What the latest evidence says about foot orthoses for children with flexible flat feet

If your child has flat feet, the most important thing to know is that in most children it is completely normal and nothing to worry about. A recent review of the research suggests foot orthoses can help a specific group, older children with symptoms, but they are not something every flat-footed child needs. Here is what the latest evidence actually shows, and how we think about it in clinic.

What "flexible flat feet" actually means

Nearly all babies and toddlers have flat feet, the arch simply has not developed yet, and there is often a normal pad of fat where the arch will be. For most children the arch appears on its own somewhere between about four and eight years of age. "Flexible" flat foot means the arch flattens when the child stands but returns when they are on tiptoes or sitting, which tells us the joints are moving normally. This is different from a rigid flat foot, which stays flat and is far less common and worth checking.

Because flexible flat feet are so common and usually painless, the honest question is not "how do we fix every flat foot" but "which children actually benefit from doing something, and does it work?" That is exactly what this new research set out to answer.

What the review looked at

A systematic review and meta-analysis published in Frontiers in Pediatrics in 2024 pooled the results of six randomised controlled trials, together including 297 children with flexible flat feet. A meta-analysis combines several studies so the overall picture is clearer than any single small trial on its own. The researchers looked at two kinds of outcome: measurements of foot alignment on X-ray, and pain.

What it found

In older children, wearing foot orthoses produced small but statistically significant improvements in the way the foot lined up on X-ray. Three measurements improved: the lateral talar-first metatarsal angle (an average change of about 2.8 degrees), the lateral talo-heel angle (about 5.1 degrees), and the calcaneal pitch angle, which reflects the height of the arch (about 1.8 degrees). "Statistically significant" means the result was unlikely to be down to chance, each of these had a p-value of 0.0005 or smaller.

For children who had pain, orthoses were also linked to a meaningful reduction in pain, though that result was less certain, it only just reached significance (p = 0.04). The direction, though, was clear: less pain rather than more.

It is worth being honest about what these numbers do and do not mean. They tell us orthoses can nudge the alignment of the foot and ease pain in the right child. They do not tell us that a better X-ray angle guarantees a better-functioning foot for life, and the changes were modest. Good care is about matching the tool to the child, not chasing a perfect image.

The most important nuance: age matters

The clearest finding was that orthoses helped older children. In younger children the picture was much less certain, and the authors were candid about why: in young children the bones of the foot are still forming, so both the X-ray measurements and the response to treatment are harder to interpret. This fits what we see in practice, a flat foot in a comfortable four-year-old is usually a stage of normal development, not a problem to treat.

Beyond orthoses: the bigger picture

Orthoses are only one part of the picture, and often not the first step. Well-fitting, supportive shoes, plenty of active play, and simple foot and calf strengthening all matter, and for many children a bit of patience is genuinely the right "treatment" as the arch and muscles develop. The value of a review like this is that it helps us be specific about when to add orthoses rather than reaching for them by default.

What this means for parents

A few practical takeaways. First, flat feet in a child who is running, playing and pain-free generally need reassurance and monitoring, not orthoses. Second, the picture changes when there is pain, tiredness in the legs, frequent tripping, or a foot that is not developing as expected, these are the situations where an assessment is worthwhile and where, in an older child, orthoses have evidence behind them. Third, this was still a small body of research; the authors themselves called for larger, longer studies, so it is reasonable to treat orthoses as one useful option among several rather than an automatic answer.

When we see a child with flat feet, our first job is to work out whether anything needs doing at all. A biomechanical assessment lets us check whether the foot is flexible, whether it is causing symptoms, and how the child is moving overall. From there we can be honest with families about whether watchful waiting, footwear advice, activity and strength, or orthoses is the sensible next step. The aim is the right amount of care, not the most.

Common questions

Do all children with flat feet need orthotics?

No. Most flexible flat feet in children are normal and painless and do not need treatment. Orthoses tend to be considered when there are symptoms such as pain or fatigue, and the evidence for them is strongest in older children.

At what age should the arch appear?

The arch commonly develops on its own between around four and eight years of age. A flat foot before then is usually part of normal development.

Will my child grow out of flat feet?

Many do, as the arch develops and the muscles strengthen. Because this varies, the useful question is whether the flat foot is causing any problems now, rather than the appearance alone.

When should I get my child's feet checked?

It is worth having an assessment if there is foot or leg pain, the child tires or trips more than expected, the feet look very different from each other, or the foot stays flat and stiff on tiptoes.

This is general information based on one recent review, not a diagnosis or personalised advice, and every child is different. If you have concerns about your child's feet, a short assessment is the best way to get an answer tailored to them.