Flat Feet

A few important points

• Flat Feet are common in healthy babies and toddlers and usually resolve by 6 years of age as the longitudinal arch develops.
• Flat Feet persist in at least 10% of children, commonly are found with other features of hypermobility and are often familial (check parents feet !!).
• Management involves explanation, reassurance, and advice regarding appropriate supportive footwear (i.e., supportive heel cup and mid-foot support with fastened laces).
• Physiotherapists, orthotists and podiatrists may provide exercises and insoles if problems persist.

Photo: Flat feet in a healthy 4 year old - the medial arches form when standing on tip-toe - (mobile flat feet). Note that the changes are symmetrical.

When should flat feet warrant concern? 

• If there is an absent arch when the child stands on tip-toes ('non-mobile flat feet'). 
• There are asymmetrical changes (i.e., one foot fixed and flat). 
• There is evidence of pressure on the foot such as blistering / callosities.
• There is swelling or restriction of joints.
• There is Limping observed or the child has persistent pain.
• In teenagers with a fixed/painful flat foot, think of Tarsal Coalition which is a condition where bones in the foot are fused together. 
• Inflammatory Arthritis can also cause a painful stiff flat foot. Radiographs can be unremarkable. Referral is required for further investigation. 

The indications for referral are:

• Joint stiffness or swelling. 
• Absence of arch on tip-toe.
• Signs of pressure (e.g., blistering).
• Persistent pain.
• Limp or symptoms interfering with function (sport/play).
• Systemic features. 

Referral is advised to rheumatology or orthopaedics. Conditions to consider are: 

• Inflammatory Arthritis – joints are stiff, warm or swollen (often the midfoot). 
• Tarsal Coalition – joints fixed and painful on walking and weight bearing. 

Photo: Stiff Flat Foot due to Inflammatory Arthritis (Juvenile Idiopathic Arthritis).