AMPLIFIED PAIN SYNDROMES: WHAT SHOULD YOU KNOW

Amplified pain syndromes (APS) is an umbrella term used to describe increased sensitivity to pain due to abnormal nerve connections in the nervous system. Diagnoses in children that fall under this umbrella term include juvenile fibromyalgia, central sensitization, and generalized chronic pain, among others.

In combination with a variety of factors, APS may be caused by:

• Injury
• Illness
• Psychological stress

 Individuals with APS may experience:

• Pain that is localized or widespread
• An onset of pain that is sudden or gradual
• Pain with an unknown cause
• Pain triggered by stress, illness, or prior injury, with pain continuing beyond a typical healing phase
• Pain described as achy, dull, sharp, shooting, burning, throbbing, and/or stabbing
• Pain that affects function and the ability to participate fully in daily activities
• Decreased school attendance, decreased involvement in sports, and disinterest in social participation

Signs and Symptoms

• Pain that is heightened in response to a normal event or minor injury that wouldn't typically be perceived as painful
• Impaired muscle endurance and weakness, poor cardiopulmonary (heart) endurance, poor posture, impaired balance, and/or impaired functional abilities
• Pain in response to a sensation such as a light touch, pressure, temperature, and/or vibration that would not normally provoke pain
• Swelling, temperature, and/or color changes to the skin of the affected area

Other common associated signs/symptoms may include: headache, blurry vision, memory problems, chest pain, heart palpitations, dizziness, abdominal pain, nausea, vomiting, diarrhea, constipation, abnormal limb movements, sleep disturbance, and fatigue.

Treatment

Physical therapists work with other medical professionals to provide physical therapy and education for people experiencing APS. Working one-to-one with individuals with APS, physical therapists teach exercises to decrease the fear of movement and apply exposure-based treatments to help desensitize painful areas. They aid in shifting focus from pain to function, encourage the use of stress management strategies, and help people recognize daily causes of stress.

Treatment may be provided in an inpatient or outpatient setting and may include:

• Exercise therapy: Daily strengthening and aerobic exercise to retrain the nervous system, decrease the fear of movement, and help people work through pain and discomfort and focus on functional improvements
• Desensitization: Daily repeated exposure to sensations that are perceived as painful in order to retrain the nerves' response to light touch, pressure, vibration, and temperature
• Stress education: Guidance about stress management, which may include recommended counseling services, relaxed breathing exercises, mindfulness training, and/or self-regulation strategies
• Decreased attention to pain: Education on how to limit discussion and decision makingdue to pain in order to decrease its importance to the brain, and return to normal daily activities.

Authored by: Brandi Dorton, PT, DPT, and Danielle Feltrop, PT, DPT, of Children's Mercy Hospital

PT FOR ATHLETES

If you’re an athlete, you know that long periods of training followed by performing at peak levels can take a toll on your body. Whether you’ve experienced an acute injury or have become hurt as a result of overuse, the professional physical therapists from Champion Performance and Physical Therapy in Prairie Village, Kansas can help you get back in the game with their effective sports physical therapy programs.

If you’re an athlete considering sports physical therapy, take a look at some of the ways in which you could benefit from treatment at Champion:

• Less Downtime: Sports physical therapy helps athletes regain muscle strength without damaging the injured area further. This will help you proactively work to repair injured tissue and get back to your training or active recovery period faster and with less downtime.
• Better Odds For A Full Recovery: Instead of letting an injury “ride its course,” physical therapy takes a proactive approach to healing and thus increases your odds of making a complete recovery. Under the care of a physical therapist, you’ll also know exactly when you can resume your normal activity levels again, whereas athletes who don’t seek physical therapy often try to do too much too soon and risk re-injuring themselves.
• You’ll Receive Tailored Treatment: Some athletes make the mistake of trying to rehabilitate their injured body part on their own, but this approach overlooks the fact that each body and injury is unique. The professionals at Therapy Works utilize a number of different treatment methods and have the skills, knowledge, and experience to tailor their sports physical therapy program to the unique needs of each patient.

Click on the contact information tab on our website menu for a full list of contact options. 

www.kcchampionperformance.com

FAMILIES MAKING SMART "MOVES"

Making a commitment to be physically active is one of the best ways families can prevent or combat obesity and its consequences. Physical therapists support the Department of Health and Human Services' Physical Activity Guidelines, which states:

• Children should get 1 hour or more of physical activity a day.
• Adults should do 2 hours and 30 minutes a week of moderate-intensity, or 1 hour and 15 minutes a week of vigorous-intensity aerobic physical activity.

