Flat feet (pes planus) occur when the arch collapses and the entire sole makes contact with the floor. This is an extremely common observation in childhood and is usually a variation of normal development rather than a medical problem. The flexibility of a child’s joints and a natural fat pad often conceal the arch in early years. Understanding when this finding becomes symptomatic is important for parents, as this article explores the progression of the pediatric foot, signs warranting evaluation, and treatment options.
How Flat Feet Develop in Children
The vast majority of flat feet in young children are a normal stage of development. Infants and toddlers appear flat-footed due to ligament flexibility and a fatty cushion on the sole. The foot arch generally begins to appear and mature between four and six years of age as foot structures tighten and muscle tone improves. About 80% of children develop a visible arch naturally, but a small percentage retain a flat-footed appearance into adulthood without discomfort or functional issues.
The two main classifications are flexible and rigid flat foot. Flexible flat foot is the most frequent type; the arch is visible when the child is sitting or on tiptoes, but disappears when bearing weight. This type is often linked to ligament laxity, genetic factors, and usually remains asymptomatic. Rigid flat foot is less common and remains flat even when the child is not bearing weight, indicating a structural issue. Rigid flat feet may be caused by congenital abnormalities like tarsal coalition, where bones in the midfoot or hindfoot are abnormally fused, and these cases are more likely to cause symptoms.
Recognizing Symptoms Requiring Medical Attention
While most flexible flat feet do not cause problems, medical evaluation is necessary when specific symptoms arise. Parents should seek professional advice if their child experiences chronic foot or leg pain, especially around the arch, heel, or ankle. Pain that is persistent or severe enough to interfere with normal activities, such as running or extended walking, signals a need for assessment.
Stiffness or a limited range of motion in the foot or ankle is another significant sign, which can suggest a rigid flat foot. Other signs include an awkward or altered walking pattern (changes to gait) or the tendency for the heel to tilt significantly outward. Asymmetric flatness, where one foot is noticeably flatter than the other, should also be evaluated. The initial medical evaluation by a specialist will involve a physical examination of the foot in both weight-bearing and non-weight-bearing positions to determine the type of flat foot and rule out underlying structural conditions.
Non-Surgical Treatment Approaches
For symptomatic flat feet, the first line of management involves conservative, non-surgical approaches aimed at relieving pain and improving function. One common intervention is the use of foot orthoses, or shoe inserts, which provide support and alignment. Orthotic devices can be prefabricated (over-the-counter) or custom-made inserts specifically molded to the child’s foot. These devices support the arch to reduce strain on soft tissues and joints, helping to alleviate pain, but they do not actively correct or create a permanent arch.
Physical therapy is an essential component of conservative treatment, focusing on exercises designed to strengthen the intrinsic muscles of the foot and improve flexibility. Specific exercises often include heel cord stretching to address tightness in the Achilles tendon, which contributes to arch flattening. Toe curls and heel raises help to engage and strengthen the muscles that dynamically support the arch during movement. These targeted exercises improve the foot’s natural ability to function and absorb shock.
Proper footwear selection also plays a supportive role in managing symptomatic flat feet. Shoes should have a firm heel counter, which stabilizes the heel, and adequate width to allow the toes to spread naturally. Choosing supportive shoes works in conjunction with orthotics to manage symptoms and improve comfort during physical activity. For the majority of children with flexible, non-painful flat feet, the recommended approach is observation and monitoring, with intervention only necessary if symptoms develop.
Surgical Intervention Considerations
Surgical correction for pediatric flat feet is considered a last resort, reserved for a small number of severe cases. This option is indicated only when a child experiences debilitating pain that interferes with daily life, despite comprehensive and prolonged non-surgical treatment. Surgery is more frequently necessary for children with rigid flat feet, often caused by structural anomalies like tarsal coalition, or when a painful flexible flat foot fails to respond to conservative care.
The goal of surgery is to reduce pain, correct foot alignment, and restore a more functional shape. Procedures vary depending on the underlying cause and deformity. Options include soft-tissue procedures, such as Achilles tendon lengthening, or bony procedures like osteotomies, which involve repositioning the heel bone to realign the foot. In rare, severe cases, joint fusion procedures (arthrodesis) may be performed to stabilize the foot. These complex surgeries are performed by a pediatric orthopedic specialist who weighs the risks against the potential for functional improvement.