The typically developing paediatric foot: how flat should it be?

NewsBot · Aug 15, 2017

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The typically developing paediatric foot: how flat should it be? A systematic review
Hayley Uden, Rolf Scharfbillig and Ryan Causby
Journal of Foot and Ankle Research 2017 10:37

Background
All typically developing children are born with flexible flat feet, progressively developing a medial longitudinal arch during the first decade of their lives. Whilst the child’s foot is expected to be flat, there is currently no consensus as to how flat this foot should be. Furthermore, whilst feet are observed to decrease in flatness with increasing age, it is not known how flat they should be at each age increment. The objective of this systematic review is to define the postural characteristics of the ‘typically’ developing paediatric foot.

Methods
The PRISMA protocol was applied to compare all data currently published describing the typical development of the paediatric foot. The Epidemiological Appraisal Instrument (EAI) was used to assess the risk of bias of the included studies.

Results
Thirty four epidemiological papers pertaining to the development of the paediatric foot were graphically compared. Sixteen different foot posture assessments were identified of which footprint based measures were the most reported outcome.

Conclusion
Firstly, the use of the term normal in relation to foot posture is misleading in the categorisation of the paediatric foot, as indeed a flat foot posture is a normal finding at specific ages. Secondly, the foot posture of the developing child is indeed age dependent and has been shown to change over time. Thirdly, no firm conclusion could be reached as to which age the foot posture of children ceases to develop further, as no two foot measures are comparable, therefore future research needs to consider the development of consensus recommendations as to the measurement of the paediatric foot, using valid and reliable assessment tools.
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NewsBot · Mar 4, 2018

Flexible flatfoot of 6-13-year-old children: A cross-sectional study.
Yin J et al
J Orthop Sci. 2018 Feb 27. pii: S0949-2658(18)30046-0. doi: 10.1016/j.jos.2018.02.004.

BACKGROUND:
This cross-sectional study aims to investigate the flexible flatfoot (FFF) prevalence and related factors in school-aged children.

METHODS:
A total of 1059 children aged 6-13 years were included. Dynamic footprints according to the FootScan system were collected from both feet. The relationship of FFF with age, gender, side, and body mass index (BMI) was investigated.

RESULTS:
FFF percentage decreased from 39.5% at 6 years to 11.8% at 12 years and reached a plateau at 12-13 years. Overweight (OR 1.35, 95%CI 1.03-1.77, P = 0.03) and obese (OR 2.43, 95%CI 1.81-3.26, P＜0.01) showed a positive correlation with percentage of FFF children. No correlation was found between FFF prevalence and gender or side.

CONCLUSIONS:
FFF prevalence decreases with age and reaches a plateau at 12-13 years. Moreover, FFF prevalence is positively correlated with increased BMI and body height.
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Admin2 · Mar 6, 2018

Related Threads:
All the other threads on paediatric flatfoot

NewsBot · Mar 26, 2018

Foot posture development in children aged 5 to11 years: a three-year prospective study.
Alfonso Martínez-Nova et al
Gait & Posture; 26 March 2018

Highlights
•The supinated foot is not very common, but does not change over the time
•A pronated foot FPI can be expected in children aged less than 9-10 years
•Children’s foot posture shifts toward neutral as age increases
•Height, weight or BMI are not an important determinants of paediatric foot posture
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Background
The paediatric flatfoot is a common presentation but it is unclear whether the condition will resolve on its own as the child gets older or whether treatment is required. Therefore, the study objective was to evaluate paediatric foot posture, and anthropometry, in children at two time points, three years apart.

Material and methods
A sample of 1032 healthy children (505 boys, 527 girls; aged 5–11 years) was recruited for foot posture index (FPI) and anthropometry assessment (weight, height and body mass index, BMI). Assessment was repeated when the children were aged 8 years to 14 years. Paired t-tests, Anova, frequency tables and a multiple regressions were conducted.

