Flexible flatfeet (pes planus)

What are flexible flatfeet?

Flexible flatfeet is a common condition that impacts 25% of the general population. Flexible flatfoot is a normal foot type. The bones and joints in flexible flatfoot work normally. Most children are born with flatfeet, and the arch usually forms by 5 to 6 years of age. However, some children may not form an arch until they are 10 to 13 years old. Some children do not outgrow flatfeet, as 25% of adults have flatfeet.

If the foot remains flat, it does not usually cause any symptoms and most people do not need treatment. People with flexible flatfeet will have an arch that can be seen when sitting or standing on their toes, but is not seen when they are standing. A rigid flatfoot means that there is no arch, even when a person is sitting or standing on their toes. This is a different and more rare foot condition and if it is causing pain or dysfunction, they can be referred for an orthopaedic assessment.

Most children with flexible flatfeet can walk without pain, participate in sports and gym class and wear regular shoes. People whose joints are very flexible and/or have increased weight or obesity may be more likely to have flatfeet.

What are the signs and symptoms of flexible flatfeet?

Most people with flatfeet do not experience symptoms. If symptoms occur, they may include:

• sores or pressure areas to the side of the foot
• stiff foot
• limited foot movement from side to side or ankle movement up and down
• rapidly changing arch of the foot

How are flexible flatfeet diagnosed?

• A health-care provider will perform a physical exam of the foot, including the bottom of the feet to look for callouses, and the leg, including the Achilles tendon.
• Your child’s medical history will be reviewed, including if there is a family history of flatfeet or other foot conditions, or other inherited conditions.
• The wear patterns on the bottom of your child’s shoes may be looked at.
• The assessment will review the feet in sitting, standing, and standing on toes and heels positions.
• Imaging will only be completed as requested by the health-care provider.

How are flexible flatfeet treated?

The shape of a flexible flatfoot cannot be changed with braces, shoe inserts or exercises. Most flexible flatfeet do not require any treatment, especially if they are not painful.

Pain-free flexible flatfeet

Your child can wear regular shoes and participate in all activities

Painful flexible flatfeet

Treat the symptoms with:

• activity modification
• physiotherapy
• Achilles tendon and calf stretching programs
• shoe inserts
• pain management: nonsteroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen or naproxen, hot or cold application or topical NSAID creams
• weight management, if indicated

Arch pain

• Regular running shoes with supportive inserts.
• Shoe inserts with soft arch supports. These can be off-the-shelf gel inserts or custom orthotics. Usually, there is no benefit to using custom orthotics. Off-the-shelf arch supports are less expensive and easier to replace as your child grows.
• Avoid rigid arch supports because they can increase pain.
• If your child needs unique sizing for arch supports, try an online retailer.
• Physiotherapy exercises to strengthen the legs and feet.
• Stretching of the legs and feet.

Heel cord pain

If heel cords (Achilles tendon and calves) are tight and causing pain with activity, your child can try heel cord stretches. Your child should do these a minimum of two times a day for 60 seconds for each leg.

For children under 6 years of age

Calf stretch

1. Have your child lie on their back on a comfortable surface such as a firm bed.
2. With their knee straight and leg supported on the bed, bring your child's foot upwards, toward their head, bending their ankle.
3. Hold the stretch at the end of the movement (that is, as far as your child's range of motion will permit) for 30 to 60 seconds. This should not be painful for your child.
4. Bring your child's foot back to a normal position. Repeat the exercise 10 times on each leg, daily.

Achilles tendon stretch

1. Have your child lie on their back on a comfortable surface such as a firm bed.
2. With their knee bent, bring your child's foot upwards, toward their head, bending their ankle.
3. Hold the stretch at the end of the movement (that is, as far as your child's range of motion will permit) for 30 to 60 seconds. This should not be painful for your child.
4. Bring your child's foot back to a normal position. Repeat the exercise 10 times on each leg, daily.

