to be efficient ,evidence based , and clinical tested reliable framework for FF for diagnosis and choosing treatment[22]

In summary the taking the History ,Listening to parents and carefully assessing the joints , in sitting and standing position remain one of the most essential part of the Physical examination ! with system like the new and improved p-FFP being a good attempt at unifying the at times confusing diagnosis process by using systems which are evidence-based and have been proven effective in clinical practice!

• FOOT POSTURE & ANTRHOPOMETRIC ASSESSMENT:

Which is the measurement of surface landmarks or bony prominence in order

to determine the location of various structures within the foot such as MLA, these values include rearfoot angle, arch angle, height of longitudinal arch ankle, and navicular dop[3]. A Taiwanese studied compared 2 methods 2-D ( Navicular height) and 3-D (including Vn and Vf).Vn representing the foot arch volume in non bearing position, and represent the bony structure of foot. while the Vf is the footarch volume under the weight-bearing position, and represent the soft tissue . the study

demonstrated that the correlation of results were moderate to high (( r=0.642,0.712 p<0.010) which indicates that Vn and Vf values of 3-D measuring device reflect the height of MLA as well being able to provide information not only about vertical height but also the width and length of the MLA[76] Another study compared different measures used to study foot postures including plain radiograph angles as well as footprint indices such as Chippaix Smirak index, Arch index, Clarke‘s index among other and only 3 measurements parameter were show to have most reliability when it comes to coming closest to defining the FFF these are :Stehali arch index >1.07 for ages 3-6 years old , ≥ 1.28 in age 6-19 years old ,The Chippaux-Smirak index of >62.7% in groups of children 3-7 Years old and >59% in groups c children who are 6-9 ,and third is the FPI-6 Index which has to be >6 for children in 3-15 Year old category[7] . with that being Said there is Not Gold standard for Foot posture

assessment [10].

A study that was done to see how the anthropometric parameters change as children grow showed that Chippaux smirak index : increase in MLA steadily from 3 to 8 YO ,Navicular height by age 11 male navicular height it higher then that of females), FPI-6 showed that posture of health and physiological developing child from 3-17 YO is Pronatedfoot types ,clarks angle showed progression from FF to normal at around 7 YO, the article concludes that child posture is also age-dependent will tend to change over time , and that the dichotomy of Normal vs FF is also inaccurate as FF is typical part of children development [10].

A Study in New Zealand which sampled 30 children with Asymptomatic feet aimed to asses the measuring Criteria such as Foot Posture index, Angl Lunge test, and Beighton scale/and Oxford ankle foot questionnaire in Clinical assessment of lower limb.which FPI-6 and Lowe limb assessment scale showing reliability in clinical seeting , LLAS (Lower limb assessment scale) advantage is that it can be used to evaluate the hypermobility of the lower limb.The conlcusion was that all of FPI-6, Lunge Test, Beighton scale and LLAS demonstrated intra and inter reliability in pediatric population![A27] When it Comes to The Gait assessment a Australian study of Pediatric foot specialist found that GALLOP proforma which includes assessment about Pregnancy history , Milestones of child

development, neurological observation , aspect of lower limb visualized measurement to be part of a comprehensive consensus based systematic and standardized way to collect data regarding outcome measures relating to lower limb [32]

A Study which combined Australian ,New Zealand and UK combed 15 poediatric in aim to find conencus For Dx tools and intervention ,and the 2 evaluation methods that were decided upon were FPI-6 ,Rearfoot measurments as well as visual assesment (Arch evaluation) should be made when Diagnosing FF[65].

In North American a study focused on actually implementing Arch index(AI) and Navicular height(NH) techniques on 272 children in order to measure the MLA . and to see how effective are

those methods in diagnosing FF when compared to others . The results showed that AI and NH had moderate to high relationship , which supports the hypothesis that AI reflects that measurement of vertical height of MLA!. NH is direct measurement of clinical height and is easier to obtain in clinical setting hence its advantage, the result show that the AI different in boys and girls with boys have 1 size wider(for group under 5 years old).Although AI is a good method and can be slightly more precise it is Affected by both gender and wieght. Which for mere simplicity makes NH the more preferable

evaluation method [66] .

