What is pediatric flatfoot?
Flatfoot, or pes planus, refers to a condition where the medial arch of the foot is lowered or absent. In children, flat feet are often a normal part of early development, as the arch typically forms gradually with age.
However, it can be difficult for parents to distinguish between flatfoot that is developmentally appropriate and cases that may require medical evaluation. Knowing what to look for — and when to seek professional guidance — can help ensure your child’s feet are developing properly.
How flat feet develop in children: key stages and types
Flat feet are frequently observed in children under the age of six, primarily due to the presence of a thick plantar fat pad that obscures the developing medial arch. Although the foot may appear flat during this stage, arch formation typically occurs progressively throughout the first decade of life. The period between 3 and 6 years of age is considered particularly important for the natural development of the medial longitudinal arch.
- Rigid Flatfoot: Characterized by the absence of the medial longitudinal arch in both weight-bearing and non–weight-bearing positions. This form is typically associated with structural or bony abnormalities of the foot and ankle.
- Flexible Flatfoot: Defined by the presence of a medial arch when the foot is non–weight-bearing, which flattens during standing or walking. It is often linked to increased ligamentous laxity, hypermobility of the foot joints, and muscular weakness.
Flexible flatfoot is frequently benign and may resolve spontaneously as a result of three key developmental processes:
- Neuromuscular Maturation: Improved motor control and balance enhance activation of distal muscle groups, supporting arch development.
- Reduction in Physiologic Joint Laxity: Joint laxity peaks around age two and typically diminishes after age three.
- Skeletal Maturation: Progressive ossification of foot structures increases rigidity and stability of the foot’s weight-bearing tripod.
In most cases, pediatric flatfoot is not considered pathological. Clinical concern may arise when the child experiences pain, excessive fatigue in the feet or legs, impaired balance, delayed gross motor development, or if flatfoot is associated with an underlying developmental diagnosis.
Pediatric flatfoot has been associated with a variety of other orthopedic and systemic conditions. These may include Achilles tendon shortening, in-toeing or out-toeing gait patterns, lower extremity muscle weakness, malalignment or rotational abnormalities of the leg bones, generalized joint hypermobility, and obesity. Children with flatfoot may also present with complaints of pain or fatigue during physical activity. Additionally, flatfoot is more prevalent in certain populations, including children with developmental coordination disorder, autism spectrum disorder, global developmental delays, epilepsy, Down syndrome, and those with a history of trauma.
How pediatric flat feet are diagnosed
The evaluation of pediatric flatfoot involves a thorough combination of medical history and physical examination. During the subjective assessment, clinicians commonly inquire about the following:
- Achievement of major motor milestones
- History of frequent falls compared to siblings or peers
- Frequency and intensity of foot or leg pain during walking, running, or sports
- Fatigability of the foot or ankle during activity
- History of shoe wear or use of orthotic devices, including compliance with prescribed orthoses
- Presence of significant comorbidities that may be contributing to the current condition
- Family history of flatfoot or related musculoskeletal conditions
The physical examination includes an inspection of lower extremity alignment in both non–weight-bearing and weight-bearing positions, as well as during gait. Gait mechanics are carefully observed, along with an assessment of shoe wear patterns, which may provide insight into biomechanical abnormalities.
While radiographic imaging can be used to confirm the diagnosis — particularly in cases with suspected structural abnormalities — it is generally not necessary in uncomplicated, asymptomatic presentations
Treatments for flexible flat feet in children
There is growing evidence to support the effectiveness of non-surgical interventions — particularly orthotic use and physical therapy — in the management of flexible pediatric flatfoot.
In asymptomatic cases, observation remains the preferred approach, as most children will develop normal arches over time without the need for intervention.
Treatment is typically reserved for symptomatic cases, especially when a child experiences pain, fatigue, difficulty keeping up with peers, delays in gross motor or developmental milestones, or if flatfoot persists beyond the expected age of arch development.
Conservative management strategies include:
- Appropriate Footwear: Supportive shoes with a flat lace-up design, firm heel cup, arch support, wide toe box, and a "toe break" positioned in the anterior third of the shoe are recommended to promote healthy foot mechanics.
- Physical Therapy: Plays a crucial role in both assessment and intervention. Therapists evaluate gait, endurance, fatigue, pain, and functional limitations. Therapy often includes family-centered programs that incorporate play-based exercises to strengthen intrinsic and extrinsic foot muscles, support arch development, and improve motor coordination.
- Orthotics: Custom or prefabricated orthotic devices provide external arch support and should be worn with supportive footwear. Selection is based on achieving an optimal balance between structural support and comfort. The goal is to use the minimum necessary support to meet the child’s movement and postural needs. Gradual transition into orthotics is important and typically guided by a physical therapist, who monitors fit, function, and adjustment over time.
- Surgical Intervention: Rarely indicated, surgery is generally reserved for rigid flatfoot or cases involving structural (bony) abnormalities that do not respond to conservative care.
Treatment goals for physical therapy for pediatric flat foot
The primary goal in managing pediatric pes planus is not to reverse the structural anatomy of the foot, but rather to reduce symptoms, prevent progression, and minimize the risk of secondary complications, such as pain, fatigue, or impaired motor development. Most children outgrow flat feet without any issues. If treatment is needed, early support can make a big difference in your child’s comfort, movement, and confidence.
References
- Ueki Y, Sakuma E, Wada I. Pathology and management of flexible flat foot in children. J Orthop Sci. 2019 Jan;24(1):9-13. doi: 10.1016/j.jos.2018.09.018. Epub 2018 Oct 23. PMID: 30366675
- Turner C, Gardiner MD, Midgley A, Stefanis A. A guide to the management of paediatric pes planus. Aust J Gen Pract. 2020 May;49(5):245-249. doi: 10.31128/AJGP-09-19-5089. PMID: 32416653.
- Dars S, Uden H, Banwell HA, Kumar S. The effectiveness of non-surgical intervention (Foot Orthoses) for paediatric flexible pes planus: A systematic review: Update. PLoS One. 2018 Feb 16;13(2):e0193060. doi: 10.1371/journal.pone.0193060. PMID: 29451921; PMCID: PMC5815602.
Concerned About Your Child’s Feet?
Worried about your child’s foot development or frequent complaints of pain or fatigue? Schedule an evaluation with a pediatric physical therapist today to get expert guidance and peace of mind.
