Foot-Core Training With/Without Visual Feedback in Pediatric FPP

Comparison of Foot-Core Training With and Without Visual Feedback on Gait and Foot Posture in Children With Flexible Pes Planus

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.

Study Overview

• Status: Recruiting
• Conditions: Flexible Flatfoot
• Intervention / Treatment: Other: Foot Core Training; Other: Foot Core Training with Visual Feedback

Detailed Description

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
• Enrollment (Estimated): 24
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: IMRAN AMJAD, PhD; Phone Number: 9233224390125; Email: imran.amjad@riphah.edu.pk
• Study Contact Backup: Name: Muhammad Asif Javed, MS-PT; Phone Number: 923224209422; Email: a.javed@riphah.edu.pk

Study Locations

• Pakistan
  • Punjab Province
    • Lahore, Punjab Province, Pakistan, 53700
      • Recruiting
      • Rafia Grammar School
      • Contact: IMRAN AMJAD, PhD; Phone Number: 9233224390125; Email: imran.amjad@riphah.edu.pk
      • Contact: Muhammad Asif Javed, MS-PT; Phone Number: 923224209422

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

• Children aged 7-12 years with confirmed flat feet
• Both Genders
• Flexibility of flatfeet; tested using Tip toe standing test and Jack's test.
• Navicular Drop (>10mm)
• Mini Mental State Examination score > 21
• Visual acuity of 20/40 (6/12) or better in both eyes, confirmed by Snellen chart test.
• Foot Posture Index-6 (FPI-6, > +6)
• Children demonstrate altered gait parameters consistent with flexible pes planus as measured by temporal-distance gait analysis.
• Arch Height Index (< 0.31)
• Medial Longitudinal Arch Angle (<130°)
• Calcaneal Eversion Angle ( >5° eversion)
• Subtalar ROM (Dorsiflexion <10°)
• Footprint Index (Staheli >1.0 or Chippaux >45%)
• Dynamic Balance; Y-Balance Test (<85% composite score)
• Functional Scale (LEFS) (<60%)

Exclusion Criteria:

• Children with tarsal coalitions
• Congenital defects of lower limbs
• Previous foot surgery
• Foot/ankle trauma within the last six (6) months
• Received balance training or feet muscle strengthening within the last 3 months
• Visual and vestibular disturbance
• A history of head injury within the last 3 months
• Weakness of lower extremities (Manual Muscle testing grade <5)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Other
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Group A: Experiment Group 1: Foot-Core Training group; Children will perform the following exercises 2 times per week for 8 weeks, with daily practice encouraged at home. Start with 1-2 sets of 5-15 repetitions, holding each for 5-10 seconds, with 1-2 minutes rest between sets. Progress by increasing repetitions or hold durations gradually (7). The session will take 30-45 mins.	Other: Foot Core Training; 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.; Short-Foot Contraction: Lift medial arch without toe curling (5-15 reps, hold 5-10 sec); Tip-Toe Heel Raises: Rise, hold 2 sec, lower (15 reps); Towel Scrunch: Scrunch towel with toes (~1 min); Marble Pickup: Pick/place objects with toes (~1 min); Arch Lifting: Lift arch in standing (15 reps); Plantar Roll + Calf Stretch: Ball roll + stretch (15-30 sec ×2-3); Toe Spread & Squeeze: Spread and squeeze toes; Other Names: Short Foot exercises
Active Comparator: Group B: Experiment Group 2: Foot-Core Training with Visual Feedback group; Visual feedback will be provided using mirror therapy with a mirror box (36 × 36 × 48 cm). The child will sit comfortably with the mirror placed at the midline between the legs; one foot will be hidden inside the box while the other remains visible in front of the mirror. As the child performs foot-core exercises with the visible foot, the mirror creates the illusion that both feet are moving symmetrically, enhancing motor learning through visual feedback. The procedure will then be repeated by switching foot positions to ensure bilateral training. Exercises will be performed twice weekly for 8 weeks, with additional home practice encouraged. Each session will last 30-45 minutes, starting with 1-2 sets of 5-15 repetitions (holding each for 5-10 seconds) and progressing gradually with rest intervals of 1-2 minutes between sets.	Other: Foot Core Training with Visual Feedback; 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.; Short-Foot: Lift arch without toe curling (5-15 reps); Heel Raises: Tip-toe, hold 2 sec (15 reps); Towel Scrunch: Toe curl (~1 min); Marble Pickup: Pick/place objects (~1 min); Arch Lift: Standing arch raise (15 reps); Plantar Roll + Stretch: Ball roll + calf stretch (15-30 sec ×2-3); Toe Spread/Squeeze: Improves foot stability; Other Names: Short Foot Eercises with Visual Feedback