Physical therapists' extensive knowledge of pre-existing conditions (such as type 2 diabetes and obesity) allows them to help people of all ages and abilities establish life-long patterns of physical activity. For those who already are obese, physical therapists can devise safe exercise programs that reduce pain, restore flexibility, and increase strength and cardiovascular endurance. For people with type 2 diabetes, they can design and supervise exercise programs that reduce the need for medications, lower the risk of heart disease and stroke, and help manage glucose levels, among other benefits.

The following tips were designed by physical therapists to help families stay active and incorporate physical activities into their daily lives:

"Smart Moves" for Families

• Plan weekend family activities involving physical activity, such as hiking, swimming, bicycling, mini-golf, tennis, or bowling.
• Help your child plan physical activities with friends and neighbors, such as skating or softball.
• Have your kids brainstorm a "rainy day" game plan of indoor activities involving fitness games such as Wii Fit or Dance Dance Revolution.
• Remember that your family does not need to join a health club or buy fancy equipment to be active. Walking isn't costly and it's easy. So is designing a backyard obstacle course. Weights can be made from soda or detergent bottles filled with sand or water!
• Provide positive rewards for your child when he or she engages in physical activities, such as workout clothes, a new basketball, or an evening of roller-skating.
• Provide positive feedback about your child's lifestyle changes. Remember not to focus on the scale (for you or your child).
• Be your child's "exercise buddy." Plan daily walks or bike rides and set goals together for increasing physical activity rather than for losing weight. It's also great "bonding" time!
• As you schedule your child's extracurricular activities, remember to plan time for exercise and activity as a priority for the entire family. Don't just "squeeze it in."
• Encourage children to try individualized sports such as tennis and swimming. Studies show such activities are the basis of lifelong fitness habits.
• Parents and children can do exercises while watching television (or at least during commercials), such as sit-ups, push-ups, or running in place. Discourage snacking or eating meals while watching.

FLAT FEET AND FALLEN ARCHES IN CHILDREN

Babies are often born with flat feet, which may persist well into their childhood. This occurs because children’s bones and joints are flexible, causing their feet to flatten when they stand. Young babies also have a fat pad on the inner border of their feet that hides the arch. You still can see the arch if you lift your baby up on the tips of the toes, but it disappears when he’s standing normally. The foot may also turn out, increasing the weight on the inner side and making it appear even more flat. 

Normally, flat feet disappear by age six as the feet become less flexible and the arches develop. Only about 1 or 2 out of every 10 children will continue to have flat feet into adulthood. For children who do not develop an arch, treatment is not recommended unless the foot is stiff or painful. Shoe inserts won’t help your child develop an arch, and may cause more problems than the flat feet themselves. 

However, certain forms of flat feet may need to be treated differently. For instance, a child may have tightness of the heel cord (Achilles tendon) that limits the motion of his foot. This tightness can result in a flat foot, but it usually can be treated with special stretching exercises to lengthen the heel cord. Rarely, a child will have truly rigid flat feet, a condition that can cause problems. These children have difficulty moving the foot up and down or side to side at the ankle. The rigid foot can cause pain and, if left untreated, can lead to arthritis. This rigid type of flat foot is seldom seen in an infant or very young child. (More often, rigid flat feet develop during the teen years and should be evaluated by your child’s pediatrician.) 

Symptoms that should be checked by a pediatrician include foot pain, sores or pressure areas on the inner side of the foot, a stiff foot, limited side-to-side foot motion, or limited up-and-down ankle motion. For further treatment you should see a pediatric orthopedic surgeon or podiatrist experienced in childhood foot conditions.

QUICK GUIDE TO DEVELOPMENTAL DELAY

A developmental delay describes the behavior of young children whose development in moving, talking, or playing is slower than other children of the same age. The delay can be in any area(s) of development, such as movement (motor), speech, thinking, or self-care skills. About 10% of all toddlers and preschoolers in the United States are classified as having developmental delay. 

What is Developmental Delay?