Another Study Was done in India which included 150 FF patients o different degrees , the aim was to measure the effectivity of methods such as Toe Extension test as well as the FPI ,the results showed the Toe extension test was positive in 50 control and 144 patients , and was only negative in 6, which equates to 96% sensitivity and 74% predictive value ,when it came to FPI value the Sx such as midoot pain, heel pain during strenous activtiy corresponded Degree of FPI , as Patients with Score >(or rqual) 75 severe case.. were more likely to have pain in mIidfoot mid ,hindfoot, as well as heel defomity then those with score 45-74 .Which gives Credibility or both the Toe extension as being best screening tool , and FPI as being good and Grading tool! there Seems to Be many Antrhopometric parameters From FPI-6 , to Arch Index , To Navicular height, Chippaux-Smirak index with each having its own advantage in either way those parameters need to be part of the bigger picture and not the main focus of Diagnosis.

• Foot Print:

Footprint analysis is used to asses and analyze the longitudinal arches, it is also used to asses foot posture and effect of an orthotic intervention [4]. 3 measurements have proven to be the most effective they are : Arch index, Chippaux-Smirak index as well as Staheli arch index.

the Arch index being the ratio of area of middle third of the whole toeless area, the Staheli is the width in the area in the arch and heal and the ratio between them, Chippaux-Smirak index is the ratio of the maximum width of metarasal over the minimum width of the arch.[3,7]

• Radiological Studies!:

In Principle ,Radiological Examination are Not Necessary to Diagnose Flexible Flat Feet [2,3,9]. however they are required in cases where we have Pain ,Decrease flexibility, as well Surgery planning [3] . The Xray is ussually done in 2 views Both in Weight-bearing position :Antero-lateral(AP) and

lateral views [2,3,36], Oblique and Axial views are done in Case of Pain or RFF , because in RFF the Radiological studies ae required to ID the cause and the location [3,24,33]. From Different article i was able to find the key elements which are focused on during an Xray exam these are : Meary's Angle( Tali-1st metatarsal angle) which is the angle between the longitudinal axes between the talus and the first metatarsal ,which normally should be in aligment and no angle should be present.On Lateral View of Meary angle anything >4 Degrees is abnormal ,if the angle >4 degrees with convex upward this is known as pes cavus , if the angle is>4 degrees convex download this is Pes Planus (A2) another way to look at it is that if the angle is >4 with relative dorsiflexion of first grade this suggest FF . where abduction on AP view suggest FF .In AP View <15 Degrees is Considered normal! , Another measurements worth noting is the Talonavicular angle which is the measurement between the surface of talar head and the navicular with normal being <7 degrees.The Calcaneal pitch is the angle between weight bearing surface and the plantar calcaneus from anteriorr process of tuber , Normal being between 20-30 degrees, below that norm is consdired FF and above is considered cavus [9,54] ,Another thing which are important to keep an eye for are :tarsal coalition ,accessory navicular, possibility of arthritis as it might influence or choice of Treatment. when it comes to accessing navicular bone is it important to evaluate the AP/lateral/ external oblique views on

Xray[33] CT and MRI may be indicated when we have limited movement of the sub-talar or midfoot region [3] , coalitions with are fiborous or cartilaginous are not visible on Xray hence requiring CT or MRI , CT is the Gold standard for colaition Dx as it is able to show the kind of coalition ( for example osseus) and the extent of it , While MRI remains critical for surgical planning [3,33]

CHAPTER 4 : RESEARCH METHODOLOGY AND METHODS

Construction & Search Strategy:

In Order to Ensure a Standardized approach for this Literature Review, PRISMA protocol what adopted which is an evidence based system of minimum sets of items for reporting a systematic review and meta-analyses[63].For This Systemic Literature review there was search of Electronic databases such as PUBMED,NCBI ,Sciencedirect, ReasearchGate,Cochrane,Google Scholar. from the inception of November 2019. Relevant papers were selected in rigorous and organzied manner. Search term included : foot & child, pediatric flatfoot, pes planus, pes planovalgus, measurement, foot

measurement,diagnosis of flatfoot ,flexible flatfoot, growth and development, prevalence , incidence and finally '' pediatrics''Irrelevant papers were excluded after going through title and Abstract . Next there was the process of assessing the eligibility based on their full text in respect to their relevance the inclusion criteria to further eliminate papers which didnt match our criteria.the research focused on 70% of the cited papers to be published in the last 10 years and to be in English language,Paper's relevance to the topicas well as it being peer-reviewed and all studies were included (Qualitatibe and Quantitative) .Some Remaining papers were extracted from various online sources.

