Paediatric Flatfoot: Physiological Development or Misalignment Requiring Treatment?

What lies behind it

Pediatric flexible flatfoot, medically referred to as pes plano-valgus juvenilis, combines two distinct deviations in foot geometry. In the valgus component, the heel bone, or calcaneus, tilts inward into a valgus position, causing the medial malleolus (inner ankle) to protrude noticeably. The flatfoot component simultaneously describes a flattening of the medial longitudinal arch, bringing the plantar surface of the midfoot closer to the ground than in a fully developed arch.

In the first years of life, this foot shape is not a pathological condition, but rather a physiological transitional state. Infants possess a pronounced subcutaneous fat pad on the sole of the foot, which protectively covers the bony arch and gives the foot a flat, soft appearance. In addition, the capsular-ligamentous system and tendon structures in toddlers exhibit marked laxity, which is essential for flexible movement patterns when learning upright gait.

Bony development progresses over several years. The talus and calcaneus alter their alignment relative to each other under increasing load from body weight and the pull of skeletal muscles. A key role is played by the tendon of the tibialis posterior muscle, which lifts the foot arch like a dynamic reins band, supported by the plantarly located spring ligament (ligamentum calcaneonaviculare plantare).

Between the ages of three and six, the longitudinal arch noticeably erects in most children under the influence of everyday stimuli. Up to the age of eight or nine, moderate flattening of the sole of the foot without accompanying symptoms is considered a normal variant of childhood growth.

To differentiate the condition, specialists use functional tests such as the Jack test or the tiptoe test. If the foot arch spontaneously erects when the hallux (big toe) is elevated or during standing on the balls of the toes, and the heel straightens again, it is a flexible flatfoot. If this realignment is absent or if the foot cannot be passively moved into a neutral position, it is a rigid form that requires further orthopaedic evaluation.

Typical signs

The visual features of flexible flatfoot are easily recognizable to parents upon close observation while standing. Viewed from behind, the axis of the Achilles tendon in the heel area deviates inward, so that the calcaneus and lower leg do not form a straight line. Viewed from the inner aspect, the midfoot touches the ground along its full length, meaning the typical curvature between the ball of the foot and the heel is absent.

It often presents in combination with a slight knock-knee alignment of the knee joints, termed genu valgum in medical parlance. During walking, it is frequently noticeable that the toes point significantly outward to compensate for the collapsed arch, or conversely rotate inward as a compensatory pattern. Wear patterns on everyday shoes provide additional clues: if the sole is heavily worn along the inner heel edge or around the ball of the foot, this indicates altered pressure distribution.

Symptoms in children rarely manifest as localized foot pain. Affected children more commonly report rapid fatigue in the legs after short walks or active play. Children then ask for breaks unusually often, want to be carried, or withdraw from active ball games.

A striking example from podiatry practice illustrates the complexity of the symptoms: seven-year-old Amelie was brought in by her parents because she regularly complained of diffuse, dull pain in the calf muscles and along the shinbone after physical education classes. The podiatric examination revealed a pronounced valgus position of the heels combined with overload of the tibialis posterior muscle, while the foot bones themselves were entirely intact.

For accurate differentiation, isolated foot deformities must be considered. Pure pes valgus involves solely heel malalignment without flattening of the sole, whereas in pure pes planus the arch is flattened without significant outward deviation of the heel. Only the coexistence of both biomechanical changes characterizes the presentation of flexible flatfoot (pes plano-valgus).

Everyday causes

The development and consolidation of unfavourable foot statics is influenced by various everyday factors. A central role is played by the type of footwear. Overly rigid, stiff shoe soles prevent the natural rolling motion of the foot along the heel-to-ball line and severely restrict the intrinsic motion of the 26 foot bones.

Unsuitable footwear also prevents sensory feedback from the ground to the central nervous system, which inhibits the development of the deep foot musculature. Overly narrow toe boxes compress the toes and deactivate the big toe as an important stabilizer of the longitudinal arch. Equally problematic is wearing handed-down shoes from older siblings, as pre-worn insoles passively direct the younger child's gait into a malposture.