Calf stretch for children over 6 years of age

1. Have your child stand approximately two feet from a wall. Place both of their hands at shoulder height against the wall. Their feet should be parallel like train tracks.
2. With their right knee straight, have them step towards the wall with the left foot. They should lean in until a stretch is felt in the back of the right calf. Make sure they keep the heel of the right foot on the ground. If the heel cannot touch the ground, move the back leg closer to the wall until it can.
3. Hold the stretch for 60 seconds.
4. Repeat the exercise 10 times on each leg, daily. Make sure to switch sides to do on both legs.

For a deeper stretch, use as seen below or hanging their foot off a step and directing the foot inwards, to the centre and outwards to target different angles of the calves' muscle fibers.

Shoe insoles or orthotics available off-the-shelf

Good quality, low-cost orthotics can be purchased in most drugstores, department stores, sporting goods stores, some shoe stores or online. They should be replaced every 6 to 12 months depending on how often they are worn and the growth of the foot. Common reliable brands include Superfeet and Dr. Scholl’s.

When buying an insole, pick one:

• that has a middle arch support (In Superfeet, you would want to start with a lower arch support and move up in height of the arch as you get more used to them. Currently, this would mean starting with berry, light blue and then light green.)
• with foam or gel arch support instead of hard plastic
• that is a full length insert instead of a ¾ length insert
• with heel cup support

For Achilles tendon heel pain, a heel gel cup might be recommended. A 1 cm heel lift under the insole may also help.

For bunions or pain under the ball of the foot, a metatarsal pad might be recommended.

Physiotherapy

Your child is always recommended to work with a physiotherapist for stretching and strengthening the foot and ankle, as well as for soft tissue release.

Surgery

There is no evidence to support surgical correction of asymptomatic flexible flatfeet in children or teens. Surgery for flexible flatfeet is rare and almost never indicated. In rare cases, surgery for rigid flatfeet may be indicated.

At SickKids

At SickKids, we do not assess asymptomatic flatfeet as this is a normal variant of development. If pain occurs, the first line of treatment is to manage by stretching the calves and seeing a community physiotherapist.

Patients can also try inserts, starting first with a trial with an off-the-shelf gel insole like Superfeet or Dr. Scholl's.

Indications for referral: If there are footwear issues, blisters/callouses, pain and dysfunction, or stiff/rigid flatfeet (no arch at rest or when standing up on toes), and they have exhausted the above conservative interventions over a consistent period of 6-months (that included regular physiotherapy, regular and frequent stretching, use of off-the-shelf gel inserts and pain management).

Photos are required on referral as a helpful piece of information, as well as a documented thorough history of assessment and treatments completed to-date (as arranged by your primary care provider(s).

References

Staheli, L.T., Chew, D.E., Corbett, M. (1987, March). The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. The Journal of Bone and Joint Surgery, 69(3), 426-428. https://www.jbjs.org/reader.php?rsuite_id=511782&source=The_Journal_of_Bone_and_Joint_Surgery/69/3/426&topics=fa#info

Harris, R.I., & Beath, I. (1948). Hypermobile flat-foot with short tendo achillis. The Journal of Bone and Joint Surgery, 30(1), 116-150. https://www.jbjs.org/reader.php?rsuite_id=194222&source=The_Journal_of_Bone_and_Joint_Surgery/30/1/116&topics=fa#info

Evans, A.M., Rome, K. (2011). A Cochrane review of the evidence for non-surgical interventions for flexible pediatric flat feet. European Journal of Physical and Rehabilitation Medicine, 47(1), 69-89. https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y2011N01A0069

OrthoKids – Pediatric Orthopaedic Society of North America. Flexible Flat Feet. https://orthokids.org/conditions/flexible-flat-feet/

HealthyChildren.org - American Academy of Pediatrics. (2023). Flat Feet & Fallen Arches: When Is Treatment Needed? https://www.healthychildren.org/English/health-issues/conditions/orthopedic/Pages/Flat-Feet-Fallen-Arches.aspx

Murphy-Zane, M.S. (n.d.). Flexible Flatfoot in Children. OrthoInfo – American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/diseases--conditions/flexible-flatfoot-in-children