Pes planus ('flatfoot') is characterized by the lack of a medial longitudinal arch in the foot. While the exact incidence of this condition in children is unknown [1], we do know that it is very common. Given that almost all children start out with little or no arch, do flat feet pose a real problem? When, if ever, is it appropriate to intervene? Are arch supports, special shoes, or in-shoe orthotics necessary? Parents want to know, and doctors need to 'get the low-down' on flat feet.

Almost every child's foot initially has a large medial fat pad which slowly decreases during maturity. This eventually results in a more prominent medial longitudinal arch. A 1988 study [2] confirmed that 28-35% of school children have a flatfoot deformity, 80% of which are classified as 'mild.' Without treatment, more than 90% of these children will have normal arches by age ten. [3] Most children who present with the appearance of a flatfoot will, therefore, eventually develop normal longitudinal arches.

It is important, however, to differentiate a normal, flexible flatfoot from a congenital, rigid flatfoot. A rigid flatfoot is usually due to an osseous deformity, such as an abnormal fibrous or bony fusion of one or more tarsal bones. Determining the existence of a rigid flatfoot can be easily done in the chiropractor's office. If an arch is present when the child is sitting with the foot dangling, or when standing up on the toes, then the flatfoot is 'supple and is correctable with an arch support.' [4] If the foot remains flat and rigid, any attempt to support or lift up the arch may be painful and unsuccessful. [5] This condition may require referral to a specialist.

When a parent brings in a child with flat feet who is between ages six and 10, and a flexible flatfoot is confirmed, immediate intervention is necessary to encourage normal development of the longitudinal arch, and to prevent pelvic and spinal postural deformities. [6] This is especially true when one foot is flatter than the other.

Asymmetrical forces imposed during locomotor activities can eventually result in significant cumulative trauma to the foot/ankle complex, knees, hips, and low back. [6]

If the child is 10 or older, the flexible flatfoot can be considered permanent, and long-term use of orthotics will be required to prevent future problems in the feet, lower extremities, and spine. This is especially true for overweight or athletically active youngsters.

1. Strengthen the child's lower leg muscles with home exercises, especially Tibialis Posterior, and Internal/External Rotation exercises. Also, have the child perform the towel-gathering exercise ('scrunching' a towel lying on the floor with the toes) for 15 minutes daily.

2. Insist the child wear supportive shoes with a stable heel (not worn down on either side) and a strong counter (the shoe material that fits around the heel of the foot).

3. If excessive pronation and flatfoot are noted to persist as the child matures, correction with custom-made orthotics is indicated.

Proper footwear is important for the developing foot; but, whenever safety and comfort allow, going barefoot stimulates proprioceptors and encourages muscular coordination and strength. Children's shoes should have flexible soles to allow for proper foot joint movement. Proper shoe sizing and fit are critical, since the developing bones are soft and malleable. Tight, constricting shoes interfere with normal growth and may result in deformity. Frequent evaluation of size and fit (palpate the child's foot for pressure points while standing with shoes on) is an important concept for parents to understand and accept.

Orthotics are seldom needed in the early years of growth (see above). If a supple flatfoot and/or excessive pronation is seen to persist beyond ages six or seven, or is responding poorly to home care interventions, custom-made, flexible orthotics are appropriate. Their additional corrective support will encourage normal development while preventing further deformity and reducing abnormal kinetic chain stresses on the pelvis and spine during the formative years.

Parents need reassurance and appropriate recommendations when they bring in a child with a 'flat foot.' Most common childhood foot conditions will resolve during normal growth and development, needing only home-care recommendations. As always, the developing spine should be evaluated and appropriate chiropractic care is recommended.

1. Sullivan JA. "Pediatric flatfoot: evaluation and management." J Am Acad Orthop Surg 1999; 7(1):44-53.

2. Notari MA. "A study of the incidence of pedal pathology in children." J Am Pod Med Assn 1988; 78:518-521.

3. Wetton EA. "The Harris and Beath footprint: interpretation and clinical value." Foot & Ankle 1992; 13:462-468.

4. Hoppenfield S. "Physical Examination of the Spine and Extremities." New York: Appleton-Century-Crofts, 1976:232.

5. Luhmann SJ, Rich MM, Schoenecker PL. "Painful idiopathic rigid flatfoot in children and adolescents." Foot Ankle Int 2000. 21(1):59-66.

6. Kuhn DR, Shibley NJ, Austin WM, Yochum TR. "Radiographic evaluation of weight-bearing orthotics and their effect on flexible pes planus." J Manip Physiol Ther 1999; 22(4): 221-226.