Results
Initially, approximately 70% had a neutral FPI range, 20% pronated, 3% highly pronated, and 4% supinated. Initial mean FPI was 3.6 ± 2.8, being higher in boys 3.7 ± 2.8 than in girls 3.4 ± 2.7 (p = 0.034). All FPI categories changed over time, with supinated and neutral FPI increased by 19.5% and 4.7% respectively. In contrast, pronated and highly pronated FPI reduced by 10.6% and 55.6% respectively. Regression showed only 1% FPI change was explained by increased height. FPI scores were significantly reduced after three years (3.57 to 3.33; p < 0.001).

Conclusion
Children’s foot posture shifts toward neutral as age increases. There is minimal relationship with weight, height or BMI. Appreciation of developing foot posture could reduce over diagnosis and unnecessary treatment of paediatric flatfeet.
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NewsBot · May 26, 2021

The typically developing pediatric foot - The data of the 1744 children in China
Jiawei Wang et al
Foot Ankle Surg. 2021 Apr 20

Background: The medial longitudinal arch (MLA) improves with age in childhood. However, it still causes parents to worry that children have flat feet. Due to the lack of a standard to quantitatively assess the arch development in kids at certain age, the pediatricians judge the flat feet by experience, causing many cases to be overtreated. The aim of this study was to plot the distribution of MLA parameters in children.

Methods: Children without lower limb deformity and lower limb pain were recruited from 12 primary schools and kindergartens in Chongqing province-level city. Foot length (FL) and navicular height (NH) was measured manually, arch index (AI) and arch volume (AV) were measured with the Foot Plantar Scanner. Each parameter was measured in both weight-bearing and non-weight-bearing positions. Significant differences were also compared between the measurements of consecutive years.

Results: This study was the first to use a three-dimensional laser surface scanner to measure the MLA parameters of children aged 3-12 years in China. 1744 children (871 girls, 873 boys) participated in this study. FL, NH, AI and AV varied significantly with age in both the weight-bearing and non-weight-bearing positions. These parameters have significant differences between the weighted and non-weighted positions (p < 0.05).

Conclusions: The age distribution characteristics of these parameters indicated that the MLA improves with age. The establishment of a developmental scale for the children's MLA is necessary.
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NewsBot · Aug 29, 2021

Analysis of factors influencing improvement of idiopathic flatfoot
Byung-Joon Shin et al
Medicine (Baltimore). 2021 Aug 13

Idiopathic flatfoot is common in infants and children, and patients with this condition are frequently referred to pediatric orthopedic clinics. Flatfoot is a physiologic process, and that the arch of the foot elevates spontaneously in most children during the first decade of life. To achieve a consensus as the rate of spontaneous improvement of flatfoot, the present study aimed to estimate the rate of spontaneous improvement of flatfoot and to analyze correlating factors.We reviewed the records of patients examined between May 2013 and May 2019 so as to identify those factors associated with idiopathic flatfoot below 12 years of age. We included patients with who had been followed for >6 months, and those for whom ≥2 (anteroposterior and lateral) weight-bearing bilateral radiographs of the foot had been obtained. The progression rates of the anteroposterior (AP) talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle, and calcaneal pitch angle were adjusted by multiple factors using a linear mixed model, with sex, body mass index, and Achilles tendon contracture as the fixed effects and age and each subject as the random effects.We found that 4 of the radiographic measurements improved as patients grew older. The AP talo-first metatarsal angle, talonavicular coverage angle, and the lateral talo-first metatarsal angle decreased, while the calcaneal pitch angle increased. The AP talo-first metatarsal angle (P < .001), talonavicular coverage angle (P < .001), and lateral talo-first metatarsal angle (P < .001) improved significantly; however, the calcaneal pitch angle (P = .367) did not show any significant difference. In general, the flatfeet showed an improving trend; after analyzing the factors, no sex difference was observed (P = .117), while body mass index (P < .001) and Achilles tendon contracture (P < .001) showed a negative correlation.The study demonstrated that children's flatfeet spontaneously improved at the age of 12 years. It would be more beneficial if the clinician shows the predicted appearance of the foot at the completion of growth by calculating the radiographic indices and identifying the correlating factors in addition to explaining that flatfoot may gradually improve. This will prevent unnecessary medical expenses and the psychological adverse effects to the children caused by unnecessary treatment.
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NewsBot · Nov 9, 2021

