Initial pre-referral workup

Clinical history

Most children under age three have flat feet.

Ask if the child has pain in their feet.

Physical examination

Ask the child to stand on tip toes. If the arch corrects, the foot is flexible and requires no treatment. 

Alternatively, if an arch can be seen in a non-weight-bearing position, such as sitting, the foot is flexible and requires no treatment.

Investigations

For rigid flatfoot only:

• weight-bearing x-ray (AP, lateral and oblique)

GP management

Reassure parents that most children develop an arch by age six.

The vast majority of patients with flexible flatfoot do not require orthopaedic referral.

Painless, flexible, flat feet require no treatment. Orthotics do not help form an arch and are not recommended.

Refer parents to the Flat feet in children (fact sheet).

Indications for specialist referral

Routine referral

• rigid flatfoot (arch does not reform on tip toe test or in non-weight-bearing)
• painful flatfoot asymmetry
• localised tenderness
• difficulty in functional activities such as running and jumping