The lack of varied movement stimuli exacerbates the issue. In modern environments, children predominantly move on flat, hard surfaces such as asphalt, laminate, or tiles. On these smooth surfaces, sensory input signals required to activate the short foot muscles are absent.

Lack of physical activity and overweight increase the mechanical load applied to the flexible bone and cartilage tissue. When body weight exceeds the holding capacity of weakly developed ligaments, the longitudinal arch gradually sinks under continuous pressure.

Certain postural habits in childhood further encourage malalignment. These include the so-called W-sitting position, in which the child sits on the floor with lower legs folded backwards alongside the thighs. This seating position internally rotates the hip joints and promotes internal rotation of the femur, which directly affects the axial position of the heels. Systemic connective tissue laxity also leads to increased ligament flexibility, providing insufficient support to the arch of the foot.

When medical evaluation is necessary

A watchful waiting approach is not appropriate in all cases. Parents should take note if warning signs appear that go beyond normal physiological development. Prompt evaluation by a specialist in orthopaedics or paediatrics is warranted if pain occurs in the feet, ankle joints, knees, or spine.

Asymmetries also require special attention. If the malalignment is present in only one foot while the other displays a stable longitudinal arch, a functional or structural disorder is usually present and requires targeted investigation. Likewise, a rigid, immovable foot shape represents a clear indication for medical diagnostics. If the arch fails to erect during a tiptoe stance or if the foot exhibits marked stiffness during passive movement by the examiner, a bony or cartilaginous coalition may be present, such as calcaneonavicular coalition.

When assessing structural abnormalities, consider the following typical warning signs:

• Pain during weight-bearing or rest pain at night that prevents the child from sleeping peacefully.
• A visible limp, antalgic gait, or irregularities in step pattern during normal walking.
• Skin changes such as pressure-induced callus formation, redness, or swelling around the medial malleolus.
• Persistence of severe malalignment beyond the ninth year of life without a tendency toward spontaneous alignment.
• Restricted mobility in the upper or lower ankle joint during passive dorsiflexion of the foot.

Early orthopaedic assessment can reliably prevent irreversible secondary damage to joint surfaces and ascending kinetic chains.

What podiatric treatment can achieve

Podiatry serves an important interface function between medical diagnosis, orthopaedic shoe technology care, and home-based prevention. Following a thorough assessment, which includes a visual gait analysis, palpation of relevant tendon insertions, and the creation of a footprint using podography, the functional condition of the child's foot can be precisely evaluated. Learn more about our podiatric services.

For children with skin and nail changes resulting from altered pressure loads, podiatric treatment provides pain relief. As the medial arch sinks, the medial border of the foot often rubs more forcefully against the shoe lining. This can lead to painful corns, calluses, or nail fold irritation, which are professionally reduced and managed in the practice under strict hygiene standards.

In close consultation with attending physicians, we support therapy by fabricating custom silicone pressure relief devices. These tailored silicone orthoses protect sensitive skin areas from excessive friction and help gently correct toe positioning if toe deformities occur as a secondary symptom.

Podiatric consultation pays close attention to selecting appropriate footwear. Parents receive specific recommendations regarding fit, sole flexibility, and upper materials. Treatment intervals depend on the child's individual needs and typically range from six to twelve months for preventive check-ups, whereas acute pressure points require shorter intervals. As a sektorale Heilpraktikerin für Podologie (sectoral practitioner in podiatry), Helga Maria Freitag possesses the qualifications to independently assess functional complaints from a podiatric perspective and initiate targeted measures.

What you can do yourself

The most effective stimulus for building a stable foot arch is active use of the foot muscles. Parents can sustainably support the corrective process in everyday life through targeted stimuli. Regular barefoot walking on natural, uneven surfaces forms the foundation for this. Grass, sand, forest paths, or pebbles force the short foot muscles to perform continuous micro-contractions to maintain balance.

On hard indoor floors such as parquet or tiles, barefoot walking does not provide sufficient sensory stimulation. In these cases, slippers with flexible, thin soles or non-slip socks are recommended, as they allow freedom of movement without passively restricting the foot.

