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Flat Feet

When are flat feet normal? 

  • Normal in babies and toddlers, usually resolving by 6 years of age as the longitudinal arch develops.
  • They persist in at least 10% of children, are commonly associated with other features of hypermobility, and are often familial (check parents' feet !).
  • Management involves explanation, reassurance and advice regarding appropriate supportive footwear (i.e., supportive heel cup and midfoot support with fastened laces).
  • Physiotherapists, orthotists and podiatrists may provide exercises and insoles if problems persist.

Photo: Flat feet in a healthy 4 year old - which normalize and demonstrate an appropriate arch when standing on tip-toe. This normal variant is called mobile flat feet (or flexible flat feet). 

 flat feetflat feet normal arches on tip toe

When are flat feet not normal? 

  • Absent arch when child stands on tip toes (non-mobile flat feet). 
  • Asymmetrical changes (i.e., one foot fixed and flat). 
  • Evidence of pressure on the foot such as blistering / callosities.
  • Swelling or stiffness of joints.
  • Limping or persistent pain.
  • Abnormal neurologic exam (hyperreflexia, hypertonia, weakness).
  • Resulting in pain, or interfering with function (sports or play).

In teenagers with a fixed/painful flat foot, think of tarsal coalition (a congenital condition where bones in the foot are joined together).

Inflammatory arthritis can also cause a painful stiff flat foot. Radiographs can be normal. Referral is required for further investigation. 

The indications for referral (to rheumatology or orthopaedics pending your concerns and available referral pathways) 

  • Joint stiffness or swelling. 
  • Absence of arch on tiptoe.
  • Signs of skin changes from pressure (e.g., blistering).
  • Persistent pain.
  • Limp or symptoms interfering with function (sport/play).
  • Systemic features. 

 Key conditions to consider include: 

  • Inflammatory arthritis – joints are stiff, warm or swollen (often the midfoot). 
  • Tarsal coalition – joints fixed and painful on walking and weightbearing. 

Photo below : Stiff Flat Foot due to Inflammatory Arthritis (Juvenile Idiopathic Arthritis).

stiff flat foot due to inflammatory arthritis

Photo below : Radiograph showing tarsal coalition with fusion of the calcaneum and navicular bones (arrowed)

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