An Introduction to the Study of Children’s Feet: Part One

More than 60 years ago, Herman Tax agreed with the statement by Dudley Morton that “the foot is the only important part of the body for which prevailing ideas of care and treatment have remained practically unchanged for 40 years.” This fact, he wrote, was evidence of the “serious quality of neglect concerning foot care.” He went on to observe that too many in medicine have accepted that certain mechanical conditions of the feet are normal because they are common when in fact they are not normal. One of these conditions was pronation, or “postural foot weakness,” which he considered to be “the underlying and fundamental cause for a great many adult foot problems,” stating that “proper care for this condition instituted in the infant stage and carried through would make for a great reduction in the number of foot sufferers.”

Tax’s warnings of the long-term destructive potential of excessive foot pronation in the young child were astute and trailblazing. In that era, most of the medical profession exhibited a dismissive attitude toward this condition. In spite of this climate of general disregard for the immature foot, Tax identifies numerous experts as early as the late 19th century who wrote about the potential deleterious effects of the weak or flat foot in the child and hinted at the potential benefits of early intervention.

This was early recognition by a leading expert in our field that more attention must be paid to children’s feet if the goal is to improve the overall foot health of the population. We have learned much since then, but this fundamental tenet still reverberates through our approach to foot biomechanics today. In his 1944 article, Tax pointed to evolutionary changes requiring the foot to “carry the body weight” and become an “organ of locomotion” and to change from “a primitive, loose, grasping structure to a lever for lifting and propelling body weight” as giving rise to the need for greater rigidity of the foot.

Beginning some 30 years after Tax identified the unique properties of the overpronated immature foot, Joseph C. D’Amico, in his landmark writings on “developmental flatfoot,”[1] furthered our understanding of the connection between fortification of an inadequate foot for the demands placed on it by the onset of locomotion and the improvement of long-term foot health.

Anecdotal evidence that Tax was right has mounted over the years, and much of the field of podopediatrics is based on his early principles. Unfortunately, the natural history of the excessively pronated immature foot, and the link between early intervention and improved outcomes later in life, have not been adequately researched. Some small studies have shown positive effects of foot orthoses on pediatric pes valgus, but long-term, prospective analysis is lacking. More than 60 years after the publication of Tax’s article, we are encouraged by the many children we have seen grow straighter, walk better, and falter less with our help, but we lack adequate scientific evidence to move us forward. Such evidence would establish podiatrists as the undisputed experts in the evaluation and management of the child’s foot. With the recent explosion of sports participation at ever-younger ages, referrals to us would skyrocket, and many more children would reach adulthood with improved foot function and a lower risk of symptoms.

Our podiatric medical colleges and graduate medical education programs must devote more effort, time, and resources to the study of the immature foot and the documentation of persistent or progressive foot malposition, the consequences of benign neglect, and the value of early intervention.

Commentary by Russell G. Volpe, DPM Department of Orthopedics and Pediatrics, New York College of Podiatric Medicine, New York, New York