Would foot arch development in children characterize a body maturation process? a prospective longitudinal study
Chia-Hsieh Chang et al
Biomed J. 2021 Nov 1;S2319-4170(21)00147-5

Background: Flatfoot (Pes Planus), often regarded as a physiological deviation in children, is of concern to parents because there is no test to predict the development of foot arch. This study aimed to use a new diagnostic flatfoot criterion to determine 1) how the footprint index changes during the development of foot arches, 2) what factors can predict a foot arch development, and 3) whether foot arch development could be a process of body growth.

Materials and methods: 572 children were enrolled in a prospective longitudinal study of anthropometrical parameters and physical fitness twice at age of 6.7 and 8.2 years. The bimodal frequency distribution of the Chippaux-Smirak index (CSI) of the footprint was used to define flatfoot as CSI <0.58 and non-flatfoot as CSI >0.61. Body measurements and physical fitness tests were compared between children with flatfeet who developed foot arches and children who did not.

Results: Of 263 children with flatfeet, the CSI significantly changed from 0.72 to 0.46 in 70 children who developed foot arches over 1.5 years and the others had minimal change in the index. Children with foot arch development had a lower initial CSI, improved boys' performance in one-leg balance, and less increase in girls' body height than children who remained flatfooted, whereas sex and weight were similar in both groups.

Conclusion: This longitudinal study with the bimodal distribution of the CSI investigated how the development of foot arch advances in children around age 7. A significant and unique pattern in change of the CSI suggests involvement of a maturational stage in foot arch development. Along with the improved performance in one-leg balance, the unidirectional transition from flatfoot to non-flatfoot is associated with improvement in motor control of the ankle.
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NewsBot · Jan 8, 2024

Distribution of plantar pressures under static conditions, in various areas of the pediatric flatfoot in sensitive period of development – pilot study
Elena Adelina Panaet et al
Source

(1) Background: Flatfoot can alter the foot's ability to uniformly distribute the body weight on the plantar areas, possibly leading to biomechanical imbalances in the entire body. The purpose of the study was to determine the correlation between flatfoot and plantar pressure distribution in static conditions. (2) Material and methods: The study included a group of 23 children with flat feet (7.43±0.58 years old), which analyzed the correlations between the Foot Posture Index 6 (FPI 6) values and the plantar pressure distribution values. The instruments used were the Foot Posture Index 6 (FPI 6- a quantitative anatomical assessment under static conditions) and the Podata (device for recording images in real time of the body weight distribution on the plantar support). (3) Results: The statistical results have indicated significant correlations of strong intensity between the flat foot and the plantar pressure distribution in the midfoot, but also that the flatfoot significantly influences the values of the plantar pressure distribution in the midfoot. (4) Conclusion: The data showed that flatfeet influence the values of the plantar pressure distribution in the mid-area of the sole.
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NewsBot · Sep 9, 2024

Predictors of flatfoot in 11-12-year olds: a longitudinal cohort study
Tomoko Yamashita et al
Biomed Eng Online. 2024 Aug 21;23(1):83

Background: The structures around the navicular bones, which constitute the medial longitudinal arch, develop by 10 years of age. While navicular bone height is often emphasized in the assessment of flatfoot, three-dimensional (3D) evaluations, including those of structural parameters during inversion, have rarely been investigated. If the development of flatfoot during the growth process could be predicted, appropriate interventions could be implemented. Therefore, in this longitudinal cohort study, we developed a system, utilizing smartphones, to measure the 3D structure of the foot, performed a longitudinal analysis of changes in midfoot structures in 124 children aged 9-12 years, and identified factors influencing the height of the navicular bone. The foot skeletal structure was measured using a 3D system.