ELIGIBILITY CRITERIA:

Articles were chosen which were focused on the pediatric population aged <18 with the main focus being of pediatric and asymptomatic flexible flatfoot!

Inclusion Criteria:

• Article ≤ 10 years old

• The Pediatric population of <18 Years old • The article in in English

• Definition of Pediatric Flatfoot and Pes Planus

• Aimed at measuring and Diagnosing flatfoot and defining criteria for it

• Search terms of : Pediatric Flatfoot, pes planus, pes planovalgus, growth and development Exclusion criteria:

• Population >18 years old • Non English articles

• Articles with main focus on Pathological Flatfoot or Rigid flatfoot

• Patients with Congenital or painful condition such as Cerebral palsy or juvenile arthritis • Articles focusing sports medicine!

• Neurological pathologies cerebral meningocele • Traumatological conditions

CHAPTER 5 : RESULTS

Cohort Physical therapist use observation and foot posture info to make the Decision if Tx is required!

Evidence based Dx technique is required such as p-FFP or better Diagnosis and potential treatment selection Japser W.K Tong, Piu W.Kong [12] USA/Sinapo re 111 -Arch index -midfoot peak pressure Longitudinal Cohort

-Arch index increase more in boys then in Girls(Higher Arch) -the MLA remains stable at age 7-9 YO Mohsen Pourghasem . [13] Iran 1158 -Pedograph -Dennis method

Cross sectional Clear Relationship between BMI and prevalence of FFF

Armin

Abtahian MD [14]

Iran 400 -Jacks toe test -Manual measurement

Cross sectional Age and BMI had a relationship to the prevalence of BMI ,No link was demonstrated

between prevalence of FF and family history or Gender.

C.I Ezema [16]

Nigeria 474 Stehali plantar index

Cross-sectional Age, Sex, And BMI have an association with Pes planus development! Joyce phua Pua fung [17] Indonesia 259 Chippaux-Smirak Index Cross-Sectional

Higher BMI was linked with higher prevalence of FF.

Pangiotis Stavlas [19]

Greece 55866 footprint Cross-sectional frequency of elevated Arches MLA, Decreases with age!-

-Boys tend to have higher arches compared to girls of same age. Angela

Margaret Evans [22]

USA 140 foot pressure

index

Cohort tphe new adjustment p-FFP is even more an effective tool for Diagnosing pes planus! A. Kothari [25] UK 95 -Arch heigh index -Lower Limb Assessment Score

Cohort There is Risk that children with pes planus will experience pain in another part of such as Hips and knees

Angela M Evans Keith Rome [27 (Article 29) New Zealand 30 -FPI-6 -ankle Lunge test -beighton scale -Lower Limb assessment

Cohort -FPI-6 and LLAS have clinical Reliability! -FPI-6, LUNGE test, Beighton scale and LLA demonstrate accurate Intra- and inter-rater reliability in pediatric sample

Simone Cranage [32] (article 34) Australia 50 -Gallop proforma

Case GALLOP proforma is an effective method to evaluation foot and lower limb Sindhrani Dars [ Reserve 1] -Australia -New Zealand -UK 15 -FPI-6 -Visual assessment -p-FFP Cross Sectional FPI-6 &visual assessment as well as common complaints should be basis or Dx and dealing with Patient concerning Pes Planus John

C.Gilmour [Reserve 4]

America 272 Footprint Arch index (AI ) and Navicular Height ( NH)

Cross sectional Arch Height and Navicular height are good Measures or MLA , however NH is more practical in clinical setting! Sobel [Reserve 5 ] USA 150 -Rearfoot angle

Cohort Average reareoot angle o child 6-16 Year old is 4 degree of valgus and it is not significantly affected by age, side height, or weight!