The term "developmental delay" may be used to describe any type of delay dealing with motor, speech, or thinking abilities that may or may not result from a specific condition. A child with Down syndrome, for example, would be identified at birth as having the syndrome (or even before birth with prenatal tests) and also, as it becomes apparent, with having developmental delay in several areas, including motor, speech, and thinking skills. Similarly, a child with autism could be described as having autism and developmental delay, meaning that the child’s behaviors can be described as autistic, but the child also exhibits delays in developmental skills. Other children have developmental delay without having a specific diagnosis, or maybe just a motor developmental delay, where they're reaching movement milestones at a slower rate. 

Although all states provide early intervention services for children with developmental delay, each state individually defines “developmental delay” (see Resources). Thus, the term may mean different things to different people and can result in differing services to help a family with a child who has developmental delay.

Signs and Symptoms

If a child has developmental delay, he or she might play with toys for younger children or interact with people like a younger child. When children's motor skills are delayed, they might not run, skip, or jump with other children because they have not yet developed age-appropriate skills and cannot keep up with their peers.

Because the term is such a broad and general one, developmental delay often looks different from one child to the next.

In infancy, a child is first suspected to have developmental delay if common milestones are delayed, such as:

• Holding the head steadily up by 4 months (symmetry is strong here - kiddo should be able to hold their head in midline) 
• Unsupported sitting by about 6 months (normal range is 5-7 months)
• Walking by about 12 months (normal range is 9-15 months)

A child who has a general lack of movement or does not move in a lot of different ways to explore movement, might have a motor developmental delay. Some infants with a motor developmental delay have hypotonia, or low muscle tone, which contributes to their movement difficulties.

Although delays in motor milestones often are the most obvious behavior that caregivers notice, other delays might be related to a child not moving. For example, learning about objects or producing speech sounds can be affected if a child does not learn to sit or change positions. In infancy, all developmental areas are closely connected and influence each other's progress.

Some children have sensory problems adding to movement difficulty, such as hypersensitivity to touch or an inability to plan and problem-solve movement activities. Children who have some or all of these problems also might develop social or emotional problems, such as a fear of trying new motor skills.

How Is It Diagnosed?

You first should talk to your pediatrician about any concerns you have regarding your child's development. Medical problems can have an impact on overall development that your doctor can identify, such as chronic ear infections that reduce hearing and affect the child’s speech development or balance.

Developmental delay is diagnosed by using tests designed to score a child's movement, communication, play, and other behaviors compared with those of other children of the same age. These tests are standardized, or scored on hundreds of children, in order to determine a normal range of scores for each age. If children score far below the average score for their age, they are at risk for developmental delay.

A pediatrician usually will perform a screening test during infancy to determine if a child is progressing normally, often at the request of a parent who suspects the child is not performing the same skills as other children of the same age. A screening test helps to identify which children would benefit from a more in-depth evaluation. A physical therapist, who has knowledge of movement development, coordination, and medical conditions, will perform an in-depth examination to determine if a child’s motor skills are delayed and, if so, by how much they are delayed.

How Can a Physical Therapist Help?

A physical therapist will first evaluate your child, including having a conversation with you and conducting an appropriate and detailed test to determine the child's specific strengths and weaknesses. If the child has motor developmental delay, the therapist will problem-solve with you about your family's routines and environment to find ways to enhance and build your child's developmental skills.

In addition to evaluating your child and the environment in which the child moves, the physical therapist can give detailed guidance on building motor skills 1 step at a time to reach established goals. The therapist may guide the child’s movements or provide cues to help the child learn a new way to move. For example, if a child is having a hard time learning to pull herself up to a standing position, the therapist might show the child how to lean forward and push off her feet; or if a child cannot balance while standing, the therapist may experiment with various means of support so the child can safely learn ways to stand.

The therapist will also teach the family what they can do to help the child practice skills during the child’s everyday activities. The most important influence on the child is the family, because they can make sure the child has the opportunities needed to achieve each new skill.

The therapist will explain how much practice is needed to help achieve a particular milestone. A child learning how to walk, for example, covers a lot of ground during the day, and the therapist can provide specific advice on the amount and type of activities appropriate for your child at his/her stage of development.

Can this be prevented?

Once developmental delay has been diagnosed, there are steps to take to prevent further delay or to help the child "catch up." However, because this diagnosis has so much variability, the outcomes of intervention vary quite a bit. The important thing to remember is that the earlier you intervene, the more likely it will be that your child can improve and not continue to fall behind.

