Paediatric flexible flat foot:How are we measuring it and are we getting it right? A systematic review

Background: Flexible flat foot is a normal observation in typically developing children, however, some children with flat feet present with pain and impaired lower limb function. The challenge for health professionals is to identify when foot posture is outside of expected findings and may warrant intervention. Diagnoses of flexible flat foot is often based on radiographic or clinical measures, yet the validity and reliability of these measures for a paediatric population is not clearly understood. The aim of this systematic review was to investigate how paediatric foot posture is defined and measured within the literature, and if the psychometric properties of these measures support any given diagnoses. Methods: Electronic databases (MEDLINE, CINAHL, EMBASE, Cochrane, AMED, SportDiscus, PsycINFO, and Web of Science) were systematically searched in January 2017 for empirical studies where participants had diagnosed flexible flat foot and were aged 18 years or younger. Outcomes of interest were the foot posture measures and definitions used. Further articles were sought where cited in relation to the psychometric properties of the measures used. Results: Of the 1101 unique records identified by the searches, 27 studies met the inclusion criteria involving 20 foot posture measures and 40 definitions of paediatric flexible flat foot. A further 18 citations were sought in relation to the psychometric properties of these measures. Three measures were deemed valid and reliable, the FPI-6>+6 for children aged three to 15 years, a Staheli arch index of >1.07 for children aged three to six and≥1.28 for children six to nine, and a Chippaux-Smirak index of >62.7% in three to seven year olds, >59% in six to nine year olds and≥40% for children aged nine to 16 years. No further measures were found to be valid for the paediatric population. Conclusion: No universally accepted criteria for diagnosing paediatric flat foot was found within existing literature, and psychometric data for foot posture measures and definitions used was limited. The outcomes of this review indicate that the FPI - 6, Staheli arch index or Chippaux-Smirak index should be the preferred method of paediatric foot posture measurement in future research.