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Flexible flat feet clinic guidelines ‐ orthopaedic practice

Approved By: Allison Duey‐Holtz, MSN, APNP August 2, 2017

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Foot with low or absent longitudinal arch in weight-bearing conditions


Signs and symptoms

  • Anatomic characteristics: Excessive eversion of the subtalar complex during weight bearing with plantarflexion of the talus, plantarflexion of the calcaneus in relation to the tibia, a dorsiflexed and abducted navicular, and a supinated forefoot
  • Can present at any age
  • Equally prevalent in males vs. females


  • Infants are born with flexible flatfeet, and the normal arch develops in the first decade of life
  • Flat feet are normal and usual in infants, common in children, and are often present in adults with a decreasing prevalence with increasing age.

Referring provider’s initial evaluation and management:


Differential Diagnosis

  • Vertical/oblique talus
  • Tarsal coalition
  • Accessory navicular
  • Posterior tibial tendonitis
  • Overcorrected clubfoot
  • Tight Achilles
  • Calcaneovalgus
  • Peroneal spasms
  • Peroneal spasms

Diagnostic Tests

  • Radiographs
    • If rigid, painful, or asymmetrical
    • AP foot, lateral plantar flexion/dorsi flexion

When to initiate referral/ consider refer to Orthopedic Clinic:


  • Developmental variant
  • Provide parental education: most flexible flat feet resolve spontaneously and do not cause disability in adults, observation and time are the only treatments necessary (1,2,3)


  • PT for 6-8 weeks
  • +/-Orthotics
  • Referral if fail PT
  • XR Imaging for rigid or painful foot
    • For patients under 10, otherwise healthy and without symptoms-Well Child Lower Extremity For patients with symptoms/pain General Orthopaedic Clinic
    • Patients with underlying neuromuscular condition or a rigid foot should be seen by MD in General Orthopaedic clinic
    • Sports related symptoms may be seen in Sports Clinic

What can referring provider send to Orthopedic Clinic?

1. Using Epic

  • Please complete the external referral order

In order to help triage our patients and maximize the visit, the following information would be helpful to include with your referral order:

  • Urgency of the referral
  • What is the key question you would like answered?

Note: Our office will call to schedule the appointment with the patient.

2. Not using Epic external referral order:

  • In order to help triage our patients and maximize the visit time, please fax the above information to (414) 607-5288
  • It would also be helpful to include:
  • Chief complaint, onset, frequency
  • Recent progress notes
  • Labs and imaging results
  • Other diagnoses
  • Office notes with medications tried/failed in the past and any lab work that may have been obtained regarding this patient’s problems

Treatment and Drugs

Symptom management may include physical therapy, arch supports. Imaging will be done based upon exam & symptoms present.

Specialist’s workup will likely include:

After referral to Ortho Clinic:

Physical exam including:

  • Gait analysis (if pertinent)
  • Rotational profile
  • Musculoskeletal exam
  • Images only if needed

Evidenced Based Literature Review

Cappello, T. & Song, K.M. (1998). Determining treatment of flatfeet in children. Current Opinion in Pediatrics. 10, 77-81.

Garcia-Rodriguez, A., Martin-Jimenez, F., Carnero-Varo, M., Gomez-Gracia, E., Gomez-Araena, J., & Fernandez-Crehuet, J. (1999). Flexible flat feet in children: A real problem? Pediatrics. 103(6), 84-86.

Herring, J. A. (2008). Disorders of the foot. In M.O. Tachdjian & J.A. Herring (Eds), Tachdjian’s Pediatric Orthopedics (4th Ed) (pp.1035-1186). Philadelphia: Saunders Elsevier.

Staheli, L.T., Chew, D.E., & Corbett, M. (1987). The longitudinal arch. A survey of eight hundred and eighty-two feet in normal children and adults. Journal of Bone & Joint Surgery. 69, 426-428.

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