Pediatric Flat Feet Treatment: A Podiatrist’s Guide

Understanding Pediatric Flatfoot

Types of Pediatric Flatfoot:

• • Flexible Flatfoot – The arch appears when the child is not standing but flattens when weight-bearing.
  • Rigid Flatfoot – The arch remains flat regardless of foot position and may indicate structural issues.

Causes & Risk Factors:

• • Genetic predisposition, as pediatric flatfoot often runs in families.
  • Ligamentous laxity, where loose joints contribute to arch collapse.
  • Obesity, which increases stress on the foot structure.
  • Neuromuscular conditions such as cerebral palsy or muscular dystrophy.
  • Tarsal coalition, an abnormal fusion of bones in the foot.

Non-Surgical Treatment Options

1. Proper Footwear

Supportive shoes are essential for managing pediatric flatfoot. Contrary to popular belief, soft, flexible shoes are not ideal for addressing flatfoot-related pain. The best footwear should:

• Have a firm sole that does not bend in the middle.
• Include a slight heel rise for better alignment.
• Offer strong arch support.

Recommended shoe types include:

• Stable athletic shoes, such as running or cross-training shoes.
• Hiking boots, which provide arch control and ankle support.
• Cowboy boots, which feature a slightly raised heel and firm sole.

2. Over-the-Counter (OTC) Arch Supports

High-quality OTC arch supports can significantly improve symptoms by:

• Providing additional stability.
• Evenly distributing pressure across the foot.
• Reducing strain on tendons and ligaments.

These arch supports are widely available at running shoe stores and are a cost-effective alternative to custom orthotics.

3. Physical Therapy & Strengthening Exercises

Certain exercises can strengthen the foot muscles, improve flexibility, and reduce discomfort. Some recommended exercises include:

• Heel cord stretching to prevent Achilles tendon tightness.
• Toe curls and marble pickups to strengthen small foot muscles.
• Towel scrunches to enhance arch coordination.
• Calf raises to strengthen the posterior tibial tendon, which supports the arch.

4. Activity Modification

If a child’s pain limits their ability to be active, certain modifications may be necessary.

• High-impact activities like running and jumping should be reduced or avoided.
• Low-impact activities like swimming or cycling are better alternatives.

When is Surgery Needed?

Surgery is rarely required, with less than 1–2% of symptomatic pediatric flatfoot cases needing surgical intervention. It is only considered when:

• Pain persists despite conservative treatments.
• The child’s mobility is significantly affected.
• There is an underlying structural abnormality, such as a tarsal coalition that is symptomatic and limiting daily activities.

Surgical Options

When surgery is necessary, peri-articular (around the joint) procedures are preferred to preserve motion and maintain a stable walking foot. Common procedures include:

• Calcaneal osteotomy – A realignment of the heel bone to restore the arch.
• Evans osteotomy – Involves placing a wedge into the heel to realign the front part of the foot.
• Cuneiform osteotomy - A wedge of bone graft is inserted into a mid-foot bone to help rebuild the arch.
• Tendon lengthening or transfers – Used to correct muscle imbalances affecting the arch.

For some children, flatfoot can significantly impact their ability to participate in activities with their peers. When kids are unable to keep up with their classmates, becoming physically inactive, or unable to engage in activities, they may be setting themselves up for a poor quality of life with long-term consequences of inactivity. In these cases, a surgical reconstruction can provide long-lasting results, improve their mobility, and ultimately enhance their overall quality of life.

Below is a case of an 8 year old girl who was unable to participate in sports due to her severe foot pain and flat foot deformity. You can see how flat her arches are in this image below.

In her case, three osteotomies were performed by Dr Haas and Dr Cobb called a calcaneal slide, Evans, and Cotton (cuneiform osteotomy) osteotomy. We typically decide which combination of osteotomies are necessary based on the severity of deformity, type of deformity, and level of foot flexibility.

The hardware is placed in a location that will not interfere with growth plates, which is critical to allow the child to continue to grow normally. Usually the metal does not cause problems and does not require a second surgery to remove the hardware. They do not set off metal detectors at the airport.

Her recovery was 6 weeks in a cast, 3 weeks walking in a boot, and then she was walking in shoes by the 9th post-op week. She quickly was then able to return to sports and has been able to lead an active life-style since her flatfoot reconstruction.

Conclusion

• Most children with flatfoot improve with non-surgical treatments, including supportive footwear, OTC arch supports, and physical therapy.
• Surgery is only considered in severe cases with persistent pain or structural abnormalities.
• If your child is experiencing foot pain, consulting a podiatrist can help determine the best treatment plan.

If you have a child that is suffering from foot pain, or just want to speak with our experts about how your child's foot problem, call the office (505)247-4164  at Albuquerque Associated Podiatrists today, or click the online booking tool. It’s the first step toward a more active, pain-free life. We are available for same-day appointments in Albuquerque and Santa Fe.