This study investigates flexible pes planus (flat feet) in children, a condition where the medial arch collapses during weight-bearing, affecting gait, balance, and foot function. Although foot-core strengthening and visual feedback individually improve arch stability and motor control, their combined effect in pediatric populations remains underexplored. To address this gap, a randomized controlled trial will be conducted at Rafia Grammar School, involving 24 children aged 7-12 years with clinically confirmed flexible pes planus. Participants will be randomly assigned into two groups: one receiving foot-core training alone and the other receiving foot-core training with visual feedback, with interventions carried out twice weekly for 8 weeks. Changes in foot posture and gait will be assessed using standardized outcome measures, and data will be analyzed using SPSS version 23.0. The study aims to determine whether adding visual feedback enhances treatment effectiveness and supports the development of more targeted, evidence-based pediatric rehabilitation strategies.
Flexible pes planus, commonly observed in children, is characterized by a collapse of the medial longitudinal arch during weight-bearing, which can impair gait efficiency, balance, and foot function if unaddressed. While intrinsic foot muscle (foot-core) strengthening has been shown to improve arch stability and functional outcomes, and visual feedback is recognized for enhancing motor control through real-time sensory input, current literature lacks empirical evidence on the combined effect of these interventions in pediatric flatfoot populations. Most studies examine either strengthening exercises or feedback mechanisms independently, often without tailoring protocols to the unique neuromuscular learning needs of children. This gap limits the development of comprehensive rehabilitation strategies for flexible pes planus. Therefore, this study aims to compare the effectiveness of foot-core training with and without visual feedback on foot posture and gait parameters in children with flexible pes planus, thereby contributing to the advancement of targeted, evidence-based pediatric rehabilitation approaches. This randomized controlled trial will be conducted at Rafia Grammar School. Using a convenience sampling technique, children aged 7-12 years with clinically confirmed flexible pes planus will be recruited based on predefined inclusion and exclusion criteria, including cognitive readiness and flexibility of the medial arch. After baseline assessment, participants will be randomly allocated into two intervention groups (n1=12, n2=12): one receiving foot-core training alone, and the other receiving foot-core training with visual feedback. The intervention will be performed 2 times per week for 8 weeks. The study will assess changes in gait and foot posture using standardized physical and functional outcome measures. Ethical approval will be secured before starting the study, and all evaluations will be carried out consistently throughout the trial. Data will be analyzed through SPSS version 23.0.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
OTHER
Masking
SINGLE
Enrollment
24
Children will perform exercises 2×/week for 8 weeks with daily home practice. Begin with 1-2 sets of 5-15 reps (hold 5-10 sec), 1-2 min rest, progressing gradually. Session: 30-45 min. 1. Short-Foot Contraction: Lift medial arch without toe curling (5-15 reps, hold 5-10 sec) 2. Tip-Toe Heel Raises: Rise, hold 2 sec, lower (15 reps) 3. Towel Scrunch: Scrunch towel with toes (\~1 min) 4. Marble Pickup: Pick/place objects with toes (\~1 min) 5. Arch Lifting: Lift arch in standing (15 reps) 6. Plantar Roll + Calf Stretch: Ball roll + stretch (15-30 sec ×2-3) 7. Toe Spread \& Squeeze: Spread and squeeze toes
Visual feedback will be delivered via mirror therapy using a 36×36×48 cm mirror box. The child sits with the mirror at midline; one foot is hidden inside the box while the other is visible. While performing foot-core exercises, the mirror creates the illusion of symmetrical movement. The process is repeated by switching feet to ensure bilateral training. Exercises will be done 2×/week for 8 weeks (home practice encouraged), 1-2 sets of 5-15 reps (hold 5-10 sec), 1-2 min rest, session 30-45 min. 1. Short-Foot: Lift arch without toe curling (5-15 reps) 2. Heel Raises: Tip-toe, hold 2 sec (15 reps) 3. Towel Scrunch: Toe curl (\~1 min) 4. Marble Pickup: Pick/place objects (\~1 min) 5. Arch Lift: Standing arch raise (15 reps) 6. Plantar Roll + Stretch: Ball roll + calf stretch (15-30 sec ×2-3) 7. Toe Spread/Squeeze: Improves foot stability
Rafia Grammar School
Lahore, Punjab Province, Pakistan
RECRUITINGFoot Posture Index
The Foot Posture Index-6 (FPI-6) is a reliable and valid tool for pediatric foot assessment, with excellent inter-rater (ICC 0.92-0.97) and test-retest reliability (ICC 0.93-0.95). It shows good validity through correlations with radiographic measures (r = 0.37-0.77) and demonstrates strong diagnostic accuracy for flexible flatfoot (AUC 0.82, sensitivity 83.7%, specificity 80.4), supporting its clinical and research use.
