What is the recommended treatment for an 11-year-old with flat feet (pes planus)?

Management of Flat Feet (Pes Planus) in an 11-Year-Old Child

For an 11-year-old with flat feet, observation alone is the recommended first-line approach unless the child is experiencing pain or functional limitations, in which case supportive footwear and possibly orthotics should be prescribed, with surgery reserved only for persistent symptomatic cases that fail conservative management for at least 12 months.

Assessment and Classification

When evaluating flat feet in an 11-year-old child, it's essential to determine whether the condition is:

1. Flexible vs. Rigid: Most pediatric flat feet are flexible (arch appears when non-weight bearing or on toe-standing) and physiologic.
2. Symptomatic vs. Asymptomatic: Determine if the child experiences pain or functional limitations.

Key Assessment Points:

• Check for pain under the medial midfoot or in the sinus tarsi
• Evaluate Achilles tendon contracture (limited ankle dorsiflexion)
• Assess gait and functional limitations
• Rule out underlying conditions (tarsal coalition, vertical talus, skew-foot)

Treatment Algorithm

1. Asymptomatic Flexible Flat Feet

• Recommended treatment: Observation only 1, 2
• No evidence supports the use of orthotics or special footwear to change arch architecture in asymptomatic cases
• Reassure parents that this is a normal variant of foot shape in many children
• The condition often improves naturally as the child grows

2. Symptomatic Flexible Flat Feet

• First-line treatment: Conservative management
  • Appropriate footwear: Shoes should have firmness, comfortable fit, rounded toe, flexibility, flat heel, heel support, and laces or straps 3
  • Consider orthotics: May provide pain relief though evidence for altering foot structure is limited 4
  • Physical therapy: To improve foot and ankle strength

3. Symptomatic Flexible Flat Feet with Achilles Contracture

• Add Achilles tendon stretching program 5
• Monitor for improvement in symptoms

4. Persistent Symptomatic Cases

• Consider referral to pediatric orthopedic specialist if:
  • Pain persists despite 12 months of conservative management
  • Deformity interferes with normal activities
  • Pain occurs under the medial midfoot and/or sinus tarsi
  • Associated contracture of the Achilles tendon is present 6

5. Surgical Intervention (rare)

• Only indicated after failure of prolonged conservative treatment
• Should be performed by a surgeon with expertise in pediatric foot deformities
• Options may include:
  • Calcaneal osteotomy
  • Tendon transfers
  • Arthroereisis (controversial, more popular in Europe) 6, 4

Footwear Recommendations

For children with flat feet, shoes should ideally have:

• Firmness and comfortable fit
• Appropriate length and width
• Rounded toe with plenty of room
• Flexibility
• Flat heel with good support
• Laces or straps for adjustability
• Flat or absent seams 3

Important Considerations

• Developmental Context: Allowing children to walk barefoot indoors helps feet develop normally and builds muscular joint strength 3
• Regular Monitoring: The child's foot should be measured every 2-4 months to accommodate growth 3
• Avoid Unnecessary Treatment: Most pediatric flat feet resolve by adolescence without intervention 1
• Caution with Orthotics: While they may provide symptom relief, there is limited evidence they change foot structure 5

Common Pitfalls to Avoid

1. Overtreatment: Treating asymptomatic flexible flat feet unnecessarily
2. Missing Rigid Flat Feet: Failing to identify the rare rigid flatfoot that may require intervention
3. Ignoring Achilles Contracture: Not addressing tight heel cords that may contribute to symptoms
4. Premature Surgery: Recommending surgical intervention before adequate trial of conservative measures

Remember that pediatric flat feet are common, affecting up to 14% of children 7, and most cases are physiologic variants that require no treatment beyond observation and reassurance.