Flat Feet in Kids: Why do they develop and when should I do something about them?

This is the first article I've written in response to a reader's request. I'm happy to do more of this if anyone out there ever has a question about a topic in the foot and ankle. I've decided to base my writing today more firmly in medical literature with hard reference citations, rather than going off-the-top-of-my-head with information I've learned in school or residency--all of which is also based on firm research, but a physician's training is often the conglomeration of hundreds of journal articles and scientific studies that have been applied to common practice. Much of what a physician learns during residency is practical application that is learned on-the-job, rather than specifically after reading an article (although regular journal clubs ensure that the articles behind the treatments eventually get covered in most cases).

One of the most common concerns of parents who bring their child in to my clinic to be looked at is how flat their child's feet are and the way the child walks. I would bet that nearly half of the kids I meet are brought in by a parent who is concerned about the way their child's feet look while standing. They are often concerned that the flat feet are going to cause issues down the road. Most of these kids don't have any pain and don't have the faintest idea that mom or dad think something might be wrong with them. In most cases, what I see is a perfectly normal child with feet that are perfectly normal for the developmental stage they're in. Every now and then, however, you do see a child who needs some more intervention.

What is This Flat Foot You Speak of?

Flat feet are a very common trait to have. A large percentage of the population have flat feet without any pain or symptoms, in fact. This simply refers to the arch on the inside of the foot being lower to the ground than the "average" foot. In the example below, the arch is slightly lower than average, but I would generally consider it to be within normal limits. That means this foot is flat, but not excessively so. This is a pretty common foot type to have.

Shout out to my medical assistant for volunteering his foot as an example

This foot has a much more flattened arch, usually these become symptomatic

In the video above, you can see my daughter walking normally. If you look closely, she has a flat arch. In this age group, this a normal finding. In fact, until a child becomes 10 or so, they don't really have much of an arch to speak of. When you have a teenager with a flattened arch, especially one that's painful, it's much more important to evaluate.

What Can I Do At Home For My (Or My Child's) Flat Feet?

Typically, in children, I don't recommend any intervention unless they are either painful or appear to be rigid in any way. Kids tend to walk differently even from a day-to-day perspective because they are learning and experimenting daily on how their bodies work, and what movements they're capable of. Some will go through phases when they'll walk exclusively on their toes, just to see how it feels. So unless there's a movement the child is incapable of, I typically don't worry until they are older.

Other than watching the feet to see if they are going to sort themselves out, I recommend a supportive orthotic insert. Just as is found in my article on heel pain, I recommend any inserts pass the "Squish Test." This is because they are supposed to be supportive, not just cushioning. Unfortunately, the most popular orthotic in your local grocery store doesn't often pass this test. The insert is meant to hold up the arch and control the motion of the heel, so you don't have a collapse of the arch happening. There are a number of good brands of pre-made supportive inserts to choose from. I'll just list a few brands that I've successfully used in the past, although any arch support that meets my criteria is sufficient. The ones I've used in the past are Spenco, SuperFeet, and PowerStep. Most of these are accessible online, and a good number of them are available in your local sporting goods stores.

Usually, patients with a legitimate case of flat feet require custom orthotics instead of the prefabricated orthotics I've just outlined.

When Do I Need To See A Doctor For My Flat Feet?

If you're developing pain, or you feel like the flat arch is getting less flexible, I definitely recommend a specialist evaluation, because there are procedures that can be done to prevent worsening of this condition. The posterior tibial tendon is the tendon that holds up the arch. This tendon is generally able to function well, but if it gets injured or has chronic disease from years of overuse attempting to give an arch to a flat-footed patient, it needs to be treated by a specialist who can give you access to the treatments that can help prevent worsening of the condition or at least slow its progression.

As I just mentioned a moment ago, custom orthotics are often recommended in these cases. Many people are hesitant to get custom inserts for their shoes because they hope to be able to make their feet all better without having to use a device the rest of their lives. This just requires thinking about them from a slightly different perspective than is typical. If a person needs glasses, they will need a prescription the rest of their lives. They know this, they accept it. Whether it is in the form of glasses or contact lenses, they realize that without them they can't see properly.  Unless they're going to get Lasic eye surgery, they will need the lenses to help cope with the shape of their eye that leaves them unable to see far, or near, or whatever the case may be.

The same is true for orthotics for the feet. Your foot shape is inherited, so some people have high arches, some have lower arches, and some have perfect feet. Just as some have perfect vision. Orthotics are meant to make less-ideal foot shape functional again. Without surgery, your options are either put up with the limitations your foot type leaves you with or adapt using a device.

What Treatments Can I Expect If I Go To A Doctor For This?

Usually, many of the treatments I listed above are tried initially, unless they've already been tried and failed. Anti-inflammatory medications--either in pill-form or injected--are a standard first-line treatment, along with physical therapy. If these fail, often surgery is an option. I won't bore you with all the techniques, risks, benefits, complications, etc. of these surgeries, but I'll give you a brief crash course in the theories behind them. **skip to the end if you really don't want technical details--really, all you need to know is surgery is involved.

Early surgical treatments usually involve repairing the damaged tendon and helping re-create the arch. The simplest procedure to try is called arthroereisis (tough one to learn how to spell). Basically, it is used in patients that have too much mobility in the joint that holds the heel vertical. It usually involves placing a spacer-type device into the joint (called the subtalar joint), to limit how much motion it has available--kind of like putting a door stop into a doorway to prevent the door from opening too far and ramming the door handle into the wall. This is a controversial approach because it depends on your surgeon's level of exposure to the technique. Depending on where a surgeon trained, it may or may not be a recommended procedure by the doctor you meet with. I knew doctors in the area of my residency who either loved them or never used them.

The other procedures are pretty intense and involve reshaping the bones--usually done by either cutting wedges out of bones or inserting wedges into bones to straighten them out--so that the structure of the bones looks more normal. These are pretty involved and usually involve transferring a tendon over to help the original tendon carry its load.

The last option usually involves fusing arthritic joints together in a corrected position with the goal of restoring the normal shape of the foot.

Too much information about these procedures can make your head swim, so I'll leave the explanation for these for if you ever need to come into my office for a surgical consultation. Until then, this should be at least an idea of what is out there.

To sum it up, most of the time you don't need to do anything about flat feet in kids. If they're getting older (and one or more family members have had issues with painful flat feet before) it's probably a good idea to get looked at. There are some things you can try at home to help it, but sometimes a specialist needs to step in. Usually a prescription orthotic does the trick, but in rare occasions a surgery is required to straighten things out.

References:

Carr JB, Yang S, Lather LA. Pediatric Pes Planus: A State-of-the-Art Review. Pediatrics. 2016;137(3):e20151230

The link for arthroereisis leads to a google search