Foot

Flatfoot in Children: When to Worry

Flat feet in young children are usually a normal developmental variant. Assessment criteria and when orthotics may help.

Updated: September 2026·Medically reviewed by Dr. Daniele Priano
The doctor observes the foot of a barefoot child standing during an assessment of the plantar arch.

There is more to assess than the arch

A low arch can be a normal variation. The examination considers flexibility, pain and the child's activities alongside foot shape: appearance alone does not establish a need for treatment.

Read all the illustrated explanations →

In most children flatfoot is a physiological feature of growth: the plantar arch develops gradually and usually defines itself during the first school years. It is one of the most common reasons for a pediatric orthopaedic consultation and, in the large majority of cases, requires neither orthotics nor treatment.

During the visit we distinguish the flexible flatfoot (by far the most common form), in which the arch reappears when the foot is unloaded or the great toe is lifted and which is usually painless, from the rigid flatfoot, less frequent but more significant, in which the flattening persists and may be associated with pain or limited movement — a picture that deserves further evaluation to rule out structural causes such as a tarsal coalition.

A specialist evaluation is appropriate when there is pain, stiffness, marked asymmetry between the two feet, worsening over time, limitation in daily or sports activities, or when the foot remains markedly flat at school age. The goal is not to "straighten" a normal foot, but to identify the situations that really benefit from a dedicated pathway and to reassure families in the others. Orthotics or surgery, when indicated, are decided on the individual child: never an automatic choice, never a universal treatment.

Flatfoot often accompanies hindfoot valgus (the lower part of the heel tilts outward when viewed from behind): a related but distinct finding. Learn about hindfoot valgus →

Dott. Daniele Priano - Ortopedico Pediatrico

👣Dr. Priano's Advice

Flexible flatfoot is very common in childhood and often needs no treatment when it is mobile and asymptomatic. Pain, stiffness, asymmetry or activity limitation change the significance of the finding and are useful reasons for assessment.

Assessment and treatment

When to seek evaluation

  • Flatfoot persisting with growth, associated with pain, stiffness or limitation
  • Pain during walking or physical activity
  • Hindfoot rigidity
  • Arch absent even when non-weight-bearing (rigid form)
  • Marked asymmetry between the two feet
  • Early fatigue during walking

What is evaluated

  • Clinical evaluation of plantar arch in weight-bearing and non-weight-bearing
  • Jack's test (hallux dorsiflexion)
  • Hindfoot and subtalar mobility
  • Gait and posture examination
  • Possible weight-bearing radiographic study

Treatment options

  • Observation and periodic follow-up in physiological cases
  • Custom orthotics in selected cases
  • Physical therapy for muscle strengthening
  • Minimally invasive surgical treatment (arthroereisis) in selected symptomatic cases
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When Surgery Is Needed

A low arch alone is not a reason for surgery. Painless flexible flatfoot generally does not require treatment. Surgery may be discussed when pain and activity limitations persist despite appropriate conservative care and assessment confirms that the deformity contributes to the symptoms.

Read about flatfoot surgery in children.
🔗View surgical options for this condition →

Types of Flatfoot

Flexible Flatfoot

This is the most common form. The arch is low during weight-bearing but reforms off-load or when the clinician lifts the big toe. The hindfoot is mobile. In early childhood it may be a physiological variant; arch development varies, without a fixed age by which correction must occur.

Treatment: Painless flexible flatfoot generally needs no treatment, specific exercises or physiotherapy. In selected symptomatic cases, treatment may address muscle tightness, weakness or functional difficulties; orthoses may improve comfort. Surgery is considered only after individual assessment of persistent symptoms and limitations despite appropriate conservative care.

Rigid Flatfoot

The arch remains flat off-load and hindfoot movement is restricted. Pain may be present. Achilles tendon tightness alone is not equivalent to structural foot rigidity; they require separate assessment.

Causes:
  • Bony, cartilaginous or fibrous tarsal coalitions, such as calcaneonavicular or talocalcaneal coalitions
  • Congenital vertical talus
  • Neuromuscular conditions

Treatment: Always requires thorough specialist evaluation. Treatment depends on the cause: may be conservative or surgical.

Frequently Asked Questions

At what age does flatfoot correct itself?▼
Assessment is appropriate for pain, rigidity, marked asymmetry or difficulty with walking and activity. A flexible, painless flatfoot does not require treatment simply because the child has reached school age. The examination establishes whether reassurance, monitoring or treatment is appropriate.
Are orthotics needed for flatfoot?▼
Orthotics do not 'cure' flatfoot, but can be helpful in symptomatic cases to reduce pain and fatigue. They are not necessary for asymptomatic physiological flatfoot. The decision should be made case by case with the specialist.
When to operate on flatfoot?▼
Surgery is not indicated for the shape of the foot alone. It may be considered for a flexible flatfoot with symptoms and functional limitation that persist despite appropriate conservative care, or for specific structural conditions. Age, remaining growth, flexibility, calf muscle tightness, deformity and the proposed technique must be considered together: there is no automatic age threshold that applies to every child.
Is flatfoot hereditary?▼
There is a familial component: if a parent has flatfoot, the child is more likely to have it. However, most childhood cases resolve spontaneously regardless of family history.
How can I tell flexible from rigid flatfoot?▼
Flexible flatfoot shows an arch when the child stands on tiptoes or when the big toe is lifted (positive Jack's test) and is mobile on manipulation. Rigid flatfoot remains flat in all positions, is less mobile and often painful. The clinical distinction is simple but fundamental: rigid flatfoot always requires investigation to rule out tarsal coalitions or other structural causes.
My child wears down the inner edge of shoes: should I worry?▼
Wear on the medial edge is common in children with pronated flatfoot and is not concerning per se if the child has no symptoms. It becomes relevant if very asymmetric between the two sides, if it worsens rapidly or is associated with pain or early fatigue. In these cases a specialist evaluation helps determine if adjustments are needed.
Are orthopaedic shoes needed for flatfoot?▼
Rigid or “orthopaedic” shoes have not been shown to change the natural history of asymptomatic flexible flatfoot. In a healthy child, fit and comfort matter most. If the foot is painful, rigid or markedly asymmetric, choosing footwear or an orthosis before clarifying the cause may treat a symptom without defining the problem.

Important Notice: The information on this page is for educational and informational purposes only and does not constitute medical advice. Each clinical case is unique: the appropriate treatment is determined during the specialist consultation, based on a thorough clinical examination and, where necessary, diagnostic imaging. For any doubts or concerns, please consult a specialist.