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tiny, flat feets!
Flat feet are pretty unloved. It’s not that they smell more. Our society seems to have cast those with ‘pes planus’ in a rather unfavorable light. Parents broadcast their worry in the doctor’s office that their infants, kids or teens with fallen arches will suffer miseries untold: that their offspring will be less competitive athletes, they will leave ugly footprints (really, I heard that once), they will be doomed to a life of pain and chunky footwear, or they will suffer rejection by the armed forces, their peers, or a future spouse.
Before we despair too much or invest too heavily in tricked out foot orthotics, we may all do well to consider the rather fascinating principles of how kids’ feet develop. And, that those flat feet are not such a worry about after all. The 26 bones that occupy the distal end of our lower extremities have are a dynamic bunch in the first decade of life. Foot growth and anatomy illustrate some key fundamentals of how kids’ feet grow, and what is (and isn’t) normal.
Put your feet up–arched or otherwise–take a load off, and let’s kick this around a bit.
“Normal feet” run the gamut, so to speak, in children. Some kids have high arches, some have no arch, and many are in between. Most flat feet are fine and dandy, bothering fussy relatives more than anything. In rarer cases, flat feet cause pain in children, and may be due to a problem of the foot, or an issue of something going on in the rest of the body. In any case, primary care docs (cue music) can help parents and kids distinguish what is of concern, and what if anything, needs to be done.
When we arrive on the planet, our feet are way different from the form they’ll adopt in our adult lives. Newborn feet are extremely flexible, made of softer bones, and looser ligaments with a pad of fat across their bottom. These qualities allow infants to tuck snugly inside the womb. They appear flatfooted and have no discernible arch. This continues into todderhood, when the bow-legged stance and stretchy ligaments make for flattened soles of those little feet (and, flattened souls of their parents, to hear it told). Around the second birthday, we primary care types hear another round of worry: Will my kiddo ever get an arch? Maybe. Probably.
- a happy, flat footed toddler
The arch of the foot does not express itself until well after child begins to bear weight, most often between 2 and 4 years old. Growth, changing posture and anatomy, maturing muscle and gravity tone, sculpt, and shape the tarsal bones and connective tissues that bridge the midfoot. When it all occurs sweetly, they make an arch. In the late 1950s, a researcher illustrated this idea by studying the footprints of children. He found 90% of two year olds had flat feet, but that by the time children were 10, flat feet were seen in only 4% of the children. (More recent tallies put the prevalence of pes planus in kids around 10-15%)
Of note, a study published this spring found overweight children have flatter and fatter feet than their peers who were of normal weight. The cause and effect linkage is unclear, if the fallen arch generates to more fat deposition on the soles of the feet, or vice versa. In any case, it remains to be seen if kids who are overweight, who tend to have more flat feet, have a harder go of it as they enter adolescence and adulthood.
What does an arch do? The crescent shape enhances the lower extremities’ ability to bear weight and move efficiently for locomotion. However, any number of biological, environmental or genetic variables can impact upon an arch’s final shape. Thus, deformities like flat feet or fallen arches can appear at any point during a child’s growth.
And so, back to the question: Do flat feet matter in kids?
Mostly, no. But, the myths die hard.
The majority of children with pes planus have a benign condition known as hypermobile or flexible flat feet. Doesn’t that sound better already? Most of these children are unaware of any problem, experiencing little to no pain in their daily lives, or during exercise. During a physical exam, a clinician can assess mobility of the ankle and the range of motion of the joints of the foot, including the mid and forefoot.
In a hypermobile flatfoot, observers will see a child’s absent arch re-form when he bears weight and stands on his toes. Aha! Additionally, the arch of a child with flexible flat foot should appear when the foot is dangled in the air, as the seat of a chair or exam table. Bingo!
Even when flexible flat feet are identified, parents may be suprised to hear that the principal approach is observation. Through a tincture of time and a pinch of growth, discomfort in flat feet usually resolves, no matter what we do (or not). In flatfooted kids with mild discomfort, the laying on of hands comprises the entirety of the evaluation (not even getting an xray!). Foot massages can help some discomfort at day’s end, are cheap, and feel great. Kids love ‘em! Going barefoot (and being sensible about it) may help, too. Special orthotics, custom inserts or cups for parts of the foot quickly become expensive and probably aren’t effective. I generally advise parents of these kids to save their money and frustration.
Parents may find more benefit in a decent pair of sports shoes with a built-in or added arch support. Of course, well-built footwear will support the arch, but will not correct or cure the fallen arch. Alas, when barefoot, the flattened foot will return to its original shape. And, that is ok.
For the child or teen with flexible flat foot, it may be just as important to avoid footwear with little or zero support. Sorry, flipflop fans, but those plank-like beach sandals ain’t helping, and they might be hurting. Literally.
When does a flat footed child need a specialist? Primary care docs will refer when it seems something more complicated than flexible flatfoot is going on. Much more rarely, bony abnormalities, muscle problems, or neurologic issues like cerebral palsy may require involvement of orthopedists, podiatrists, physical therapy, and more involved care. The care for these kids’ inflexible feet can be much more challenging.
Per usual, the history of a patient is paramount, and parents relay critical information… Before going to the clinic to discuss the issue, parents should scope out the problem with their child. Watch them walk. Photograph (and bring photos of) footprints. When does a child complain of pain, and does it limit her activity? (toddlers and preschoolers rarely report foot pain, whereas teenagers tend to complain about everything).
Do flexible flat feet limit a child’s activity or performance? Hey, they might, but I’m not so convinced. A study in March of 2009 compared athletic performance of over 200 mild to severely flat footed 11 to 15 year olds with a same-aged group with normal arches. Researchers found no significant difference, and thus no need to ‘treat’ the pes planus kids to make them better athletes. Foot for thought.
I’ll ask parents to look for unusual wear on the inside curve of the shoebottom(s). Bring the shoes in for a looksee! Is the problem on one side, or both? Parents and clinicians need to connect dots past and present, about medical or developmental conditions that could be contributing to any discomfort, including: prematurity, old injuries, tone or coordination problems (eg cerebral palsy), or orthopedic issues like known differences in leg-length or scoliosis. If none of these issues apply, so much the better. If so, it may require broadening the focus to other body parts and systems.
And so down to this…let us not tiptoe around the issue. Not to worry, ok? Most kids with pes planus–aka flexible flat feet–are fine and do well. Their footprints may be more robust. Their arches may be wee, or even absent. Yet, flatfooted children aren’t any clumsier, slow, or less capable than their peers. We should consider them on solid footing, be they arched or not.
Baby feet photo by Jessicafm
Toddler photo by Katie Tegtmeyer
For some excellent medical illustrations of pes planus, surf here
Cartoon below by me
Jack Maypole
Jack Maypole, MD has plenty of material to work from. He is director of Pediatrics at the South End Community Health Center and he is director of the Comprehensive Care Program at Boston ...
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More on these topics:
anatomy, ankle, arch, baby, brace, cerebral palsy, child, children, coordination, cup, feet, flat feet, flat foot, flexible flat foot, foot cup, footwear, forefoot, growth, heel, hypermobile, infant, insert, kid, legs, ligament, ligamentous laxity, midfoot, muscle, musculoskeletal, neurologist, newborn, orthopedic, orthotic, pain, pediatrician, pediatrics, pes planus, podiatrist, preschooler, shoes, skeleton, tarsal, toddler, toes, tone
