Management of Pes Planus in Children
Most children with asymptomatic flexible flat feet do not require orthotics and should simply be observed, as this is a normal developmental variant that typically resolves with age. 1, 2
When Orthotics Are NOT Needed
The majority of pediatric pes planus cases are physiologic, flexible, and painless, requiring no intervention:
- Asymptomatic flexible flat feet should be monitored without treatment, as the arch typically develops naturally as foot musculature strengthens through childhood and adolescence 1, 2
- Evidence shows no difference in pain outcomes between children receiving custom orthotics, prefabricated orthotics, or no treatment at all for asymptomatic bilateral flat feet 3
- Encouraging barefoot walking indoors promotes normal foot development and proprioceptive feedback, which supports natural arch formation 4
- Outdoors, recommend flexible, well-fitted shoes made of natural materials with flat heels and adequate toe room to support normal development 4
When Orthotics MAY Be Indicated
Orthotics should be considered only in specific symptomatic cases:
- Children with painful flexible flat feet may benefit from orthoses for pain relief, though evidence shows orthotics do not alter the natural course of the condition 1
- One trial in children with juvenile arthritis and foot pain demonstrated custom-made orthoses reduced pain intensity by 1.5 points on a 10-point VAS (NNT=3) and decreased disability compared to supportive shoes alone 3
- Children with pes planovalgus experiencing nonspecific lower leg/foot pain may benefit from orthotics, particularly when associated with the flat foot deformity 5
Red Flags Requiring Specialist Referral
Certain presentations warrant orthopedic evaluation rather than conservative management:
- Rigid flat feet (arch remains collapsed during non-weight-bearing or tiptoeing) require subspecialist treatment, not simple observation 1, 2
- Associated limb deformities suggesting underlying skeletal dysplasia 4
- Signs of tarsal coalition, arthritis, or other underlying foot pathology 1
- Rheumatologic, neuromuscular, genetic, or collagen conditions 2
Common Pitfalls to Avoid
- Do not prescribe orthotics for asymptomatic flexible flat feet - current evidence does not support altering the natural course, and observation is safe and appropriate 1
- Avoid assuming all flat feet require treatment; up to 25% of the general population has a deficient medial longitudinal arch in at least one foot without functional consequences 6
- Consider other causes of leg/foot pain including hypocalcemia, cramping, or juvenile idiopathic arthritis before attributing symptoms solely to flat feet 5