Jung H Lee [Reserve Article 8 ]

South Korea 13 -Radiological assessment

Cross-sectional -Talometatarsal angle is correlated with Resting calcaneal position -Talo-calcaneal increase leads to a decrease in external rotation and increase internal rotation in gait cycle!

Vergara-amador Enrrique

Colombia 940 -Clarks Angle -Chippaux-Smirak Index

Cross-sectional -Prevalence of FFF was higher in Capital Bogotta when compared to

[Reserve article 9] -Stehali arch index -Denis Classification Coastal city o Barranquilla , and prevalence of FF decreased with age.and increased with Higher BMI . Michal Brzenzinski [Reserve article 11] Poland 6992 -Computer Podoscope -Sztriter Godunow index o Cross-Sectional

-Pes Planus Incidence Decreased with age but increased with an increase in BMI. Sudkhar Pandey [Reserve Article 13] India 150 FPI-6 Toe Extension ankle Dorsi flexion

Cohort Toe Extension Test is Best Screening Tool ,Fpi is Good diagnosing Grading Tool. Yuto Tashiro Et Al [Reserve article 18]

Japan 619 Toe Grip

Strength Dyanomatery Stehli Arch Index Cross-Sectional

Toe Grip strength is related to foot posture Children with FFF have weaker grip and hence training this grip may prevent pes planus incidence! Hawke,Rome [Reserve article 20[ New Zealand 30 -FPI -Beighton score, -Low Limb assessment Scale score( LLAS) Cross-Sectional

-FF was correlated with lower limb Flexibility!, but not greater Ankle joint Flexibility

Dref ,Kedemf [Reserve article

USA 30 Rearfoot

eversion

Cross-Sectional AHI is a reliable measuring tool!

21] AHI Hsun-Wen Chang Et Al. [Reserve Article 21.1] Taiwan 44 -Navicular height from 3-D scanner! -Cross-sectional Yang Song-hua [Reserve Article 24]

China 100 Arch index Obese Children had a flatter foot pattern and difference dynamic plantar arch when compared to nonobese!

CHAPTER 5 DISCUSSION

The controversy surrounding the flatfoot has been a long-standing one , this review aimed on finding the common ground between different studies and perspectives . As it Currently Stands in Simple terms FF is the absence of arch in a weight-bearing position, in detail, this is the absence of MLA in standing position coupled with segmental deformities such as hindfoot valgus, forefoot eversion,or midfoot abduction. FF can further be divided into FFF and RFF ,with FFF being defined as loss of arch only in weight-bearing position and its restoration in non-weight-bearing position which differentiates it from RFF something which can be distinguished by simple Plantarflexion or Jack's Toe Test![2]

Asymptomatic FF is Simple FFF without any symptoms , it is a shape and not a deformity and should be considered normal up to a point is becomes painful or affects function , almost 100% of children are born with FF .3 factors were considered to predispose FF: Age, BMI , Sex When it comes to age as the Arch start to develop at around 2-6 years old and continue to the end of first decade while reaching its maturing at around 12-13 Yo , this is consistent with why we see the prevalence of FF decrease to over >90% at 2 years old to around 4% at 10 years [25].When it comes to foot growth the bulk

of foot growth occurs within the first 3 years Years reaching 24 mm/year , by 3 the foot reaches 2/3 its adult length size however the growth persist slowly till around age of 12 in girl and around 14 in boys![20].

When it Comes to BMI most studies have shown the clear correlation between increase in BMI and increase in FF incidence! hypothesizing that extra weight puts more strain on the arch to make it flat . however when it comes to sex although some studies found that males were more likely to have FF the difference was insignificant and most studies found no concrete correlation .

