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Flat Feet

When are flat feet normal? 

  • Normal in babies and toddlers, usually resolves by 6 years of age as the longitudinal arch develops.
  • They 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.

 flat feetflat feet normal arches on tip toe

Photo: Flat feet in a healthy 4 year old - normal arches form when standing on tip toe - ie mobile flat feet. 

When are flat feet not normal? 

  • Absent arch when child stands on tip toes (non-mobile flat feet). 
  • Asymmetrical changes (i.e. one foot fixed and flat). 
  • Evidence of pressure on the foot such as blistering / callosities.
  • Swelling or stiffness of joints.
  • Limping or persistent pain.
  • In teenagers with a fixed/painful flat foot, think of Tarsal Coalition (a condition where bones in the foot are joined together).

  • Inflammatory Arthritis can also cause a painful stiff flat foot. Radiographs can be normal. Referral is required for further investigation. 

The indications for referral are:

  • Joint stiffness or swelling. 
  • Absence of arch on tiptoe.
  • Signs of pressure (eg blistering).
  • Persistent pain.
  • Limp or symptoms interfering with function (sport/play).
  • Systemic features. 

Referral is advised to rheumatology or orthopaedics pending your concerns and available referral pathways. Key conditions to consider include: 

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

stiff flat foot due to inflammatory arthritis
Photo above : Stiff Flat Foot due to Inflammatory Arthritis (Juvenile Idiopathic Arthritis).

Photo below : Radiograph showing tarsal coalition with fusion of the calcaneum and navicular bones (arrowed)


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