TRUTH IS: Some babies are more prone to developmental (physical) delay. Babies who are larger, quite frankly, tend to develop their motor skills at a slower rate than do some of the smaller kiddos. Why? Because they have more load to lift, and when you're first learning how to lift a load, it's easier if it's lighter. How long would you see a delay like this? Not long. Up to a couple years, maybe. Most kiddos catch up with the other kids their age without a problem. 

CAUTION: Babies who have little or no active "tummy time" play may be prone to developmental delay. The American Academy of Pediatrics (AAP) has recommended that all infants sleep on their backs to reduce the incidence of sudden infant death syndrome (SIDS). As a precaution, many parents have avoided placing infants on their tummies altogether. However, research has shown that avoiding tummy time can slow the rate of accomplishment of motor-skill (movement) milestones. Evidence also indicates that infants who are kept in baby equipment (infant chairs, carriers, sling seats at activity centers) for long periods of time are at a higher risk of motor delays than infants who have sufficient opportunities for active movement.

AAP's new recommendation, "Back to Sleep, Tummy to Play" (see Resources), encourages parents to let a child be on the floor to play in many different positions. This allows the child to learn how to move, and stimulates the brain and muscles so that rolling, reaching, crawling, and eventually walking can be achieved. Experiencing lots of different positions allows children to experiment with their bodies and build new movements. And exploring new movements helps them learn to think differently, and may even stimulate speech and social skills.

THE QUICK GUIDE TO CEREBRAL PALSY (CP)

Cerebral Palsy (CP) is a general term used to describe a group of disorders that affect the normal development of movement and posture. CP is caused by an injury to the brain—such as infection, stroke, trauma, or the loss of oxygen to the brain—that occur before, during, or after birth or within the first 2 years of life. The injury to the brain is "nonprogressive," meaning that it does not get worse after the initial injury. However, the day-to-day activities that can be affected by the injury during an individual's childhood can worsen throughout the individual's life.

Difficulties from CP can range from mild to severe. Individuals with CP may have trouble seeing, hearing, feeling touch, thinking, or communicating. They may also experience seizures.

CP affects approximately 3.6 infants per each 1,000 born in the United States. The number of children diagnosed with CP has grown in recent years as a result of the increased survival rates of premature babies and those born with low birth weights. The average life expectancy of adults with CP has increased as well. People with CP can benefit from physical therapy throughout all the stages of their lives.

Physical therapists are experts in helping people with CP improve their physical functions. They can help them stay active, and healthy, and perform day-to-day tasks such as walking, operating a wheelchair, and getting in or out of a wheelchair to and from a bathtub, bed, or car.

What is Cerebral Palsy?

Cerebral palsy is a broad term used to describe the effects on the development of motor skills caused by nonprogressive injuries to the developing brain. Types of CP are given different names based on the type of movement problem and the areas of the body affected:

• Spastic involves increasing spasm of the muscles as the person moves faster.
• Ataxic involves decreased coordination and unsteadiness throughout the body.
• Dyskinetic involves unpredictable changes in muscle tone and movement that create unstable posture.
• Mixed describes a combination of the movement problems noted above (spastic, dyskinetic, or ataxic).
• Quadriplegia describes CP that affects both arms and legs, the neck, and the trunk.
• Diplegia affects either both legs (the most common form of the disorder) or both arms (less common).
• Hemiplegia affects just one side of the body.

Signs and Symptoms

Symptoms of CP differ from one person to the next. Symptoms might appear as early as 2 months of age and are usually seen before a child is 2 years old. Parents usually notice early signs that their child is not able to hold his or her head up as well as other babies, or easily reach, roll, sit, crawl, or walk.

Other symptoms of CP related to movement can include:

• Tight muscles that worsen with stress, illness, and time
• Tight joints that do not bend or stretch all the way, especially in the hands, elbows, hips, knees, or ankles
• Muscle weakness, or a decline in movements that the child had already been performing
• Lack of efficient movement of the legs, arms, trunk, or neck
• Lack of coordination
• "Floppy" muscles, especially in the neck or trunk
• Muscle tremors

Other symptoms of CP can include:

• Difficulty speaking or being understood
• Learning disorders (even though the child has normal intelligence)
• Vision problems
• Hearing problems
• Seizures
• Pain in joints that is often caused by tight muscles or poor posture
• Decreased mouth muscle strength or coordination leading to problems with eating and/or increased drooling
• Constipation
• Difficulty holding urine
• Slower-than-normal growth

How Is It Diagnosed?