When it comes to Diagnosis although it was mainly centered on physical examination there was no consensus over the Diagnostic criteria however one thing that kept popping up is the Pediatric flatfoot clinical care -pathway(FFP) and its more improved version p-FFP (Pediatric flat foot

proforma) which has been shown to be evidence-based,consencus guideline which is reliable in clinical practice as well as something which is easily communicable to the patients (Traffic Light Approach) . Another thing that was agreed upon that Radiological studies are not Necessary For Asymptomatic Flatfoot and should be reserved for Symptomatic cases as well as surgery

planning[8,22].

When it Comes to Treatment the most articles agreed that Treatment is only reserved for Sx cases and that as long as no pain , deformity or function impairment is present managing the factors like Weight as well as follow up was the best thing to do , it also highlight the importance of educating parents as some parents are not content with this simplistic approach and often demand some form of treatment which may comes in form of orthroses or special footwear which shows to play no positive role in improving the condition.In Symptomatic cases conservative methods such as orthoses are used.first with variable success with certain preference given to the custom made orthoses in terms of results.if all conservative treatment fails surgery may be considered with osteotomy being a safe and most efficient choice across different studies.

When it Comes to the transition between Asymptomatic Flatfoot to so Called health flatfoot . the exact estimates vary but we see an inversely proportional relationship between age and prevalence of FF from around 54% at 3 YO to 24% 6YO and 17% from 6 to 12 YO [1] , of Course these values differ between different studies but the decreasing trend of FF prevalence with age is universal.with the key shift occurring between 6-8 year old in the mean of the population .however the full process of completing by the end of first decade for most children.

When it comes to how we think of Asymptomatic Flatfoot we perhaps should change our approach to it from looking at it as condition that needs to be addressed instead of Pathologizing the FF because it differs than that of Adult instead of putting labels such as '' pediatric foot '' or ''developmental FF'' as if we are describing something atypical . Absence of arch in young children is Just Normal part of the developmental process . The focus should not be on saying the foot is ''Flat'' rather it should be viewed as a compliant and developing structure which responds to different internal and external factors . The focus on Flatfoot should be not be studied as stand alone phenomenon but as part of bigger framework not just the MLA but as 3-D model of foot development, morphological and anthropometric function of typical pediatric foot and comparing the Footof child against the benchmark of total pediatric popullation[23] . With only real abnormality being Pain , deformity or impairment in function! .when it comes to the Asymptomatic Flatfoot in different nations and ethnicities no valid and specific

relationship that may exist between foot posture and ethnicity were formally known [10] . No study was found which focused specifically on comparing people of different ethnicities on based on fine

common parameters such as age group , height and BMI(which also plays into nutritional aspect of every culture) as even in same country /culture the proportions can vary.

CHAPTER 6 CONCLUSION

I-Asymptomatic Flexible Flat foot is a foot with collapsed MLA in weight-bearing position with the absence of any Sx , deformity or functional impairment.the terms of FFF and Asx FF are used interchangeably so long there is no pain or deformity , concerning the parameters visual, anthropometric , radiological are used however only 3 have shown a level of consistency and reliability : Chippaux-Smirak index, FPI-6 , Staheli arch index. p-FFP has also been shown to be reliable, evidence-based tools which may help guide management.

II-Child foot Development is more of Spectrum process which is affected by sex ,the major part occurring from 0-3 years old with foot reaching 2/3 of adult length and continues till early years seconds Decade with girl growth being 2 years earlier then boys on average

III-The Arch Development start somewhere around 2-6 Years Old with the mean of population transitional to adult foot model somewhere around 6-8 years old

IV-There is No Data To Show Link between Prevalence of nationality or ethnicity with Respect to Asymptomatic Flexible Flat Foot!

The topic of flatfoot is important for pediatric because of its vast encounter in practice as almost every child can be considered to be flatfooted at some point,the goal needs to be on finding the common ground between all Diagnostic and Treatment Criteria coupled some individuality for each case,

CHAPTER 7 : LIMITATION

Limitation of this study include : -Only English articles were Reviewed

-although Literature base is Large and there are studies with big sample sizes , there is lack of pan-national studies which covered multiple countries simultaneously based on common parameters

-some studies did not cite support for their choice of measurement

-the topic itself is controversial with many varying opinion and each have its some basis to it

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