Flexible Flat feet – Pes Planus


Flat feet are a great concern of many parents and because of its common occurrence, it is a frequent question asked of pediatricians. Parental concern is often related to its cosmetic appearance, or the fact that the child’s ankles appear to cave inward.  Most orthopedic surgeons consider flat feet to be a normal variant. 

  1. Flat feet are defined as a lower or absent longitudinal arch when the individual is in the weight bearing position. It is associated with medial soft tissue bulging of various degrees. 
  2. It is normal in infants and young children and the incidence decreases with age. The younger child has laxity of the bone-ligament complex and this improves with age.
  3. In older children and adults, it may be associated with generalized ligamentous laxity, a generalized condition that may be found in other family members.

Physical Examination

  1. Flattening of the arch when the child stands but this will disappear when the child is not weight bearing or walks on their toes.
  2. Pronation of medial foot when standing.
  3. May demonstrate other evidence of ligamentous laxity by manipulating fingers and wrists.


  1. Reassurance and observation are appropriate.  No treatment is necessary, and flexible flat feet tend to improve with age, without intervention. 
  2. Radiographs of the foot are not helpful and are not clinically indicated.
  3. If the child complains of pain associated with their flat feet, causes of flat feet associated with pain (see below) should be investigated.
  4. Historically, special shoes and orthotics have been recommended, but there is no scientific evidence to support their use.  They are also expensive and uncomfortable; children often refuse to wear them.

Flat Feet Associated with Pain

  1. Tarsal coalition syndrome: the most common cause of flat feet associated with pain in children and adolescents, this condition occurs when one or more of the tarsal bones are inappropriately fused (at a location where a joint should be present). 
  2. Contracted heel cord associated with cerebral palsy
  3. Tarsal osteochondritis
  4. Posterior tibial tendonitis
  5. JRA
  6. Calcaneal apophysitis (Sever's disease)

*Flat feet associated with pain should prompt a referral to a pediatric orthopedic surgeon, or podiatrist experienced with childfoot foot problems. 


  1. Cappello,Teresa and Song, Kit M. Determining treatment of flatfeet in children. Current Opinions in Pediatrics. 1998, 10: 77-81
  2. Pfeifer M et al. Prevalence of Flat Foot in Preschool-Aged Children. Pediatrics August 2006
  3. Scherl, S.  Common Lower Extremity Problems in Children.  Pediatrics in Review.  2004, 25; 52-62.
  4. 4.American Academy of Pediatrics. (5/26/2011). Flat Feet and Fallen Arches. Healthy Children. Retrieved 02/12/2012, from http://www.healthychildren.org/English/health-issues/conditions/orthoped...

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