What are the treatment options for pediatric flatfoot?

Pediatric Flatfoot Treatment

For asymptomatic flexible flatfoot in children, observation without intervention is the recommended approach as most cases resolve spontaneously by adolescence. 1

Diagnosis and Classification

Proper classification is essential for determining appropriate treatment:

• Flexible Flatfoot:

  • Normal arch when non-weight bearing or on toe-standing
  • Most common type (approximately 45% of preschool children and 15% of older children)
  • Usually resolves with age without intervention 1, 2

• Rigid Flatfoot:

  • Arch remains flat even when non-weight bearing
  • May indicate underlying pathology (tarsal coalition, congenital vertical talus, or skewfoot)
  • Requires specialist evaluation 1

Treatment Algorithm

1. Asymptomatic Flexible Flatfoot

• Recommended treatment: Observation only
• Rationale: Most cases resolve spontaneously by adolescence 1, 3
• Follow-up: Monitor foot development every 2-4 months 1
• Parent education: Reassurance that this is a normal variant of foot development 4

2. Symptomatic Flexible Flatfoot

• First-line interventions:

  • Activity modification
  • Proper footwear selection (firm heel counter, adequate width at metatarsal joints, rounded toe box)
  • Address obesity if present 1

• Second-line interventions (if symptoms persist):

  • Non-custom arch supports or custom orthotics
  • Physical therapy (stretching exercises for Achilles tendon, strengthening exercises for intrinsic foot muscles) 1
  • Note: While orthotics may provide pain relief, evidence suggests they do not alter the natural course of flexible flatfoot 3, 2

3. Rigid Flatfoot or Refractory Symptomatic Cases

• Referral: Pediatric orthopedic specialist
• Imaging: May be required to identify underlying pathology
• Surgical options (rarely indicated):
  • Achilles tendon lengthening (for contracture)
  • Osteotomies (to realign foot)
  • Arthrodesis (fusion of joints)
  • Arthroereisis (insertion of implant into sinus tarsi) 3, 4

Special Considerations

• Barefoot walking: Encourage barefoot walking indoors to develop foot muscles and proprioception 1

• Footwear recommendations: Use lightweight, flexible footwear made of natural materials for outdoor use 1

• Indications for specialist referral:

  • Rigid flatfoot
  • Painful flatfoot not responding to conservative measures
  • Progressive deformity
  • Asymmetric flatfoot
  • Significant functional limitations
  • Associated neuromuscular disorders 1

Common Pitfalls to Avoid

1. Unnecessary treatment: Most pediatric flatfeet are asymptomatic and do not require intervention 5, 2

2. Overreliance on orthotics: Despite their common use, evidence supporting orthotics for asymptomatic flexible flatfoot is poor 6, 2

3. Premature surgical intervention: Surgery should be reserved only for cases that fail thorough conservative management and have persistent pain that interferes with normal activities 2, 4

4. Failure to distinguish between flexible and rigid flatfoot: This distinction is crucial for proper management 1

5. Neglecting Achilles tendon contracture: A flatfoot with Achilles tendon contracture may be painful and benefit from a stretching program 4

By following this evidence-based approach, most children with flatfoot can be managed effectively with minimal intervention, preserving quality of life while avoiding unnecessary treatments.