“The child’s foot is not just a smaller version of an adult’s foot”.
An illuminating thought by the English colleague Raymond J. Sullivan.

The child’s foot has its own physiological evolution and an entirely different pathology.

The Evolution

All of us were born with flat feet: it’s physiological!

As we grow up and learn to walk, having flat feet, thus a larger base of support, represents an evolutionary advantage not a disease. It will then be between the ages of 8 and 12 years that the children’s feet will gradually assume the appearance of a normal physiological adult’s foot.

The correct age for a first orthopaedic evaluation of the foot is between 6 and 8 years old, unless the paediatrician suggests an early visit.

At 2 years old: almost 100% of feet are flat. At 10 years old: 4% are still flat.

At 2 years old: almost 100% of feet are flat. At 10 years old: 4% are still flat.

We could face physiological phenomena both when a child walks with his feet pointing toward the inside and when they walk on tiptoe. However, in these cases it is useful to consult with an orthopaedic doctor.

A different path and early diagnosis are needed, instead, for children with foot deformities that are evident at birth. These diseases are characterised by deformities of different sized deformities which are classified under the name of clubfoot pathology and nowadays we can find bright solutions using less and less surgery, thanks to the Ponseti method.

Finally, different circumstances apply to patients with neurological deficits of a genetic nature (Charcot-Marie-Tooth disease) or disease outcomes such as polio, which have a devastating impact on the foot and ankle area.


Most of the time flat feet in the child is asymptomatic and the children are visited by an orthopaedist for different concomitant pathologies. Usually it is osteochondrosis (for example: Osgood-Schlatter’s disease, Haglund’s deformity), benign diseases that affect the nuclei of bone accretion (production “factories” of bone growth) that often have a spontaneous resolution as growing continues.

There may be some weak signals that are not related directly to flat feet, such as fatigue, cramps, and episodic lameness. The child rarely complains about pain inside the arch of foot, which may indicate suffering of the posterior tibial tendon.

Sometimes, flat feet can cause hallux valgus deformity, creating the so-called “juvenile hallux valgus.”


As anticipated, the right time for a first medical evaluation is between the ages of 6 and 8.

Talking to the child and his parents, observing the wear of his shoes and seeing him walk, are the four necessities witnesses to diagnose a pronator syndrome (flat feet). If necessary we will perform a weight-bearing X-ray of the foot, to study the evolution of the deformity.

Synostosis (bony bridges between joints, which painfully reduce movement) are instead deformities that require in-depth analysis through a CT scan of the hind foot..

Finally, patients with pes cavus from hereditary disorders, those with the Charcot-Marie-Tooth disease or children born with clubfoot may require different timings and imaging investigations.

Orthotics – The Conservative Treatment

The history of the treatment of flat feet in children is made of corrective orthotics and orthopaedics footwear.

Today it is scientifically proven that these protections have no therapeutic utility. Already in 1956 a study published in the Lancet (the most important scientific magazine) denied any effectiveness in orthotics with corrective purpose for the child.

The most effective therapy for a child with simple flat feet is good nutrition, a balanced life and the practice of a sport they like, which will permit the harmonious development of body and spirit.

However, it is important to get to a diagnosis of pathological flat feet within 8-9 years of life, not to preclude therapeutic possibilities offered by the minimally invasive surgery, feasible only in the development stage of the child.


If diagnosed, you can operate pathological flat feet of children ages 9 to 13.

Italy and Spain stand out in the field of paediatric surgical treatments, with the “calcaneus-stop” technique, about which I myself have published a study, and with the latest endorthesis.


Calcaneus-stop insertion of a screw in the calcaneus to create a

Calcaneus-stop insertion of a screw in the calcaneus to create a “stop” and prevent pronation of the foot.


With the “calcaneus-stop” a screw is inserted in the calcaneus, through a small incision in the side. This screw induces a corrective proprioceptive stimulus in the child’s foot; at a distance of time, after the implant, in most cases the removal of the prosthesis is required.

The evolution of this technique is represented by the endorthesis: the prosthesis implant (very similar to a small screw with a diameter of 8-9 mm) inside the tarsal sinus, between the calcaneus and the talus. It also has the aim of driving, through proprioceptive stimuli, the residual growth of the foot, obtaining progressively an effective correction.


Detail of a paediatric foot corrected with an endorthesis, a small prosthesis with a diameter of only 8 mm

Detail of a paediatric foot corrected with an endorthesis, a small prosthesis with a diameter of only 8 mm


Lateral radiographic of a foot corrected with an endorthesis: a small prosthesis (diameter 8 mm) inserted in a cavity 'already' present in the foot: the tarsal sinus

Lateral radiographic of a foot corrected with an endorthesis: a small prosthesis (diameter 8 mm) inserted in a cavity ‘already’ present in the foot: the tarsal sinus


Today, the most widespread small prostheses are made of titanium (inert material, which does not create reactions) and are no longer removed in 90% of cases.

In the rare cases in which the patient feels little discomfort during sport activities and in sudden changes of direction, you can remove them one year after the surgery without compromising the correction obtained.

It is an operation recommended up to the age limit of 15 years or so (based on the skeletal age of the patient); it is definitely not very invasive, especially when compared to possible corrections in older ages.


The young patient, accompanied by parents (of which is required joint consent for the operation), is called for the pre-admission. During this stage the child undergoes the last examination, the details of the operation are explained and we proceed with the usual anaesthetic evaluation.

Surgery is performed under general anaesthesia, as recommended for paediatric patients.

I usually opt for a bilateral operation to give the child a single anaesthesia and guarantee him, from the start, a symmetrical support. The total duration of the operation I perform is of an average 10 minutes.

My patients come out of the operating room with two absorbable stitches and a small rigid boot in fiberglass per side.

The child is generally admitted for one night and discharged the next day.

Back in the game

A frequent question is: “Why is it necessary to wear the small plaster boot after children’s foot surgery?”.

It is not a priority, but I think it is important to allow the patient to load and walk soon with confidence on both operated feet with greater stability and without pain.

After 15 days the two plaster casts are removed; they are often broken at that point for the weight of the little lively patients who should not be blamed for this but, on the contrary, encouraged to load on the two plaster casts.

Already after 3 days from surgery they can walk, accusing little pain, go back to school, with possible disappointment, thus avoiding prolonged absences. The important thing is not to make them go for long walks and receive excessive loads.

Already after 15 days, once the plaster casts have been removed, they can return to do sports in water, and after 45 days start running. For sports that involve a minimum of traumatic risk, recovery time can be up to to 4-6 months.