Date Published: February 16, 2018
Publisher: Public Library of Science
Author(s): Sindhrani Dars, Hayley Uden, Helen A. Banwell, Saravana Kumar, Heiner Baur.
Flexible pes planus (flat feet) in children is a common presenting condition in clinical practice due to concerns amongst parents and caregivers. While Foot Orthoses (FOs) are a popular intervention, their effectiveness remains unclear. Thus, the aim of this systematic review was to update the current evidence base for the effectiveness of FOs for paediatric flexible pes planus.
A systematic search of electronic databases (Cochrane, Medline, AMED, EMBASE, CINHAL, SportDiscus, Scopus and PEDro) was conducted from January 2011 to July 2017. Studies of children (0–18 years) diagnosed with flexible pes planus and intervention to be any type of Foot Orthoses (FOs) were included. This review was conducted and reported in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. McMaster critical review form for quantitative studies, was used to assess the methodological quality of the included studies. Given the heterogeneity of the included studies, a descriptive synthesis of the included studies was undertaken.
Out of 606 articles identified, 11 studies (three RCTs; two case-controls; five case-series and one single case study) met the inclusion criteria. A diverse range of pre-fabricated and customised FOs were utilised and effectiveness measured through a plethora of outcomes. Summarised findings from the heterogeneous evidence base indicated that FOs may have a positive impact across a range of outcomes including pain, foot posture, gait, function and structural and kinetic measures. Despite these consistent positive outcomes reported in several studies, the current evidence base lacks clarity and uniformity in terms of diagnostic criteria, interventions delivered and outcomes measured for paediatric flexible pes planus.
There continues to remain uncertainty on the effectiveness of FOs for paediatric flexible pes planus. Despite a number of methodological limitations, FOs show potential as a treatment method for children with flexible pes planus.
Pes planus, commonly known as flat feet, describes feet with lowered medial longitudinal arches [1, 2]. Pes planus can be classified into two types, rigid and flexible, if the arch reforms in non-weight bearing compared to weight-bearing it is considered flexible pes planus which is often associated with hindfoot (also known as rearfoot) eversion [3, 4]. If the arch height does not change during non-weight bearing compared to weight-bearing it is classified as rigid pes planus which affects around 1% of the population [1, 5]. While paediatric flexible pes planus is common, affecting around 48% to 77.9% children [6–8] there is ambiguity in terms of its definition, diagnosis and management strategies. The prevalence estimates of flat feet within the literature, whilst inconsistent, suggests that it is more frequently seen in younger children, males and those who are overweight or obese [7, 9, 10].
As there continues to remain uncertainty on the effectiveness of FOs for paediatric flexible pes planus [14, 20], the aim of this systematic review was to up-date the most recent review of the literature and synthesise the current body of evidence (2011–2017). A modest body of evidence base consisting of 11 studies representing several research designs was identified. The summarised findings from this review indicate that FOs may have a positive impact across a range of outcomes including pain, foot posture, gait, function, structural and kinetic measures. Despite these consistent positive outcomes, the current evidence lacks clarity and uniformity in terms of diagnostic criteria, interventions delivered and outcomes measured for paediatric flexible pes planus. Therefore, due to the equivocal nature of the evidence base, an explicit recommendation for the effectiveness of FOs in the management of paediatric flexible pes planus cannot be made and caution is required when interpreting these findings. These findings build on the previous systematic review conducted by MacKenzie et al. (2012), which identified the growing role of FOs and its potential to positively influence a number of subjective and objective measures. While the previous review did not provide specific recommendations, this systematic review does. There are two reasons for this. Firstly, the evidence base on the effectiveness of FOs for paediatric flexible pes planus has evolved since the previous systematic review. This systematic review used a comprehensive search strategy across eight databases (compared to four in the previous systematic review) to identify research studies which formed the evidence base for this systematic review. Secondly, unlike the previous systematic review which did not use any formal means of synthesising data from the included studies, this systematic review used a widely utilised, established framework (NHMRC FORM Framework) to synthesise the evidence base and develop its recommendations. The NHMRC FORM Framework considers a range of different evidence constructs when framing a recommendation. What remains consistent with both systematic reviews, is shared concerns regarding the methodological quality of evidence base and its implication for clinical practice.