Results: Over 2 years, foot length and instep height increased during development, while navicular height decreased. The 25th percentile of the instep height ratio and navicular height ratio at ages 9-10 years did not exceed those at ages 11-12 years, with percentages of 17.9% and 71.6%, respectively, for boys, and 15.8% and 49.1%, respectively, for girls. As the quartiles of the second toe-heel-navicular angle (SHN angle) increased at ages 9-10 years, the axis of the bone distance (ABD) and SHN angles at ages 11-12 years also increased, resulting in a decrease in the navicular height ratio. A significant inverse correlation was found between changes in SHN angle and navicular height ratio. These findings indicate that the navicular bone rotation of the midfoot is a predictor of the descent of the navicular bone.

Conclusions: This study revealed that some children exhibit decreases in navicular bone height with growth. As a distinct feature, the inversion of the navicular bone promotes flattening of the midfoot. Thus, this study provides insights into changes in midfoot development in children and provides an effective evaluation index.
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NewsBot · Nov 21, 2024

Valgus deformity of the distal tibia in children and adolescents with idiopathic flatfoot: can it be predicted using 3D movement analysis?
Chakravarthy Ughandar Dussa et al
Gait & Posture 20 November 2024

Highlights
•Distal tibial valgus deformity was found in 42% of idiopathic flatfoot cases.
•The tibio-calcaneal angle during standing (STCA) was the best predictor but only explained 9% of the variance.
•The standing and gait analysis data does not provide any indication of an underlying distal tibial valgus deformity.
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Background
Distal tibial valgus deformity, though common in various medical conditions, has not been extensively studied in idiopathic flatfoot. It clinically presents as hindfoot valgus, mimicking flatfoot deformity, and requires X-rays for detection. Severity is quantified using resting calcaneal angle and standing tibio-calcaneal angles (STCA), but their prognostic value for identifying distal tibial valgus deformity remains unclear. The use of routine invasive radiographs in idiopathic flatfoot is controversial as instrumented non-invasive gait analysis gains popularity for investigative purposes.
Research Question
This study aimed to determine the prevalence of distal tibial valgus deformity in children and adolescents with idiopathic flatfoot using radiography and to identify parameters assessed during standing or walking that predict this deformity.
Methods
A retrospective study included outpatients aged 7-17 years with idiopathic flatfeet. Participants underwent clinical examination, foot and ankle X-rays, and instrumented 3-dimensional gait analysis. A lateral distal tibia angle (LDTA) < 86° indicated valgus deformity, with LDTA 86-92° considered normal. Two groups were analysed: ankle valgus (LDTA < 86°) and normal ankle (86-92°). STCA, ankle tilt, intermalleolar height difference (IMHD), and eight kinematic parameters were correlated with LDTA.
Results
The study included 136 patients (mean age 11.5 years, SD=2.2). Sixty-three patients had ankle valgus (LDTA 83.8°, SD=1.7°), and 73 had normal ankles (LDTA 88.8°, SD=1.3°), showing a significant difference between groups (p < 0.001). STCA during standing was the best predictor, though it explained only 9% of variance, limiting robust prediction.
Significance
The prevalence of distal tibial valgus deformity was 42% in idiopathic flatfoot cases, highlighting the necessity for routine ankle radiographs due to the inability to clinically suspect this deformity. Further studies should explore the biomechanical effects and their clinical implications for management.
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NewsBot · May 24, 2025

Do gait patterns normalize concurrently with the recovery of foot arches in children with flatfoot? A prospective cohort study
Yihong Zhao et al
Journal of Biomechanics; Volume 187, June 2025, 112758

