Parental anxiety is understandable given the historical reputation of flat foot and the continued conflicting information available in the non-medical literature and on the internet. Scientific evidence available is limited, but a recent Cochrane review and epidemiological study conclude that flexible flat foot is present in up to 40% of pre and primary school age children and should therefore be considered normal. There is no evidence to support the use of insoles, adapted footwear or physiotherapy for asymptomatic feet. There is no evidence that asymptomatic flat feet in children lead to subsequent lower limb or back problems. This contrasts with claims made by some non-medical practitioners which promote confusion.

For the majority of children with flat feet this is their normal. Reassuring features include the following:

• Both feet are affected and have been since toddlerhood (not always completely symmetrically).
• There is no significant, persistent pain or swelling.
• The arches form well on tiptoe standing (or depression of the first metatarsal head in children too young to tiptoe stand).

In certain circumstances an orthopaedic consultation is required. Indications for review are:

• Unilateral flat foot
• Evolving flattening in previously normal feet
• Flat foot associated with persistent pain or swelling
• Stiff/rigid flat foot.

To determine if a flat foot is stiff or rigid the following tests may be used:

• Ask the child to stand on their tiptoes. This should recreate the medial longitudinal arch.
• Perform Jack’s test. With the child sitting, dorsiflex the great toe. Using the windlass mechanism this should recreate the medial longitudinal arch.

Flexible flatfeet are not pathological and require no treatment. For this reason they do not routinely require review in a paediatric orthopaedic clinic nor referral to orthotics.