Flat feet, also known as pes planus, is a common pediatric condition related to arch development. The child appears to have “flat feet,” or no medial arch (instep) when standing or walking. The condition occurs in 20% to 37% of the world’s population, and most often appears in childhood. Flat feet are usually flexible, painless, and go away by the time a child reaches adolescence. In some cases, flat feet may affect motor (movement) skills and physical activity, posture, or persist into adulthood. Flat feet also may cause pain.

Parents may seek treatment from a physical therapist for their child’s flat feet if they feel the child’s motor development or physical activity is limited or if the child is having pain. A physical therapist may help manage and treat the symptoms of flat feet in children. They will choose fun activities that promote strength and age-appropriate posture of the feet. Treatment may help decrease pain to improve a child’s participation in regular activities.

Physical therapists are movement experts. They improve quality of life through hands-on care, patient education, and prescribed movement. You can see a physical therapist directly for evaluation and treatment without a physician’s referral.* To find a physical therapist in your area, visit Find a PT.

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*A referral may still be required by your insurance policy, corporate policies, or state practice laws (some states limit the type of treatment or number of visits without a referral).

On this page

• What Are Flat Feet in Children?
• Signs and Symptoms
• How Is It Diagnosed?
• How Can a Physical Therapist Help?
• Can This Injury or Condition Be Prevented?
• What Kind of Physical Therapist Do I Need?

What Are Flat Feet in Children?

Flat feet are a normal part of foot development. Up to 97% of 2-year-olds present with flat feet and this is considered appropriate. However, it is valuable for a child with flat feet beyond age 2 to have an assessment by a physical therapist to determine if early treatment is needed to prevent future problems. Flat feet that persist past 8 years of age are a cause for concern. If flat feet persist, it suggests the muscles of the feet are weak or not well-developed and do not properly support the bones of the foot. This weakness or underdevelopment may cause pain, affect walking, or limit a child’s physical activity.

Flat feet typically include the collapse of the instep (the medial longitudinal arch). This leads to the entire sole of the foot making contact with the ground when standing or walking. The condition is classified in two ways: flexible or rigid.

• Flexible flat feet. The arch collapses under the body’s weight but reappears when the foot is lifted.
• Rigid flat feet. The arch remains flat regardless of weight-bearing (standing, walking) or sitting. It often causes pain and discomfort.

Flat feet may result from several causes, including:

Genetic predisposition. Flat feet may be inherited. Genetics may be a primary cause of the condition. Flat feet often occur in families with a history of this type of foot structure.

Hypermobility. Another common cause of flat feet is hypermobility (excessive movement). This occurs when the ligaments in the foot are too flexible. It allows the arch to collapse under pressure or weight-bearing. Hypermobility is common in children with low muscle tone.

Muscle imbalances. Tendon tightness, particularly in cases of Achilles (heel cord), can also prevent the proper lifting of the foot’s arch during walking.

Signs and Symptoms

If you suspect your child may have flat feet that are of concern, you may notice the following signs or symptoms:

• Middle arch or foot pain after activity.
• Awkward walking (gait).
• Pain during walking.
• Noticeable changes in foot development, such as no medial arch or the loss of this arch.
• Avoidance of or difficulty with physical activity.

How Is It Diagnosed?

Flat feet are diagnosed using a combination of clinical evaluations and imaging studies. The process may include:

Physical examination. A physical therapist looks at the foot structure in both standing and sitting to determine if the arch reappears when the foot is off the ground (indicating flexible flat feet). They also check for pain and alignment issues.

Gait analysis. A physical therapist may observe a child’s walking patterns. They will check to see if the muscles and joints are moving or working when the foot is in contact with the ground.

Imaging. When a physical exam raises questions or concerns, pictures of the bones or tissues may be needed. These may include:

• X-rays. These are used to check the alignment of the bones. In particular, the way the heel bone, ankle bones, and all the bones of the foot align. X-rays also can indicate the severity of the condition.
• Ultrasound. In children, ultrasound may be used to in addition to or in place of X-rays. The bones in a child’s foot are not mature until around age 7. The bones of children have more cartilage that can be seen with ultrasound.

