The flat feet – A balancing act for the feet
From harmless flat feet in children to a painful problem in adulthood
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If flat feet do not simply “grow out” during childhood, they can severely restrict mobility and quality of life. Andrea Knichel, Leading Senior Physician for Foot and Ankle Surgery and Pediatric Orthopedics at the Sportklinik Hellersen, explains what parents should look out for — and what modern treatment options are available for both children and adults.
What is flatfoot in children and what are the first symptoms?
Andrea Knichel: Flat feet appear in children when they start walking and are completely normal, as the muscles that support the arch of the foot first have to get used to the strain. In addition, during the first few months of walking, the arch of the foot is flat due to the thick layer of fat under the longitudinal arch. With increasing age and strengthening of the muscles, the foot straightens and the fat pad reduces.
A permanent flat foot can only be observed until the end of foot growth (at around 12 years of age for girls and 14 years of age for boys). The inner ankle protrudes prominently, the foot is clearly tilted inward at the ankle joint, and the shoes are worn asymmetrically on the inside. In childhood, there is usually no pain — complaints often only arise when footwear exerts uncomfortable pressure on the foot. Children with muscle weakness or motor impairments are particularly affected.
And what are the signs and symptoms in adulthood?
Andrea Knichel: Adults suffer from stress-related pain in the midfoot and rearfoot. This can limit both running and sports activities as well as the ability to work.
An acquired flat foot is caused by increasing weakness or injury to a tendon on the inside of the foot. The load is no longer absorbed by the supporting joint structures and ligaments. With age, the elasticity and stability of the soft tissue structures decrease. This is followed by an increasingly painful misalignment with a lowering of the longitudinal arch of the foot and inward buckling of the ankle joint. Sometimes the changes begin painlessly, e.g., in diabetics or rheumatism patients.
In the case of congenital or childhood flat feet, pain often occurs in adulthood without any specific triggering event. This develops gradually and becomes more pronounced between the ages of 30 and 40.
Video: What parents should know: flat feet in children
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What role do external factors play?
Andrea Knichel: Lack of exercise in childhood and childhood obesity play a decisive role. The choice of shoes is also crucial: shoes should always fit perfectly and should never be too small. This is especially important for children's feet, which are still growing, which is why feet should be measured regularly when buying shoes. Good rearfoot support and a solid footbed are recommended.
However, the best training for the feet is still walking barefoot. This trains the foot muscles and activates the sensorimotor system for stable foot positioning. The right choice of shoes is just as important for adults. Being overweight and a lack of exercise can also literally “flatten” the foot.
How is flat feet diagnosed in adults and children?
Andrea Knichel: Flat feet are diagnosed in both children and adults through a thorough examination. The foot is assessed barefoot while standing and walking. In addition, the toe gait is tested to distinguish between fixed deformities or deformities caused by torn tendon structures and deformities that are still flexible. Fixed deformities in children can be attributed to congenital bone connections in the foot, while in adults they are often due to advanced osteoarthritis in the midfoot or rearfoot area. In such cases, individually tailored treatment with or without surgery is required.
In addition to a physical examination, children also require X-ray diagnostics to assess the bone structure and remaining foot growth. Adults also undergo an X-ray examination to determine the extent of the misalignment and possible signs of joint wear. In addition, MRI is an important diagnostic tool for assessing soft tissue structures such as tendons and capsules — especially on the inside of the foot — as well as bone quality and possible overload reactions. This information is crucial for choosing the right individualized therapy.
What treatment options are available for flat feet in children?
Andrea Knichel: In most cases, the treatment of flat feet in children begins with conservative measures. In the case of flexible flat feet, the focus is on strengthening the foot muscles. Walking barefoot is particularly effective, as it trains the muscles and improves sensory control of the foot at the same time. In addition, physiotherapy can help to improve foot position in cases of limited mobility or shortened calf muscles. The cooperation of parents is crucial here, as the exercises must be repeated regularly at home in order to achieve improvement. Simple everyday play also challenges and trains the whole body.
Shoe insoles are not necessary for children with normal muscular and motor development and flexible flat feet. They are only fitted if pressure points or pain develop in the shoe. This does not steer foot growth in the “right” direction. Children with hypermobile joints or who suffer from muscle weakness, on the other hand, need supportive shoe inserts or foot orthoses.
Video: Flat feet in adults: recognizing symptoms and taking the right action
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When is surgery necessary for children?
Andrea Knichel: Surgical treatment is usually only considered if the deformity is pronounced or if pain occurs. The ideal time is two years before the foot has finished growing (usually at age 9 for girls and age 10 for boys). The aim of such an operation is to take advantage of the remaining growth of the feet for correction. To do this, a minimal procedure is performed on the foot to prevent it from bending inward. The procedure keeps the foot in the correct position around the clock so that it can grow in the desired direction.
This method, called arthrorise, is effective and sustainable because the foot grows 24 hours a day, which is the only way to achieve a permanent correction. Shoe inserts cannot achieve this because they are only worn for a limited time each day. Growth guidance in childhood can have a major impact on the future with very little effort.
What treatment options are available for flat feet in adulthood?
Andrea Knichel: Corrections of flat feet in adulthood are usually very extensive and require a long treatment period. Treatment requires a stage-appropriate approach, as the severity of the deformity and the condition of the tendons, joints, and bones can vary. In the early stages, when the tendon (posterior tibial tendon) is not yet torn, conservative measures are the primary focus. Pain and swelling often occur during weight-bearing activities, but the foot has not yet dropped. First, the tendon is relieved with supportive shoe inserts so that it can recover. Targeted strengthening exercises are then necessary to prevent recurrence.
In the more advanced stages, when structural changes to the tendons or joints are already present, the therapy must be individually tailored. If the misalignment is flexible and caused solely by a tendon defect, a joint-preserving procedure can be performed. This involves replacing the damaged tendon with a healthy one. In addition, correction of the heel position is necessary to improve the statics of the foot. However, if there is osteoarthritis, pronounced joint wear, in the affected joints, correction of the misalignment by stiffening the lower ankle joint is necessary.
"Flat feet can be prevented in both children and adults through targeted measures."
Andrea Knichel
Leading Senior Physican of Foot and Ankle Surgery and Pediatric Orthopedics
Are there alternatives to surgery?
Andrea Knichel: For patients for whom surgery involves high risks, a custom-made orthopedic shoe is the most sensible option. This is made to measure based on a plaster cast or laser measurement. It cushions and supports the foot and ankle joint in the position dictated by the foot, thus reducing pain caused by overload and pressure points.
Both joint-preserving and joint-sacrificing surgeries require intensive and lengthy follow-up treatment. However, if they heal properly, they enable mobility to be maintained and, ideally, freedom from pain in everyday life.
normal foot
flat foot
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How can flat feet be prevented?
Andrea Knichel: Both children and adults can prevent flat feet with targeted measures. It is particularly important for children to regularly train their muscles through play and sport. Walking barefoot outside in summer or wearing non-slip socks indoors is another important element that improves foot muscles, coordination, and sensorimotor skills. Maintaining a healthy body weight is also important, as being overweight puts excessive strain on the feet and impairs their development. Wearing the right shoes is essential: they should be regularly adjusted in length and width to accommodate foot growth and prevent the foot from slipping inside the shoe. Shoes with good cushioning insoles provide comfortable support for the foot; medical insoles should only be used in special cases.
Occasional barefoot walking and targeted exercises to strengthen the foot muscles can also help adult feet maintain their shape. When choosing shoes, a good fit is more important than fashion considerations.