To actively strengthen the foot and lower leg muscles, playful exercises can be seamlessly integrated into daily routines. Use the following practical approaches:

• Grasping games: The child attempts to pick up small objects such as marbles, clothes pegs, or coloured pencils from the floor using their toes and place them in a container.
• Towel scrunching: A towel lying flat on the floor is scrunched up solely by pulling it in with the toes while sitting or standing.
• Toe and heel walking: Walking together on tiptoes like a stork or on heels like a penguin strengthens the calf and shin muscles.
• Balancing: Walking along a rope laid on the floor or across balancing stones trains proprioceptive awareness and coordination.
• Using barefoot paths: Exploring different textures stimulates mechanoreceptors on the sole of the foot and improves muscle activation.

The exercises should be performed without pressure to perform. Five to ten minutes of daily playful training are sufficient to provide significant impulses for muscular development.

Common mistakes

In an effort to help the child, well-intentioned but biomechanically unfavourable decisions are regularly observed in practice. A widespread mistake is prescribing rigid, supportive orthotic insoles too early in symptom-free preschool children. Passive supportive elements relieve the foot muscles of work. If the longitudinal arch is permanently cushioned from below, muscular activity of the tibialis posterior muscle atrophies, which can worsen the malalignment once the insoles are removed.

Another mistake lies in selecting improper footwear. Parents frequently purchase shoes with an integrated, pronounced footbed for young children. However, nature designed the infant and child foot to structure itself through weight-bearing and intrinsic movement. A firmly preformed footbed in children's shoes hinders this natural process and can lead to abnormal loading.

Equally problematic is passing down worn shoes from older siblings or relatives. Every foot creates a unique wear pattern in the midsole and outsole due to its individual gait pattern. When wearing these shoes, a younger child adopts the altered statics of the previous owner, which negatively affects their own gait pattern.

Dismissing complaints of pain prematurely as mere growth pains also poses a risk. While genuine growing pains typically present diffusely, mostly at night, and disappear completely by morning, load-dependent pain after sports or walking points to mechanical overload. Such signals should always be taken seriously and evaluated by a professional.

Scientific evidence and context

The scientific literature in paediatrics and orthopaedics confirms that flexible flatfoot in infants and young children represents a normal physiological developmental stage. A large-scale epidemiological study by Pfeiffer et al. demonstrated that the prevalence of flatfoot in three-year-old children exceeds 50 percent, whereas this figure drops to below 15 percent in six-year-olds [1]. This natural decline underlines the high rate of spontaneous correction during normal longitudinal growth.

Investigations by Evans et al. address the efficacy of therapeutic interventions in symptom-free children. The evidence clearly demonstrates that the preventive use of corrective insoles in asymptomatic flexible flatfoot offers no statistically significant advantage over natural progression [2]. The authors emphasize that passive management without a clinical indication tends to inhibit rather than promote muscle development.

In children with symptoms or severe deformities, the picture is different. Studies on the effect of sensorimotor or proprioceptive insoles show that targeted pressure stimuli applied to the sole of the foot can positively influence the activity of stabilizing muscle chains [3]. Stimulating specific muscle spindles alters motor control during the stance and swing phases of gait, leading to a reduction in overload pain.

Systematic reviews by Hollander et al. highlight the importance of barefoot activities and targeted muscle training. Children growing up predominantly barefoot in developing countries or rural areas exhibit a significantly higher longitudinal arch and a lower tendency toward deformities compared to regularly shod peers [4]. These findings demonstrate the paramount role of active stimuli for long-term foot health.

Treatment in Memmingen

At the FREITAG® Podologie GmbH practice at Kempterstr. 25 in Memmingen, we support families from the city as well as the entire catchment area of Unterallgäu, Allgäu, and Oberschwaben with all questions regarding pediatric foot health. Under the leadership of Helga Maria Freitag, we offer expert podiatric consultation and care tailored individually to your child's age and developmental stage.

If you wish to clarify uncertainties regarding your child's foot alignment or already have a medical recommendation, you are welcome to schedule a consultation appointment at our practice. Please contact our practice directly or learn more about our practice profile on our overview page.