Although a child's pediatrician may identify a delay in movement development and refer the child to a physical therapist, physical therapists are often the first medical professionals to identify signs and symptoms of CP. The therapist will:

• Conduct a medical history, asking questions about the parents' concerns, the pregnancy, birth, and the general health of the child
• Perform a thorough evaluation that includes:
  • observing the child in different positions to assess movement patterns
  • hands-on assessment of the child's muscle tone, strength, flexibility, and reflexes
  • determining developmental milestones (how well he or she can sit, stand, or grasp objects)

Your therapist will collaborate with your child’s physician, who may order further tests—such as blood work, magnetic resonance imaging (MRI), or computerized tomography (a CT Scan)—to reach a final diagnosis.

How Can a Physical Therapist Help?

A physical therapist is an important partner in health care and fitness for anyone diagnosed with CP. Therapists help people with CP gain strength and movement to function at their best throughout all the stages of life.

The physical therapist will provide care at different stages in the individual's development, depending on his or her unique needs. Therapy may be provided in your home or at another location such as a community center, school, or a physical therapy outpatient clinic. The physical therapist will work with other health care professionals, such as speech/language pathologists or occupational therapists, to address all the individual's needs as treatment priorities shift.

Physical Therapy in the Early Years: Birth to Age 4

Physical therapists can help caregivers support their child's movement development by providing hands-on training for positioning, movement, feeding, play, and self-calming. Your therapist will also suggest changes at home to encourage movement development, as well as communication, hearing, vision, and play skills. It is important to remember that it is through play that young children learn many skills. Your therapist will develop an individual program of play activities that match your child's specific needs—to improve strength, movement, and function. At this age, physical therapy is generally provided at home, in a daycare center, or in an outpatient clinic.

Physical Therapy in the School Years:  Ages 5 to 12

Physical therapists train caregivers to help the child with CP accomplish functional goals and promote the highest quality of life through all stages of development. The treatment plan and goals will change as your child ages. Pre-school and school bring challenges for your child to navigate new environments each year. At this age, children also experience growth spurts, requiring adjustments to therapy and equipment used to help the child. Care priorities can focus on walking, transfers, personal hygiene, play, socialization, and adaptive equipment needs to meet the social and physical changes that occur during this time period. Physical therapy may be provided in outpatient and/or school settings. School-based therapy focuses on accommodations and modifications to ensure your child has the best possible learning environment.

Physical therapy benefits the adolescent with CP by focusing on prevention of posture problems and joint limitations. This is done by encouraging mobility and fitness, managing muscle and/or joint pain, and recommending braces and other helpful equipment to maintain health and function. The physical therapist will educate parents about self-care, maintaining daily routines, socialization, physical activity, and plans for the child's schooling and future careers.

It is important to note that lifelong health habits are formed at this age—and developing an individual fitness program can improve the person’s health and function for the remainder of his or her life. Children with CP are at a greater risk than the general youth population of not exercising enough and becoming sedentary, which can lead to weight issues and medical complications. These issues progress gradually but can have a significant impact on the quality of life of the child and of the caregivers. Physical therapists are skilled in developing individual exercise programs that use each child's strengths and abilities. For instance, a therapist might recommend adaptive sports such as bowling, swimming, cycling, volleyball, tennis, and basketball to promote physical fitness and socialization with peers.

Physical Therapy in Adulthood: Age 18+

Many individuals with CP live highly functional lives as adults. Many have careers and families. In adulthood, people with CP often focus on pain management, conserving energy, adaptive equipment, and environment modifications to promote independence at work and at home. Physical therapists can help with managing these concerns. Like many adults, individuals with CP have muscle and joint pain in adulthood. Physical therapists can prescribe an exercise routine that enables the individual to stay strong and minimize joint issues.

Physical therapists are skilled in all of these areas, and they partner with people with CP and their caregivers to address their individual goals for realistic, positive outcomes.

What Kind of Physical Therapist Do I Need?

All physical therapists are prepared through education and experience to treat patients with cerebral palsy. However, you may want to consider:

• A physical therapist who is experienced in treating people with CP
• A physical therapist who focuses on treating infants and children
• A physical therapist who is a board-certified clinical specialist or who has completed training in pediatric or neurologic physical therapy, meaning he or she has advanced knowledge, experience, and skills

You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.