Flexible flatfoot in childhood usually undergoes a spontaneous return to normal. However, during this process, it remains unclear whether the gait pattern will be adjusted concurrently and the mechanism of such adjustment. We investigated the mechanism underlying the change in gait patterns in children after the natural recovery of flat feet through a two-year follow-up study, from the perspectives of plantar loading and gait stability. A total of 15 flatfoot children in the recovery group and 17 typically developed children in the control group were included after extensive sample screening. Three data acquisitions of plantar pressure and Center Of Pressure (COP) were performed every 12 months using a Footscan® pressure plate. Independent t-tests and statistical parametric mapping analysis were used to explore differences between the recovery and control groups at each measurement. At baseline, the recovery group showed higher midfoot loading and a more laterally shifted COP. At the 12-month point, the recovery group manifested a significantly lower load ratio but higher standardized maximum force at the lateral forefoot. At the 24-month point, the recovery group changed to show a considerably higher load ratio under the second metatarsal head, accompanied by a more lateral and posterior COP displacement at the late stance phase. During the recovery of flexible flatfoot morphology in childhood, gait patterns eventually show significant improvement while exhibiting different characteristics at various stages. This study reveals the biomechanical adaptations following the natural recovery of flatfoot in children, contributing to a comprehensive understanding of the impact of pediatric flatfoot.
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NewsBot · Jun 4, 2025

Impact of body weight and age on plantar pressure in typically developing children: Normative data and methodological considerations
Anika Behrendt et al
J Child Orthop. 2025 May 31:18632521251335875.

Purpose: Pedobarography is frequently employed for the identification and characterisation of foot pathologies in paediatrics. However, the lack of standardised normalisation methods presents a challenge for cross-age comparisons. This cross-sectional study provides normative plantar pressure data for typically developing children aged 4-17 years and compares normalisations and explanatory powers of parameters measuring peak and total load.

Methods: Dynamic foot pressure of 101 typically developing children aged 4-17 years was measured at self-selected speed using the mid-gait protocol. They were divided into five age groups: 4-6, 7-8, 9-11, 12-14 and 15-17 years old. Force and pressure variables measuring peak and total load were normalised by body weight or scaled by maximum value and the foot region where the peak pressure occurred was identified.

Results: The absolute values demonstrated an increase in load with advancing age. In contrast, when normalised to body weight, peak pressure and pressure time integrals decreased. The scaled peak pressure showed a load shift to the forefoot. The results indicate that the normalised parameters exhibit superior qualitative significance, suggesting a more dynamic gait pattern and improved morphology of the foot in relation to body weight with increasing age.

Conclusions: This study shows that standardisation of the measurement protocol is imperative because results in typically developing children can vary depending up parameter selection and normalisation technique.
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NewsBot · Jun 4, 2025

Impact of body weight and age on plantar pressure in typically developing children: Normative data and methodological considerations
Anika Behrendt et al
J Child Orthop. 2025 May 31:18632521251335875.

Purpose: Pedobarography is frequently employed for the identification and characterisation of foot pathologies in paediatrics. However, the lack of standardised normalisation methods presents a challenge for cross-age comparisons. This cross-sectional study provides normative plantar pressure data for typically developing children aged 4-17 years and compares normalisations and explanatory powers of parameters measuring peak and total load.

Methods: Dynamic foot pressure of 101 typically developing children aged 4-17 years was measured at self-selected speed using the mid-gait protocol. They were divided into five age groups: 4-6, 7-8, 9-11, 12-14 and 15-17 years old. Force and pressure variables measuring peak and total load were normalised by body weight or scaled by maximum value and the foot region where the peak pressure occurred was identified.

Results: The absolute values demonstrated an increase in load with advancing age. In contrast, when normalised to body weight, peak pressure and pressure time integrals decreased. The scaled peak pressure showed a load shift to the forefoot. The results indicate that the normalised parameters exhibit superior qualitative significance, suggesting a more dynamic gait pattern and improved morphology of the foot in relation to body weight with increasing age.

