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Foot and ankle problems affecting children

Jump to flat feet / in-toeing

Flat feet (pes planus)

All children have flat feet at birth. As they grow, an arch develops to a variable extent. Some people will always have flat feet, which is a variant of normality. Flat feet are only abnormal if they are painful or rigid.



  • Check to see if an arch can be restored using Jack’s test:
  • With the child seated, dorsiflex the big toe, an action which tensions the plantar fascia. Normally an arch will form.
  • Check for subtalar flexibility – a fixed subtalar joint may represent tarsal coalition, where the tarsal bones do not fully separate during development.



  • Flexible flat feet do not normally need treatment. Insoles and orthotics do not improve function, do not permanently restore the arch and are often uncomfortable.



  • X-rays are not necessary for the majority of cases.



  • If a child has a persistent pain
    • a flat foot which does not produce an arch with Jack’s test
    • a rigid subtalar joint
    • is asymmetrical compared to the other foot
  • please make a referral.
  • Coalitions may be treated with resection of bony bars or fusion of select joints in the foot.

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During growth, there is a natural progression from feet pointing inwards (in-toeing) as seen in toddlers, to the feet pointing outwards (out-toeing) as seen in  adults. The speed of progression is variable and there is a range of normality as some children become out-toeing more slowly than others.



  • The child is usually unaware of a problem, but anxious parents may attribute their child’s in-toeing gait for many problems including poor performance at sport.



  • Assess the forefoot progression ankle, which is the ankle subtended by the long axis of the foot with the direction of travel whilst walking.
  • Pathological in-toeing may be caused by cerebral palsy, spina bifida, arthrogryposis, hip dysplasia or Perthes’ disease. Therefore, always examine the hips, leg lengths, spine and neurology.



  • Clinical examination is usually all that is required for most cases.



  • If there is asymmetry, pain, spasticity, progression in the ‘wrong’ direction or marked deviation from normal alignment, please make a referral.

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