General tips when you're looking for a physical therapist (or any other health care provider):

• Get recommendations from family and friends or from other health care providers.
• When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping people who have cerebral palsy.
• During your first visit with the physical therapist, be prepared to describe the symptoms in as much detail as possible, identify what makes the symptoms worse or better, and discuss your goals.

GENU VALGUM IN YOUTH AND ADOLESCENCE

What is Genu Valgum? 

Valgum, more commonly referred to via medical terminology as "valgus" or "knock-knee" is a condition in which the knees angle inward toward each other, or the midline of the body, when the legs are fully straight.  The opposite occurrence is genu varum, otherwise known as "bowleggedness". 

Flexibility in the joints during childhood is completely normal, and is the reason why your children can sit cross-legged, or any other position you wonder how you were ever able to do.

Cases vary from slight to extreme, and are developed under a multitude of circumstances, including passively due to activity levels, hereditary, or retained as a result of a genetic disorder. Children who are "pigeon-toed" have an increased variability of retaining valgus into adulthood. According to , the average child has most prominent increase in valgus around age 4 at average 8 degrees, lessening each year with valgus averaging <6 degrees by age 11. Children in this study who's valgus was deemed within normal limits ranged from anywhere up to 12 degrees for ages 2-11. 

What does that mean?

Valgum is extremely common, more common in fact than it's counterpart in genu varum. During youth, it's nothing to be extremely concerned about. Often, as children age and become engaged in more strenuous physical activities ( ex: running while playing soccer), the musculature in the lower extremities will naturally reduce the angle of varum. In other words - many a times, valgum is corrected on it's own. 

What if it doesn't?

In most cases, physical therapy is an option to increase the strength on the lateral (outsides) aspect of the lower extremities, which will help to reduce the angle in a controlled environment. Teaching proper body mechanics through movement will increase the ability of the child to improve his/her valgum without the trained eye of a physical therapist, or the watchful eyes of their parents around. 

If the angle is more severe, other options can be provided and discussed with an orthopedic specialist and a primary care physician to determine the best course of action. 

Why should we correct it?

Genu valgum is not considered an emergency situation - nor should it be. It's a natural aspect of growing - simply something to be monitored. However, allowing valgum to stabilize and continue on into adulthood will create problems for the child later on in his/her lifetime. Multiple studies have shown that the presence of untreated valgum has an extremely high correlation with osteoarthritis of the knee and hip, misalignments of the pelvis and sacrum, which increase the risk of low back pain, leg length discrepancies, musculoskeletal issues, to name a few. 

If that doesn't convince your young adult to improve their valgum condition, it may help to remind them that valgum is also correlated with an increase in non-contact ligamentous/soft tissue tears in the knee joint - those will end a season fairly quickly, and will increase their risk to tear a ligament simply performing a daily activity, such as jumping down off of a small ledge, or stepping off of a curb. 

Knowledge is power!

"FLAT FEET" IN CHILDREN

Flatfeet (also known as pes planus) describes a condition in which the longitudinal (lengthwise) and/or medial (crosswise) arches of the foot are dropped down or flat. The entire bottom of the bare foot is in contact with the floor or ground surface during standing, walking, and other weight bearing activities. The condition is often present at birth (congenital) in one or both feet. When only one foot is affected, the problem is referred to as unilateral pes planus or flatfoot. When both feet are involved, the condition is bilateralflatfeet.

This guide will help you understand:

• what parts of the foot are affected
• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the foot are involved?

The Anatomy of the foot is very complex. When everything works together, the foot functions correctly. When one part becomes damaged, it can affect every other part of the foot and lead to problems. With a flatfoot deformity, bones, ligaments, and muscles are all affected. A combination of malalignments results in the flatfoot appearance. 

Bones

The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint. 

The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heel bone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. 

The subtalar joint allows the foot to rock from side to side. People with flatfeet usually have more motion at the subtalar joint than people who do not have flatfeet. The increased flexibility of the subtalar joint results in many compensatory actions of the foot and ankle in order to keep proper foot alignment during standing and walking.

Just down the foot from the ankle is a set of five bones called tarsal bones. The tarsal bones work together as a group. They are unique in the way they fit together. There are multiple joints between the tarsal bones. When the foot is twisted in one direction by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting. 

