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Am Fam Physician. 2023;107(3):232-233

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Clinical Question

Does treatment with customized or prefabricated foot orthoses improve pain, function, or quality-of-life scores in children with flat feet (pes planus)?

Evidence-Based Answer

Customized or prefabricated foot orthoses do not result in significant improvements in pain, function, or parent and child quality-of-life scores. Importantly, quality-of-life scores were not reported in patients who were asymptomatic. There is a need for further targeted studies to identify the clinical utility of foot orthoses in children with flat feet that are associated with underlying conditions; however, asymptomatic flat feet in children should not be routinely treated.1 (Strength of Recommendation: C, consensus, disease-oriented evidence, usual practice, expert opinion, or case series.)

Practice Pointers

Flatfoot is a common condition estimated to affect 44% to 70% of children three to six years of age.1 Historically, foot orthoses have been suggested as treatment to promote postural stability and efficient gait function. However, recent data suggest that the use of foot orthoses in childhood flatfoot may not be necessary.2,3 Flat feet develop as a child ages and usually self-correct without the need for intervention.4 This Cochrane review evaluated whether customized or prefabricated foot orthoses provided benefits to children with flat feet in patient-reported pain levels, functional status, or parent and child quality-of-life scores.

The Cochrane review included 16 trials with a total of 1,058 participants ranging from 11 months to 19 years of age, all with flexible flat feet. The trials were conducted in outpatient clinics in nine countries (Australia, United States, United Kingdom, Iran, Egypt, Turkey, Republic of Korea, India, and Taiwan). The authors included studies that evaluated one of several major outcomes, including pain measures, gait and function assessment, and health-related quality-of-life scores. Trials that included validated outcome measures in which multiple measures were evaluated were preferentially included. Several well-validated childhood pain scales assessed pain outcomes and provided objective measures, such as functional data scales, including the Foot Function Index, timed walking, timed up and go test, six-minute walk test, and vertical jump height. The Pediatric Quality of Life Inventory assessed child- and parent-rated quality of life.

Patients who experienced little pain at the beginning of the trial showed little improvement in pain scores. Custom and prefabricated foot orthoses, compared with each other and with shoes, resulted in little to no reduction in the proportion of children reporting pain. There were no statistically significant benefits, and all included studies were considered low to very low quality on the GRADE scale.

Some improvements were noted when children with symptoms, specifically those with juvenile idiopathic arthritis, were included in the studies. In these patients, customized foot orthoses compared with shoes resulted in a small improvement in clinical function and child- and parent-rated quality of life. Prefabricated foot orthoses compared with shoes showed no significant change in these outcomes. When comparing customized foot orthoses with prefabricated foot orthoses, there were no differences in improvement in pain or function.

None of the trials were at low risk of bias; many trials were at risk for selection, performance, detection, and selective reporting biases. The review authors further downgraded the data due to small sample size and small effects across scaled outcome measures. The authors of this Cochrane review encourage further research but only in relevant childhood foot conditions that cause symptoms.

Current practice guidelines from the American Academy of Family Physicians and the American Academy of Pediatrics suggest that painless childhood flat feet, which are flexible in nature, should be monitored without the need for intervention.5,6 There is no routine recommendation if the condition is symptomatic; however, both organizations mention the limited data to support the use of foot orthoses to modify symptom burden. Family physicians should carefully consider the need for intervention in childhood flat feet on a case-by-case basis.

The practice recommendations in this activity are available at

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These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, assistant medical editor.

A collection of Cochrane for Clinicians published in AFP is available at

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