Dr Michael Phegan ( left ) Consultant foot and ankle surgeon , Gold Coast University Hospital , Gold Coast , Queensland .

Dr Andrew Wines ( right ) Consultant foot and ankle surgeon , Mater Hospital , North Shore Private Hospital , Royal North Shore Hospital , Ryde Hospital , Sydney Adventist Hospital , Northern Beaches Hospital , Sydney , NSW ; and Dubbo Base Hospital , Dubbo , NSW .

First published online on 12 May 2023

BACKGROUND

IN the paediatric population , musculoskeletal

issues are among the most common reasons for attending a GP , accounting for up to 10 % of all presentations . 1 The rates of musculoskeletal issues increase 10-fold in the decade between the ages of three and 14 , with an overall prevalence of 30 %. 1

In terms of musculoskeletal concerns in general , the most affected regions in school-age and adolescent-age groups are the foot and ankle . 2

Of all foot and ankle problems , the highest percentage of children presenting to GPs are those with a concern for a perceived deformity in the form of flat feet , as well as in-toeing and out-toeing during gait ; some parents are concerned about the long-lasting implications on the normal development of gait . 2

Foot and ankle problems in the paediatric population may vary depending on the stage of development and primary aetiology of the complaint . While many are self-resolving and within the spectrum of normal development across the population , undiagnosed post-traumatic ,

congenital , inflammatory or neuromuscular diseases may mimic benign presentations . 3

This How to Treat covers some of the more common presentations of foot and ankle deformity that may be encountered in the primary care setting . It also offers insights on diagnosis , treatment and appropriate referral , with tips and tricks to ensure more insidious diagnoses are not missed .

PAEDIATRIC FLAT FOOT

PAEDIATRIC flat foot ( see figure 1 ) is

the most common reason for a child with a foot and ankle deformity to present to a GP . 4 Much of the concern is driven by parents worried about the degree of deformity , worsening of the deformity , a failure to improve over time or pain associated with overuse . Flat foot deformity , in most cases , is very normal but may be exaggerated in those with ligamentous laxity . 5 Conditions that may mimic flat foot — which can lead to pain , worsening deformity and limitations with gait — include tarsal coalition , accessory navicular and congenital vertical talus .

Children almost universally are ‘ flat-footed ’ when they start walking . 6 This is most likely due to a constellation of contributing factors , including ligamentous laxity and lack of neuromuscular control . Because of the almost universal presence of this condition in early life , diagnosis of more insidious causes may be missed or delayed . Unfortunately , this may lead to a delay in appropriate treatment and have significant effects on the development of a child ’ s gait .

Feet may appear , for all intents and purposes , normal until a load is applied ; at which point , they deform into a flattened posture on weight-bearing . This may mean that many parents will not recognise the issue until their child begins standing and walking .

Risk factors

Age is one of the factors predisposing

to a flat foot deformity . The younger a patient , the more likely they are to have a flat foot . Physiologic correction may not occur until later in development . Generalised ligamentous laxity or an underlying disease of collagen will contribute to the presence and persistence of flat foot .

Given that females are more likely to have ligamentous laxity , there is also a preponderance in this group .

Clinical presentation

Patients and their parents may present

with concerns about deformity — with or without pain . There is typically a history of flat foot , accompanied by what the parents perceive to be an abnormal gait , with episodes of instability , trips and falls or generalised pain after periods of exertion . Screening the patient for risk factors and red-flag signs ( see box 1 ) and symptoms can be a relatively quick exercise .

As part of history-taking , obtaining a generalised obstetric history to determine any perinatal issues , a family history , and reviewing any conditions currently being treated , is essential . Note the age at which the child began walking ( if they have already started to walk ) and when the deformity was first noticed , as well as any treatment to date . If the deformity is associated with pain , determine what precipitates the pain , how quickly it is managed with rest or stretching , and whether there is a requirement for analgesia .