The tarsal bones are connected to the five long bones of the foot called the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at the joints. Finally, there are the bones of the toes, the phalanges. 

Ligaments and Tendons

Ligament are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure. 

The large Achilles' tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the heel bone to allow us to rise up on our toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. Failure of the posterior tibial tendon is a major problem in many cases of pes planus.

Many small ligaments hold the bones of the foot together. Most of these ligaments form part of the joint capsule around each of the joints of the foot. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac.

The spring ligament complex is often involved in the flatfoot condition. This group of ligaments supports the talonavicular joint. The spring ligament complex works with the posterior tibial tendon and the plantar fascia to support and stabilize the longitudinal arch of the foot. Failure of the ligaments that support this arch can contribute to flatfoot deformity. Injury, laxity(looseness), or other dysfunction of the ligament and tendon structures can result in deformity of the foot and/or ankle resulting in pes planus. 

Muscles

Most of the motion of the foot is caused by the stronger muscles and tendons in the lower leg that connect to the foot. Contraction of the muscles in the leg is the main way that we move our feet to stand, walk, run, and jump.

There are numerous small muscles in the foot. While these muscles are not nearly as important as the small muscles in the hand, they do affect the way that the toes work. Damage to some of these muscles can cause problems.

Most of the muscles of the foot are arranged in layers on the sole of the foot (the plantar surface). There they connect to and move the toes as well as provide padding underneath the sole of the foot.

Causes

What causes this problem?

Flexible flatfoot refers to a foot that looks flat when standing but appears to have an arch when the foot isn't resting on the floor or against a flat surface. Sometimes the term fallen arches is used, but doctors prefer not to use this term in favor of the more accurate medical term pes planus. 

Most babies and young children have what looks like flat feet. This is normal. Before the bones are formed, much of the foot and ankle are still made up of soft tissue, fat, and cartilage. The arch has not formed fully yet. The joints are still hypermobile when the child starts to get up on feet to walk. This is when the flatfoot deformity becomes obvious and parents may become concerned that something is wrong with their child's foot. The vast majority of children will grow out of their flat foot deformity. Even if the deformity does not fully correct with age, it is unlikely to cause the child any difficulty in the future.

Stress and activities during early childhood requiring strength in the feet are actually the training needed to develop normal muscle, tendon, ligaments, and bone in the foot and ankle. But in some cases, the arch doesn't form and the foot remains flat into adulthood. Flatfeet do tend to occur in families as an inherited condition.

There are many possible causes for the flatfoot condition. Biomechanically, many soft tissue structures must connect and support one another to prevent a flatfoot deformity. Tibial (lower leg bone) rotation, hindfoot alignment, and position of the joints of the foot, midfoot, hindfoot, and ankle are all important factors. There is no one cause of flatfoot deformity that can be identified.

In the flexible flatfoot, the bones are usually normal - but the supporting ligaments are lax or loose. The joints are hypermobile. As the soft tissues and joints of the foot and ankle try to maintain a normal foot position, increased stress is placed on them. This can lead to fatigue and loss of strength resulting in a sagging of the arch. This can affect the chain of anatomical structures all the way up the leg.

There are some uncommon causes of flatfoot that do affect the bones. A Tarsal Coalition refers to a condition where two or more bones in the midfoot or hindfoot fail to form separately during development. They remain connected together, altering the bone structure of the foot and limiting flexibility of the foot. This is a different type of flatfoot deformity altogether and is commonly referred to as a spastic flatfoot. This type of flatfoot deformity is not flexible. In fact, the foot is quite rigid due to the abnormal connection between the bones of the foot. This condition can be painful. 

Symptoms

What does the condition feel like?

For most children, the flexible flatfoot deformity causes no symptoms. They do not suffer from pain, swelling, or sore feet. Children with flexible flatfoot deformity may wear out shoes a bit different from a normal person, but there usually is not any reason to be concerned.

In moderate to severe cases, the patient may report fatigue and tired, sore feet after standing on them all day. During those times, they may limit their own activities.

In the uncommon severe cases, calluses may appear where pressure occurs as the bones make contact with the floor or hard surface. The loss of joint stability may alter the foot's ability to absorb the load and conform to uneven ground or surfaces.

Rarely, the flatfoot deformity may get worse with age. Excess pressure on the surrounding soft tissues (ligaments, capsules, tendons, muscles) can lead to other problems such as malalignment of the patella (kneecap), hallux valgus (Bunions), and rotation of the knee and hip.

