Management of Flat Foot (Pes Planus)
Flexible Flat Foot in Children
Most children with flexible flat feet require no treatment, as this represents a normal developmental variant that typically resolves with age. 1, 2
Conservative Management Approach
Observation is the primary management strategy for asymptomatic flexible flat feet in children, as the condition is physiologic and usually resolves by adolescence without intervention. 1, 2
Encourage barefoot walking indoors to promote normal foot development and proprioceptive feedback that supports natural arch formation. 3
Recommend flexible, well-fitted shoes made of natural materials with flat heels and adequate toe room for outdoor use to support normal development. 3
Orthotics may provide symptomatic relief for children with pes planovalgus experiencing nonspecific lower leg or foot pain associated with the flat foot deformity, though evidence does not support their ability to alter arch architecture or natural history. 3, 2, 4
When to Refer to Pediatric Orthopedic Specialist
Refer immediately if any of the following red flags are present:
Rigid flat foot that does not correct with toe standing or when non-weight bearing, as this may indicate tarsal coalition, congenital vertical talus, or other pathology requiring treatment. 1, 2
Pain or functional disability that persists despite conservative measures, as this may warrant orthopedic interventions including physical therapy, bracing, or surgical procedures. 2, 4
Associated limb deformities suggesting underlying skeletal dysplasia or syndromic conditions. 3
Skewfoot deformity (forefoot adduction with hindfoot valgus), which requires manipulation and serial casting as soon as detected. 1
Important Differential Diagnoses to Exclude
Rule out hypocalcemia, cramping, or juvenile idiopathic arthritis before attributing leg/foot pain solely to flat feet. 3
Tarsal coalition should be suspected in rigid flat feet, particularly if symptoms develop in late childhood or adolescence; treatment includes resection with interposition of extensor digitorum brevis for calcaneonavicular coalitions. 1
Congenital vertical talus requires surgical treatment, as manipulation and casting have proven inadequate. 1
Rigid Flat Foot in Children and Adults
Rigid flat feet require specialist evaluation to identify underlying pathology, as they may represent tarsal coalition, arthritis, or other structural abnormalities.
Management Strategy
Asymptomatic rigid flat feet may not require treatment but warrant monitoring for development of pain or functional deficits. 4
Symptomatic rigid flat feet may benefit from orthotics for pain relief, though surgical options including osteotomies or fusions should be considered for persistent symptoms. 4
Surgical intervention timing should ideally occur before the foot becomes completely rigid in adolescence or adulthood, as simple procedures like arthroereisis or osteotomies in younger children may prevent the need for arthrodesis later. 5
Adult Flat Foot Management
Adults with flat feet and associated deformities require proper footwear and pressure redistribution to prevent complications.
Footwear Recommendations
Shoes should be 1-2 cm longer than the foot with internal width equal to the width at the metatarsal phalangeal joints, and adequate height for toes. 6, 7
Custom-molded shoes or orthoses are indicated for patients with bony deformities (hammertoes, prominent metatarsal heads, bunions) to redistribute pressure and reduce pain. 6, 7
Fit evaluation must occur with the patient standing, preferably at the end of the day when feet are most swollen. 6
High-Risk Populations Requiring Specialized Care
Patients with diabetes and peripheral neuropathy require annual comprehensive foot examinations, daily self-inspection, appropriate therapeutic footwear, and regular podiatric care to prevent ulceration. 6, 7
Patients with connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome) may have flat feet as part of systemic involvement; hindfoot deformity scores 2 points in Marfan diagnostic criteria. 6
Common Pitfalls to Avoid
Do not assume all flat feet are benign without assessing flexibility, pain, and functional impact. 2, 4
Avoid prescribing orthotics for asymptomatic flexible flat feet in children with the expectation of changing arch architecture, as no evidence supports this practice. 1, 2, 4
Do not delay referral for rigid flat feet in children, as early intervention with simple procedures may prevent need for more extensive surgery later. 5