Foot

Flatfoot in Children: When to Worry

Name: Flatfoot in Children Milan: When Orthotics Are Needed and When They're Not
Creator: Dott. Daniele Priano
Published: 2026-01-15

Does your child have flat feet? Learn if it's normal or pathological, when orthotics are needed and criteria for specialist evaluation. Milan expert.

Medically reviewed: April 2026·Dott. Daniele Priano

In short

Flatfoot in children is in the vast majority of cases physiological and evolves with growth. Only a small share requires insoles and an even smaller minority has a surgical indication. The aim of the visit is to distinguish flexible, asymptomatic flatfoot from forms that deserve attention.

When an evaluation can be useful

After 4-5 years if the foot still appears markedly flat
Pain in the foot, ankle or knee during or after activity
The child tires easily when walking or avoids sport
Before buying corrective shoes or insoles on third-party advice

The aim of the visit is not always to start a treatment: often it is to understand whether the situation can be observed calmly or whether further investigation is needed.

Book a paediatric orthopaedic evaluation See how the paediatric orthopaedic visit works

Visits in Milan at Pini and CTO, subject to availability.

When not to wait

Rigid flatfoot (does not correct on tiptoe)
Significant and persistent pain
Clear asymmetry between the two feet

If you recognise one of these signs, contact your paediatrician or the emergency service.

Quick Answers

At what age does flatfoot correct itself?

Physiological flatfoot corrects spontaneously in most children by age 6-7. The plantar arch develops gradually with growth and muscular reinforcement. If it persists beyond this age or is symptomatic, a specialist evaluation is recommended.

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?

Surgical treatment (arthroereisis) is reserved for symptomatic forms that do not respond to conservative treatment, generally after age 9-10. It is a minimally invasive procedure with excellent results when properly indicated.

See all 7 questions →

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.

Related: Valgus Heel (Hindfoot Valgus)

Flatfoot often associates with hindfoot valgus (the heel tilts inward). This is a related but distinct condition that may require specific evaluation. Read the specific guide.

Learn about Hindfoot Valgus →

👣Dr. Priano's Advice

Until age 6-7, a flexible flatfoot is almost always physiological. If your child walks well and has no pain, monitoring growth is usually sufficient.

When to seek evaluation

Flatfoot persisting beyond 6-7 years
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

🏥

When Surgery Is Needed

When conservative treatment (physical therapy, orthotics, observation) is no longer sufficient to manage symptomatic flatfoot, surgical options can be evaluated. Surgery is proposed only in selected cases and always after careful clinical assessment.

In selected cases where flexible flatfoot is symptomatic and surgical indication is present, several minimally invasive techniques can be evaluated. These include subtalar arthroereisis, endosenotarsic endorthesis, calcagno-stop, calcaneo-stop or C-stop. The choice of technique is not automatic and varies case by case, based on the child's age, foot flexibility, degree of deformity, presence of pain, and clinical and radiographic evaluation. Learn more about flatfoot surgery in children.

🔗View surgical options for this condition →

Types of Flatfoot

Flexible Flatfoot

Most common form (>90% of cases). The plantar arch is absent when weight-bearing but reforms when non-weight-bearing or during hallux dorsiflexion (positive Jack's test). The hindfoot is mobile with no joint rigidity. Physiological until 6-7 years of age.

Treatment: In most cases, observation and muscle strengthening are sufficient. Custom orthotics may be helpful in symptomatic cases or to improve comfort during activities. Arthroereisis is reserved for persistent symptomatic forms that do not respond to conservative treatment.

Rigid Flatfoot

Less common but more significant form. The arch is absent both in weight-bearing and non-weight-bearing. The hindfoot is rigid with limited subtalar mobility. Often associated with pain.

Causes:

Tarsal coalitions (bone fusions)
Congenital vertical talus
Achilles tendon contracture
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?▼

Are orthotics needed for flatfoot?▼

When to operate on flatfoot?▼

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?▼

No. Modern scientific evidence has ruled out that rigid or 'orthopaedic' shoes change the evolution of physiological flatfoot. Flexible, lightweight shoes with thin soles are preferable, allowing the foot to move freely and muscles to work properly. Barefoot movement on varied surfaces is excellent stimulation for arch development.

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.