When the flatfoot deformity is the result of a tarsal coalition, the situation is different. The foot may become painful. The child may begin to complain of foot and ankle pain after a minor twisting injury and the pain not resolve after a normal healing period. The symptom of pain combined with decreased motion and flatfoot deformity should suggest a more serious problem in the foot. 

Diagnosis

How do doctors diagnose the problem?

The history and physical examination are probably the most important tools the physician uses to diagnose this condition. Clinical tests can be done to differentiate flexible flatfoot from rigid flatfoot. The examiner will check mobility in the forefoot, hindfoot, and ankle. Muscle weakness and/or muscle tightness will be assessed. The wear pattern on the shoes can offer some helpful clues. 

X-rays or other more advanced imaging such as CT scans or MRIs may be ordered but these are rarely needed. The examiner may be able to see and feel a prominent bump with tenderness around the area when an Accessory Navicular bone is present. X-rays will show if there is an accessory navicular or tarsal coalition as part of the problem.

A very simple test called the wet footprint can be done at home or in the doctor's office. The patient places the foot in water and then places the foot down on a piece of paper or thin cardboard. After making a footprint, the foot is lifted off the paper. Someone with a flat foot will leave a complete footprint where the sole makes contact with the paper.

The physician may have you perform a single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). 

Treatment

What treatment options are available?

Nonsurgical Treatment

There may be no treatment needed for mild cases of flatfeet, especially flexible flatfeet. This condition often corrects itself in time as the child grows and develops. Young children should be encouraged to walk barefoot whenever it is safe to do so. This will increase sensory input into the foot. At the same time, navigating various floor and ground surfaces helps build strength and stability.

For older children and adults, a simple modification to the shoe may reduce the fatigue and discomfort in the foot. Sometimes purchasing shoes with a good arch support is sufficient. Try to find a comfortable shoe with an arch support, firm heel counter (back of the heel), and a flexible sole (bottom). Supporting the arch helps decrease the tension in the posterior tibialis tendon. Stretching the Achilles' tendon helps maintain normal motion of the hindfoot, which in turn, helps maintain alignment of the midfoot.

For other patients, an off-the-shelf (prefabricated) shoe insert works well. The goal is to support the foot and prevent further stretching of lax ligaments and tendons. These supports will not reverse the structural deformity and they will not build and arch by wearing them over time. These inserts simply help the shoe better fit the foot and support the structures of the foot. Improving alignment can take tension off the soft tissue structures, reduce fatigue, and improve the biomechanics of standing and gait (walking).

Further treatment is usually not needed for the flexible flatfoot deformity. Surgery is rarely needed for this condition. Patients with severe symptoms that do not respond to conservative care may benefit from further orthopedic evaluation and treatment. In rare cases, surgical intervention to correct the problem and realign the foot may be suggested.

Surgery

For children with a shortened Achilles' tendon, a program of stretching exercises or serial casting may help reduce pressure on the talus bone and offer significant pain relief. Severe cases of flatfoot (pes planus) may require surgery to reconstruct the arch or fuse the bones. This is very rare as conservative (nonoperative) care is usually sufficient.

Children with tarsal coalition or an accessory navicular bone require orthopedic evaluation and management. Surgery is done to correct the problem by the early teen years (before skeletal maturity). 

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Flatfeet seen in very young children just starting to walk often resolve with time. The very act of gripping with the toes to maintain support and balance along with the development of the bones forms the arches.

For older children who still have flatfeet, stretching and strengthening exercises won't cause an arch to form where there isn't one anatomically. But these activities can help ease any pain or discomfort caused by the condition. The same is true for any supports or shoe inserts that are used. However, shoe inserts or shoes specially-made to improve their condition tend to allow them to increase their desire to perform physical activity, as it does not correlate with a conditioned response to expect pain following exercise.  We recommend seeing a specialist then coming into us here at Champion Performance and Physical Therapy for exercises to improve your child's ability to be active and get exercise without pain. 

After Surgery

Corrective surgery is only done in cases of severe, painful and disabling flatfoot position. This is very rare. Reconstructive surgery for tarsal coalition or an accessory navicular bone requires a period of immobilization in a cast followed by rehabilitation to restore strength in the foot and ankle. In some cases, more than one operation is needed as the child grows and develops. Pain relief and joint stability are the goals.