Conclusions: This study shows that standardisation of the measurement protocol is imperative because results in typically developing children can vary depending up parameter selection and normalisation technique.
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NewsBot · Jun 5, 2025

Analysis of centre of pressure trajectories and plantar pressure distribution to map development of foot-ground interactions from new to confident walking infants
Eleonora Montagnani et al
PLoS One. 2025 Apr 16;20(4):e0321632

Independent walking is a crucial milestone, allowing infants to explore their environment efficiently. This phase introduces complex foot-ground interactions. However, previous studies have focused on either center of pressure (CoP) or plantar pressure distribution alone, often losing critical information. The impact of variables like body weight, height, and foot size on pressure distribution in infants remains also underexplored. Our study uses continuous statistical approaches to comprehensively analyze anterior-posterior (AP) and medio-lateral (ML) trajectories of CoP and plantar pressure distribution in infancy, mapping foot-ground interactions from new to confident walking stages. Thirty-nine infants walked across an EMED xl platform as new and then confident walkers. Frames of pressure steps were exported and processed in Matlab 2019b. Upon data normality assessment, AP and ML trajectories of new and confident walking steps were compared with parametric two-sample paired SPM1d t-test. Plantar pressure distribution between new and confident walking were compared using the nonparametric two-sample paired SPM1d t-test. Nonparametric linear regression analysis at pixel-level considered variables like body weight, height, foot dimensions, and walking experience, ensuring only non-correlated items were included. Our analyses revealed significant changes in CoP and plantar pressure distribution from new to confident walkers. New walkers initially contact the ground with the central part of their foot, while confident walkers show a more posterior initial contact. Confident walkers also exhibit more medial heel contact and a progression of CoP trajectories closer to the foot's longitudinal axis. Regression analysis indicated that increasing walking experience significantly predicts higher pressure in the lateral and central forefoot. These findings underscore the importance of combining multi-segment joint analysis with plantar pressure data to fully understand foot development during infancy. This project highlighted key aspects of the unique biomechanics of infants' foot development, emphasizing the need for further research to enhance understanding and inform clinical practices.
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NewsBot · Jun 5, 2025

Analysis of centre of pressure trajectories and plantar pressure distribution to map development of foot-ground interactions from new to confident walking infants
Eleonora Montagnani et al
PLoS One. 2025 Apr 16;20(4):e0321632

Independent walking is a crucial milestone, allowing infants to explore their environment efficiently. This phase introduces complex foot-ground interactions. However, previous studies have focused on either center of pressure (CoP) or plantar pressure distribution alone, often losing critical information. The impact of variables like body weight, height, and foot size on pressure distribution in infants remains also underexplored. Our study uses continuous statistical approaches to comprehensively analyze anterior-posterior (AP) and medio-lateral (ML) trajectories of CoP and plantar pressure distribution in infancy, mapping foot-ground interactions from new to confident walking stages. Thirty-nine infants walked across an EMED xl platform as new and then confident walkers. Frames of pressure steps were exported and processed in Matlab 2019b. Upon data normality assessment, AP and ML trajectories of new and confident walking steps were compared with parametric two-sample paired SPM1d t-test. Plantar pressure distribution between new and confident walking were compared using the nonparametric two-sample paired SPM1d t-test. Nonparametric linear regression analysis at pixel-level considered variables like body weight, height, foot dimensions, and walking experience, ensuring only non-correlated items were included. Our analyses revealed significant changes in CoP and plantar pressure distribution from new to confident walkers. New walkers initially contact the ground with the central part of their foot, while confident walkers show a more posterior initial contact. Confident walkers also exhibit more medial heel contact and a progression of CoP trajectories closer to the foot's longitudinal axis. Regression analysis indicated that increasing walking experience significantly predicts higher pressure in the lateral and central forefoot. These findings underscore the importance of combining multi-segment joint analysis with plantar pressure data to fully understand foot development during infancy. This project highlighted key aspects of the unique biomechanics of infants' foot development, emphasizing the need for further research to enhance understanding and inform clinical practices.
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The typically developing paediatric foot: how flat should it be?

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Palliative care needs in people with or at risk of developing diabetic foot ulcers

Do you have a bunion? Developing shoe to help.

DX with high arch & developing a callus

Cubans developing therapy for diabetic ulcers

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