Time frame: Baseline, 8 weeks
Temporal Distance Gait Analysis:
Temporal-distance gait analysis using footprint methods is a valid and reliable tool for assessing pediatric gait. It measures parameters like step length, stride width, and cadence via footprints on a marked walkway. Studies show good test-retest reliability (ICCs 0.52-0.98), supporting its use in children with gait abnormalities, including flexible pes planus.
Time frame: Baseline, 8 weeks
Arch Height Index
The Arch Height Index (AHI) is a reliable and valid measure of pediatric foot structure. It shows strong intra- and inter-rater reliability (ICC ≥ 0.76-0.90) in both sitting and standing positions. Evidence supports its precision and consistency for assessing foot posture in children.
Time frame: Baseline, 8 weeks
Medial Longitudinal Arch Angle
The Medial Longitudinal Arch (MLA) angle is a reliable and valid clinical measure for assessing pediatric foot posture. It shows excellent intra-rater (ICC 0.88-0.90) and inter-rater (ICC 0.80-0.85) reliability in children aged 6-12 years. It is a simple, non-invasive tool that accurately reflects arch structure and is useful for evaluating flexible flatfoot.
Time frame: Baseline, 8 weeks
Calcaneal Eversion Angle
The Calcaneal Eversion Angle is a reliable clinical measure for assessing rearfoot position in weight-bearing stance. It shows good intra-rater reliability (ICC = 0.84) with consistent repeated measurements, and acceptable inter-rater reliability. Overall, it is a valid and practical tool for evaluating foot posture in both children and adults.
Time frame: Baseline, 8 weeks
Subtalar joint range of motion
The subtalar joint ROM, assessed via goniometry in weight- or non-weight-bearing positions, is a reliable and valid measure in children. It shows good intra-rater reliability (ICC 0.74-0.90) and acceptable inter-rater reliability (ICC \~0.50-0.72). Overall, it is a clinically practical tool for evaluating foot and ankle mobility in pediatric populations.
Time frame: Baseline, 8 weeks
Footprint Index (Staheli or Chippaux):
The Staheli Index (SI) and Chippaux-Smirak Index (CSI) are reliable footprint-based tools for detecting pediatric flatfoot. They show excellent intra-rater (ICC 0.92-0.99) and good inter-rater reliability (ICC 0.79-0.96), with low measurement error (SEM 0.08-0.21, MDC 0.22-0.59). Both demonstrate strong validity through correlations with radiographic arch measures (r = 0.66-0.79).
Time frame: Baseline, 8 weeks
Y-Balance Test
The Y-Balance Test (YBT-LQ) is a reliable and valid measure of dynamic balance in children. It shows excellent inter-rater (ICC 0.84-0.92) and test-retest reliability (ICC 0.81-0.92), with low SEM (1.80%-3.10%) and MDC (4.98%-8.60%). These findings confirm its sensitivity and clinical usefulness for assessing dynamic postural control in pediatric populations.
Time frame: Baseline, 8 weeks
Lower Extremity Functional Scale
The Lower Extremity Functional Scale (LEFS) is a reliable and valid patient-reported tool for assessing lower limb function in children and adolescents. It shows excellent internal consistency (Cronbach's α = 0.972) and strong construct validity. It also correlates highly with pediatric quality of life measures (r = 0.859).
Time frame: Baseline, 8 weeks
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