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June 07, 2015
Category: Uncategorized

  Excessive PRONATION can be a problem for children as well as adults.  Pronation is a triplane motion of the foot.  This means that when standing up, the foot normally goes through a motion described as pronation, and it occurs in all 3 body planes.  The arch typically lowers, the front part of the foot turns out a little, and the heel tends to evert (or turn so that it rolls out from under the ankle).  All of this is NORMAL - to a degree!  In order for the foot to adjust to uneven surfaces when it hits the ground, the foot is supposed to PRONATE, and then STOP PRONATING, and then SUPINATE - or start going the other way.  The arch should raise, the heel go back under the ankle, and the front of the foot rotate IN to make it a rigid lever to help push the body forward.  No one is 100% normal, but many people pronate or flatten out the foot TOO much when they stand, and this leads to what is often called a FLAT FOOT.   In adults, excessive pronation can lead to heel pain (plantar fasciitis), bunions, hammertoes, arch strain, and a whole host of other secondary problems.  

   There are many adults who pronate or flatten out their feet too much when they walk.  This starts in childhood.  Babies typically have a bulge of fat in the arch of the foot making all of them look like they have flat feet.  As they mature, this fat in the arch area should reduce, and the young child's foot  should take on the appearance of an adult foot, only smaller.  Some children have what looks like a very flat foot WEIGHTBEARING AND NON-WEIGHTBEARING.  This means the foot looks flat whether they are sitting or standing.  This is known as a RIGID FLATFOOT DEFORMITY.  Other children look normal when sitting, but when they stand, the arch lowers, their heels turn out from under the ankle, and they turn the front of the foot out.  This is known as a FLEXIBLE FLATFOOT DEFORMITY.  Not every child with flat feet (also known as pes valgus or pes planus) needs treatment.  The degree of the deformity is important, how the child walks, and whether or not there is any pain are imporatant considerations. 

   Custom orthotic devices are usually the first line of treatment for symptomatic and/or painful flat feet in kids.  Not all kids will say they hurt.  Some will not want to participate in sports, get tired easily, or seem to just be lazy.  If they relate LEG pain, especially cramping at night after they have had a busy day of activity, they may be suffering from this problem.  When in doubt, the best bet is to get it checked out.  A Podiatrist can evaluate the child's lower extremities ( feet, legs, knees, and hips) to see what may be abnormal.  If a hip, leg, or knee problem is found, referral to a Pediatric Orthopedist may be indicated.  If the problem is with the foot or ankle primarily, a custom foot orthotic may solve the problem.  The earlier this is instituted, the better.  If this does NOT resolve the problem - and I have seen cases where it completely eliminated the problem on ONE foot, but with deformity and/or pain remaining on the other foot - it may be necessary to consider surgery.  Unlike in adults, particularly in the FLEXIBLE FLATFOOT, soft tissue procedures may correct the deformity without resorting to osseous or bone procedures (often called osteotomies or arthrodesis - where bones are cut and repositioned or fusions of joints performed).  The use of implantable devices - once called a STA-PEG procedure, where a plastic plug or peg was placed in the foot to act as an "internal orthotic" - can be done successfully in many children, as long as significant arthritic changes have not occurred and the patient is young enough for the device to limit pronation successfully.    Secondary procedures, such as Achilles tendon lengthenings may also be needed, but the goal is to avoid surgery whenever possible.  In very young children, where there is an internal or external rotational problem in the lower limb, casting can also be instituted to attempt to turn the foot either OUT or IN, and there are also devices that can help with this, if used carefully and judiciously, in children that are not walking yet.  

   Excessive pronation or FLAT FEET can be considered borderline, mild, moderate, or severe.  It takes a skilled practitioner to determine the degree of the deformity, the necessity of treatment  and type of treatment that is necessary not only to resolve any presenting symptoms, but to reduce the likelihood of further problems as the child matures.  There are many adults with severe flat feet and secondary arthritic changes in the feet and ankles where the problem could have been prevented by recognizing and treating the problem when the patient was a child.  


Richard S. Eby, DPM

Eby FootCare and Laser Center

(423) 760-3115