These diagnostic tools help determine whether the child’s flat feet are flexible or rigid. They also help determine if treatment is needed. Typically, a physical therapist will perform the child’s physical examination and gait analysis. Other health care professionals might use X-rays or ultrasound to determine the extent and severity of the condition. Although imaging is not always required to make a diagnosis of flat feet, it can be helpful. Images may help your physical therapist create your child’s specific plan of care.

Your physical therapist will start by gathering information about your child’s health history. They may ask you questions like:

• Was anything noticed about the feet at birth or during development?
• How does your child prefer to play?
• What kind of activities does your child participate in?
• What activities do you notice difficulties with? Long walks, running, or jumping?
• If and when does your child experience pain, and where?

Your physical therapist will then conduct a physical exam. This might include a:

• Whole body examination, including a detailed exam of the feet.
• Posture analysis. How your child stands and moves.
• Gait analysis. How your child walks.
• Pain assessment.

How Can a Physical Therapist Help?

Your child’s physical therapist will use the best available evidence to develop a treatment program based on your child’s condition and goals. The plan may include several noninvasive treatment methods. These are aimed at improving mechanics (the way your child moves their bones and joints), decreasing pain, and enhancing motor function or physical activity. Your child’s physical therapy program may include:

Patient and family education. Your child’s physical therapist will educate your child and the family about exercises to do at home and other supportive measures.

Manual therapy. The physical therapist may provide hands-on “cues” or place your child in the best alignment during activities in therapy. They may also perform manual (hands-on) therapy methods, such as soft tissue techniques, to address your child’s muscles, joints, or ligaments.

Balance and gait training. Physical therapists address walking patterns to reduce stress on your child’s feet and legs. They also may work on a child’s balance to improve how they walk and move in space.

Muscle strengthening and stretching. Your child’s physical therapist will guide your child in exercises that strengthen the muscles supporting the arch and the ankle. They also can recommend stretches to lengthen tight muscles. Tightness can contribute to the collapse of the foot arch.

Orthotics. Your child’s physical therapist may recommend foot or ankle splinting, bracing, or other supportive footwear. These may provide arch support or pain and pressure relief.

Coordination with other specialists. The physical therapist also may recommend that you consult with additional specialists, such as an orthotist or podiatrist, to address any related problems.

If Surgery Is Needed

Surgery for this condition is rare and only occurs in extreme cases when previous interventions, such as physical therapy, have not improved the child’s quality of life. If surgery is needed, physical therapy should be initiated within five days after the operation. Treatments after surgery may be for arch development, strengthening of the foot muscles, and improving the child’s walking pattern.

Can This Injury or Condition Be Prevented?

Physical activity may help decrease the risk of flat feet in some children. Encouraging active motor play and daily physical activities from a very young age lays the foundation for strong legs and feet.

However, flat feet may be caused by factors that cannot be prevented or changed, such as a child’s genetic makeup.

Once flat feet have been identified as a concern, treatment is crucial. Supervised physical activity with emphasis on foot strengthening and appropriate supportive footwear may decrease a child’s risk of secondary injury or pain. Proper treatment helps a child with flat feet reach their fullest motor potential and may prevent worsening of symptoms over time or with growth.

What Kind of Physical Therapist Do I Need?

All physical therapists are trained through education and clinical experience to evaluate, manage, and treat various symptoms and conditions. You may want to consider seeing a physical therapist who is:

• Experienced in treating pediatric flat feet or gait disorders.
• A board-certified clinical specialist in pediatric or orthopedic physical therapy, or who has completed a residency or fellowship in pediatrics. This physical therapist has advanced knowledge, experience, and skills that may apply to your condition.
• Has a practice that focuses on noninvasive treatment of gait or treatment of primarily pediatric patients.

You can find physical therapists in your area with these credentials and clinical expertise through Find a PT, provided by the American Physical Therapy Association.

General tips when you are looking for a physical therapist (or any other health care provider):

• Get recommendations from family, friends, or other health care providers.
• Ask about the physical therapist's experience treating flat feet or gait abnormalities before you make an appointment.
• Be prepared to describe your child’s symptoms in as much detail as possible. Make a note of what makes your child’s symptoms worse or better.

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