Flat feet is a very common problem seen in the office. Some children may experience problems that limit their activities, while others are completely asymptomatic.  When this foot deformity occurs in infants, children, or adolescents, it is termed pediatric flatfoot.  There are various forms of pediatric flatfoot, but they all share one common trait, which is a partial or total collapse of the arch while in a standing position

The term flat foot has been applied to any condition that causes a lowering of the medial longitudinal arch while standing.  Flat feet are closely associated with abnormal biomechanics of the foot, otherwise known as over-pronation.  Pronation is complex motion of the foot that occurs in three body planes simultaneously during walking.  Pronation describes the motion and position of the foot when it flexes upward (dorsiflexion), turns away form the body (abduction), and the heel rolls outward (everted), all occurring simultaneously.  Pronation is considered normal because it is required for normal walking and running.  Excessive pronation has been an associated contributor to many adult foot and ankle pathologies  including the development of heel pain, bunions, hammertoes, shin splints, stress fractures, and many other chronic overuse injuries.

The normal foot is a complex construct of numerous structures, comprising of 28 bones, 30 joints and 128 ligaments, 22 muscles and 49 tendons.  These structures are positioned in such a manner as to provide a rigid foundation to support the weight of the body in certain times of the gait cycle, but also become flexible enough to absorb shock and conform to the different contours of the ground.  During the gait cycle, the foot is able to alternate between rigidity and flexibility because of the construct of the arch.   As a simple rule, when the arch is high, the foot acts as a rigid lever, providing a stable platform for support and pushing off or propulsion.   And when the arch is low or in a pronated position, the foot is flexible for conforming.  Any abnormality in the positioning of the foot during the gait cycle can lead to improper foot function. 

Flatfeet are a common developmental positon of the foot during early walking between the ages of two to four years of age. As pediatric physical development progresses a more formed arch should take place. Treating children early in development with the use of an orthotic device often depends on the severity in appearance of the flat foot as well as the contribution of a strong family history of flatfeet.

It is not uncommon for parents or pediatricians to recognize this deformity in infants and children early, but the problems associated with flatfoot may go unnoticed for a long period of time.  Most children with flatfoot have no symptoms, but some have one or more symptoms.  The symptoms generally correspond to the type of flatfoot.  Signs and symptoms may include: 

• Pain, tenderness, or cramping in the foot, leg, and knee
• Physical flat foot appearance of the foot
• Wanting to be carried by parents excessively
• Awkwardness or changes in walking or running
• Difficulty in fitting and wearing shoes
• Decreased endurance while participating in physical activities
• Voluntary withdrawal from physical activities

In the older children vocalization of complaints of pain may become more vocal and specific in their nature.

Children complaining of pain in one or both feet beginning at the age of 8 years should be screened to rule out a developmental structural anaomoly called tarsal coalition. Tarsal coalition is an abnormal bridge of soft tissue, cartilage or bone that occurs in 1:1000 births and can be a cause of flat feet, limitation of motion of the foot and pain. Tarsal coalition is often times characterized by stiffness to motion of the joints below the ankle called the rearfoot as well as pain to the region. It is diagnosed by the clinical examination as well as by the use of regular x-rays, CT scans and MRI’s to the rearfoot region.

The diagnosis of tarsal coalition is a very important diagnosis to make in that it can be corrected surgically is symptoms require and generally has better surgical outcomes if done earlier in childhood than later.

Parents are often times the first to bring to the attention of their pediatrician concerns that they have about their children’s feet. Oftentimes reassurance from the pediatrician is all that is needed to alleviate these concerns. As a parent, it is important to keep in mind any pertinent family history regarding symptomatic or asymptomatic flatfeet as well as any secondary non-verbal clues that your child may be providing you.