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Foot 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.	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.	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.	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.	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.	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.	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).	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.	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).	Baseline, 8 weeks

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Tiptoe standing test	The Tiptoe Standing Test is a valid clinical tool for differentiating flexible from rigid pes planus, based on reformation of the medial longitudinal arch during tiptoe stance. It shows good reliability, with intra-rater ICC 0.80-0.90 and inter-rater ICC 0.70-0.85. Despite some observer variability, it remains a practical and efficient pediatric screening method.	Baseline
Jack's test	Jack's Test (Hubscher Maneuver) assesses medial arch flexibility and windlass mechanism function for diagnosing flexible flatfoot. It shows excellent intra-rater reliability (ICC 0.85-0.92) and moderate to high inter-rater reliability (ICC 0.75-0.88), especially with trained examiners. It also correlates well with radiographic measures, making it a valid tool for distinguishing structural vs functional deformities in children.	Baseline
Navicular Drop Test	The Navicular Drop (ND) Test is used to assess medial arch flexibility and confirm flexible flatfoot. It measures the change in navicular height from non-weight bearing to weight bearing, with >10 mm indicating flexible flatfoot. It shows acceptable reliability (ICC 0.61-0.79) and is a valid measure of medial arch function.	Baseline
Mini-Mental State Examination	The Mini-Mental State Examination (MMSE) is a well-established cognitive screening tool with strong validity and reliability. It shows good construct and criterion validity, correlating well with full neuropsychological assessments. It also demonstrates high test-retest reliability (r = 0.80-0.89) and strong inter-rater reliability (ICC ≈ 0.75).	Baseline
Snellen Visual Acuity Test	The Snellen Visual Acuity Test is a standardized measure of distance vision in children, performed at 6 meters using optotypes. It demonstrates high reliability (ICC 0.89-0.94) and strong validity with clinical vision assessments. It also shows good diagnostic accuracy for refractive errors, with sensitivity of 80%-92% and specificity of 85%-94%.	Baseline
Manual Muscle testing	Manual Muscle Testing (MMT) shows good validity and excellent intra-rater reliability (ICC ≈ 0.99), particularly when performed by trained clinicians. Inter-rater reliability is variable (ICC 0.37-0.87), depending on examiner consistency and standardization. With experienced assessors, reliability can be very high (ICC up to 0.984), making it a useful clinical tool when properly applied.	Baseline

Collaborators and Investigators

• Sponsor: Riphah International University
• Investigators: Principal Investigator: Hafiza Syeda Javeria Fayyaz, MS-PT, Riphah International University

Publications and helpful links

General Publications

• Salinas-Torres VM, Salinas-Torres RA, Carranza-Garcia LE, Herrera-Orozco J, Tristan-Rodriguez JL. Prevalence and Clinical Factors Associated With Pes Planus Among Children and Adults: A Population-Based Synthesis and Systematic Review. J Foot Ankle Surg. 2023 Sep-Oct;62(5):899-903. doi: 10.1053/j.jfas.2023.05.007. Epub 2023 Jun 5.

Study record dates

Study Major Dates

• Study Start (Actual): April 13, 2026
• Primary Completion (Estimated): July 10, 2026
• Study Completion (Estimated): August 30, 2026

Study Registration Dates

• First Submitted: May 5, 2026
• First Submitted That Met QC Criteria: May 5, 2026
• First Posted (Actual): May 11, 2026

Study Record Updates

• Last Update Posted (Actual): May 11, 2026
• Last Update Submitted That Met QC Criteria: May 5, 2026
• Last Verified: May 1, 2026

More Information

Terms related to this study

• Keywords: Gait; Pediatrics; Visual feedback; Pes Planus; Foot-core training
• Additional Relevant MeSH Terms: Talipes; Musculoskeletal Diseases; Musculoskeletal Abnormalities; Congenital Abnormalities; Lower Extremity Deformities, Congenital; Limb Deformities, Congenital; Foot Deformities; Foot Deformities, Acquired; Foot Deformities, Congenital; Congenital, Hereditary, and Neonatal Diseases and Abnormalities; Flatfoot; Physiological Phenomena; Behavior Therapy; Psychotherapy; Behavioral Disciplines and Activities; Biofeedback, Psychology; Feedback, Psychological; Feedback, Physiological; Homeostasis; Feedback, Sensory
• Other Study ID Numbers: REC/RCR&AHS/HAFIZASYEDAJAVERIA

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No