The use of the foot orthoses in the treatment of paediatric flat foot: an evidence based overview

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Flatfoot in the paediatric population is a common concern and is presented regularly in paediatric health-care settings. (1) Despite this, there is no universally excepted definition for this condition, although consistent attributes include a valgus heel and a flattened medial longitudinal arch. (2) Other names frequently used include pes planus, (1) hypermobile flatfoot, (3,4) and pronated foot. (10) The lack of a standard definition of this condition, a wide spectrum of severity and the many different etiologies for flatfoot make it difficult to differentiate normal from pathologic foot thus to compare the results of treatment. (5)

A range of conservative interventions have been reported in the literature from advice to foot orthoses, stretching exercises, footwear selection and modifications, serial casting and appropriate weight reductions. (1) This clinical review however, will focus on the use of foot orthoses as it is very frequently prescribed and there is much controversy surrounding its use. There is a common agreeance between clinicians that symptomatic children should be treated to reduce pain and prevent further deformity. (2,4,6,7,) The controversy relates to those that are asymptomatic and they consist of a larger proportion of the paediatric population. (2,8) Many studies have produced undeniable conclusions that foot orthoses do not modify the natural development of flatfoot. (8-11)


The literature was reviewed to identify studies that investigated the use of foot orthoses as part of conservative treatment of paediatric flatfoot. The literature was then structured keeping in mind with the hierarchical levels of evidence. (2) The focus of this review was on randomized controlled trials as they have a strong level of evidence (2). Optimum level of evidence comes from a systematic review based on a meta-analysis of a variety of randomized controlled trials (1) however, since there is only one current study by Rome et al. (1) which is still in progress and so cannot be included in this review. Since there is a relative lack of randomized controlled trials in this area, three case series will be included as they are specific to the use of foot orthoses. Although the level of evidence is not as strong as randomized controlled trials, they can still provide useful evidence.

Given that there is no universally accepted definition for flatfoot, (11-13) we included studies that referred to flatfoot as “pronated foot”, “pes planus”, or “hypermobile flatfoot”. Although flatfoot can exist as an isolated pathology, it can also be part of a larger pathology such as ligamentous laxity, neurological or muscular abnormalities, genetic syndromes and collagen disorders. (1,5)

Sources and selection criteria

This review was prepared by searching the following databases: Medline 1966-present; AMED; CINAHL via Clinicians Health Channel; Cochrane library; Pubmed and Google Scholar. Key words used were “paediatric”, flatfoot”, and “foot orthoses”.

The electronic search was complemented by the following:

– Checking of reference lists of relevant articles for additional studies reported;

– Searches of abstracts in conference proceedings and special issues of journals;

– Correspondence letters by professionals working in the area of topic using BMJ.

Summary points

* Flatfoot is one of the most common conditions seen in paediatric health care.

* There is no universally excepted definition for flat foot however clinically it presents with a low or absent medial longitudinal arch and a valgus heel. The condition can be flexible (physiologic) or rigid (pathologic).

* On examination of the child it is important to determine the classification (flexible or rigid) and consider other risk factors that may affect the treatment plan such as ligament laxity, obesity, rotational deformities, varus and valgus deformities of the tibia or equinus deformity. Other important considerations should be family history, trauma history, activity level, and previous treatment.

* Generally there is a common consensus between clinicians that symptomatic children should be treated, the controversy relates to those that are asymptomatic which consists of a large proportion of the paediatric flatfoot population.

* There is a lack of good-quality research in this area and more long-term longitudinal studies are required to guide clinicians when treating children with flatfoot.


Flatfoot may be classified as flexible (physiologic) or rigid (pathologic) on the basis of its etiology, clinical features, natural history, and potential for causing disability. (7) Flexible flatfoot is a benign condition and is thought by some to be an anatomical variant related to ligament laxity (9) where the arch flattens on weight-bearing and reappears upon non-weight-bearing and toe-standing. (7) These feet are hypermobile with flexible talo-calcaneal joints and may or may not have an associated contracture of the Achilles tendon. (5) Flexible flatfoot may be asymptomatic or symptomatic. (6) Asymptomatic flexible flatfoot should be monitored clinically for onset of symptoms and signs of progression. (6) Symptomatic flexible flatfoot produces subjective complaints such as pain along the medial side of the foot, pain in the sinus tarsi, leg and knee, and everted heels. (6) Rigid flatfoot is characterized by a lowered medial longitudinal arch on both weight-bearing and non-weight-bearing and by stiffness of the rearfoot and midfoot. It occurs mostly in children with some underlying pathology, tends to persist, and frequently causes disability. (6,7)


An understanding of the normal evolution of the medial longitudinal arch in the child’s foot is very important when diagnosing. (6,13) When the child is born, the foot is in a calcaneo valgus position with no longitudinal arch apparent but a pad of fat on the medial side as shown in figure 1. (13) The arch starts to develop after the age of about 2-3 years where this flat arch is considered normal (13) and develops progressively over the first decade of life. (5) According to Fixsen, (13) the most useful test in diagnosing flexible from rigid flatfoot is the great toe extension test (Jack’s test) in which, when the child is asked to stand on their tip toes, the medial arch appears, heel goes into varus and the tibia externally rotates. (13) If these occur then most certainly the clinician is dealing with a flexible flatfoot and not pathological.

Figures used from Fixsen 1998 published in the Journal of the Royal Society of Medicine.


Table 1 summarizes the two randomized control trials which is the best available research addressing the use of foot orthoses for paediatric flatfoot. (9,10) Whitford and Esterman, 2007 (10) conducted a randomized parallel, single-blinded, controlled trial of custom-made and prefabricated orthoses on 178 children between the ages of 7 and 11 years with “flexible excess pronation”. The diagnosis was based on calcaneal eversion and navicular drop. Outcomes included gross motor proficiency, self perception, exercise efficiency, and pain. Since pain in the lower limb is used as a critical criterion for provision of orthoses, (10) pain was measured using a visual analogue scale at baseline and follow-up. Analysis of data of children with pain found no evidence of the effectiveness of orthoses for pain relief.

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