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Flatfoot

What is flatfoot?

Flatfoot is a common foot shape that doctors sometimes call pronated foot. When a person with flatfoot stands up, the arch in the middle of her foot disappears and the foot seems to lie flat on the ground.

There are three different types of flatfoot. It is important to know which kind your child has so that you and your child’s doctor can decide whether she needs treatment, and if she does, which kind of treatment.

Flexible flatfoot

Almost all children with flatfoot have what is called flexible, or hypermobile, flatfoot. This condition is not painful, causes no disability and does not need any treatment. It always affects both feet.

Flexible flatfoot with a short Achilles tendon

The second type of flatfoot is called flexible flatfoot with a short Achilles tendon. It may cause pain and disability, but it happens very rarely in young children. It affects both feet.

Rigid flatfoot

The third type, rigid flatfoot, is the least common. Rigid flatfoot most often shows up in people who have a problem with the bones in their feet (tarsal coalition).

About one in four people with rigid flatfoot has pain and disability. About half of the time, rigid flatfoot affects both feet.

How do you evaluate flatfoot?

Arch develops on toe standing.
Arch develops on toe standing.

First, we examine your child’s foot and ankle. We look at her feet as she stands up. We may ask her to stand on tiptoe or dangle her foot in the air as she sits on an exam table.

When a child has flexible flatfoot — the kind that needs no treatment — we can see an arch in her foot when she stands on tiptoe or lets her foot hang down.

When a child has rigid flatfoot, which may cause problems, we usually cannot see an arch even when she stands on tiptoe.

Toe stand.
Toe stand.

We also check to make sure the joints in your child’s feet and ankles all move well.

If your child’s ankle does not move much, it could mean that her Achilles tendon is shortened or tight. That may be a sign that she has flexible flatfoot with short Achilles tendon.

If your child’s feet hurt and she has the type of flatfoot that usually is not painful, we may take radiographs to get more information about what may be causing the pain.

Who gets flatfoot?

Flatfoot.
Flatfoot.

Almost all babies are born with flatfoot. Studies estimate that 80% to 90% of babies born in North America have flatfoot, and studies in other countries have turned up similar numbers.

Most of these babies have flexible flatfoot.

Children often outgrow flatfoot naturally. But at least 20% of adults in North America have flatfoot.

About 25% of these adults have flexible flatfoot with a short Achilles tendon and 9% have rigid flatfoot.

What is your experience with flatfoot?

The former director of our Department of Orthopedics, Dr. Lynn T. Staheli, produced groundbreaking research that changed the way doctors worldwide understand and treat flatfoot.

Research led by Dr. Staheli showed that, in most children, flatfoot is a common shape that does not cause pain or disability. Most children naturally develop arches in their feet during their first decade of life.

This work prompted doctors at other medical centers to do research that showed that special shoes and shoe inserts do not help create an arch in a flatfoot. These findings ended the use of expensive treatments that do not work.

Further, researchers at Children’s Hospital found that shoes once used to treat flexible flatfoot made some of the children who wore them feel abnormal and hurt them psychologically.

For the rare cases when surgery is needed, doctors at Children’s Hospital developed the most common operation now used nationally to correct severe, painful flatfoot with short Achilles tendon in adolescents. Doctors use this operation only when other more conservative treatments do not work.

How do you treat flatfoot?

First, we always evaluate your child to find out what type of flatfoot she may have. Your child needs treatment only if flatfoot causes pain or disability.

Non-surgical treatments

If your child has normal flexible flatfoot that doesn’t hurt, we recommend no treatment. Your child should wear regular shoes and be treated no differently than if her feet had arches.

If your child has general aching pain in her feet or legs after activities, we recommend a simple and inexpensive over-the-counter cushioned arch support or a running shoe with a built-in arch support.

To treat flexible flatfoot with a short Achilles tendon, we may attempt to stretch the Achilles tendon. It is more difficult to stretch this tendon if your child has flatfoot than it is if she has an average-height arch. It requires us to rotate the foot inward to elevate the arch while the Achilles tendon is being stretched.

We suggest avoiding the use of hard arch supports for flexible flatfoot with a tight Achilles tendon. These rigid arch supports, often made of hard plastic, can cause more pain than is present without them.

Surgery for flatfoot

In rare cases, flatfoot is not helped by more conservative treatment and children need surgery to relieve their pain, which is usually focused on one spot and not a general, achy feeling.

In almost all cases that require surgery, the child is at least age 8 and her Achilles tendon is short. Surgery involves lengthening the short Achilles tendon as well as correcting the flatfoot deformity.

The doctor lengthens the heel bone (calcaneus) using a bone graft inserted on the outer side/edge of the middle of the foot. This procedure is called calcaneal lengthening osteotomy.