Foot analysis in children and adolescents: when is it relevant, and when is it not?

The foot normally has an arch along its length and across the forefoot. With flat foot the arches are reduced or absent. NHI describes that small children normally have some degree of flat foot until they are about 3 to 4 years old, and that this usually disappears with growth [1]. The Journal of the Norwegian Medical Association writes that flexible flat foot is common in small children, that the majority develop a normal arch before the age of 10, and that most have no symptoms [3].

The fat pad under small children's feet can be mistaken for flat foot [2].

Flat foot is identified by looking at the feet and at whether the inner arch drops when the foot is loaded. With flexible flat foot the foot regains a normal shape when unloaded, for example when standing on tiptoe. With rigid flat foot the foot is flat even without load [1].

Lægehåndbogen describes that the foot is examined both standing and sitting, that the heel-rise test and Jack's test are used to assess flexibility, and that the length of the Achilles tendon can be tested. X-ray is relevant with a specialist when rigid flat foot is suspected [2]. NHI writes that X-ray is not necessary except for rigid flat foot with pain [1].

At our clinic, chiropractor Truls Ottesen performs foot analysis and insole fitting for both children and adults.

Some children have a sore foot, widespread tenderness and tire quickly during physical activity. If rigid flat foot has been ruled out, supportive insoles can be used as symptom-relieving treatment [3]. In older children and adolescents, uneven loading can cause pain at the front of the lower leg or in the knees, and the shoes are often worn unevenly, especially on the inside [1].

Lægehåndbogen mentions pain and swelling along the inner side of the foot as possible symptoms in children with flat foot, and that one should ask about pain at rest and when walking [2]. Heel pain in active children can have other causes, for example Sever's disease, which is caused by irritation of the growth plate at the back of the heel bone [6].

Children without symptoms are not treated. Lægehåndbogen recommends walking barefoot, weight control and physical activity [2]. NHI writes that the vast majority do not need treatment, and that treatment is only relevant when flat foot causes symptoms [1]. The Journal of the Norwegian Medical Association writes that there is no evidence that children with flat foot need special shoes or insoles, and that the children can wear the type of shoe they like [3].

Findings on a foot examination must therefore be seen together with whether the child actually has symptoms.

A systematic review from 2024 included six randomised trials with a total of 297 children with flexible flat foot. In older children, foot orthoses gave better values on several radiographic measures and less pain, but for pain there were only two studies and large variation between them. In younger children there was no clear effect on the radiographic measures. The authors emphasise that the samples are small and that more studies are needed [4].

Another review from 2023 included four randomised trials with children. The authors considered that they could not conclude that foot orthoses are useful for flexible flat foot in children and adults overall, and the data from children were not pooled [5]. NHI writes that custom-made insoles may relieve symptoms somewhat, but that the effect is not firmly documented [1].

With painful flat foot, stable shoes are often the best measure, according to the Journal. The heel counter must be stiff enough to hold the heel in place, the shoe must be the right size, and laces or Velcro must hold the foot back. The sole should not twist, and the child should be active without shoes as well [3]. For older children and adolescents, NHI mentions exercises such as heel raises on both feet, stretching the Achilles tendon if it is tight and training with a resistance band [1].

Children who use insoles are checked annually because of growth [2]. Lægehåndbogen recommends referral when rigid flat foot is suspected, or for persistent and marked symptoms despite conservative treatment [2]. The Journal writes that children with considerable symptoms despite good footwear should be assessed in specialist health services [3].

If the child has pain in the foot, heel or lower leg, or the shoes wear unevenly, a chiropractor can examine the foot and assess whether the findings match the symptoms. If needed, shoes, exercises or insoles can be discussed. Read more about insoles and chiropractic.

Do all children with flat feet need insoles?

No. The Journal of the Norwegian Medical Association writes that there is no evidence that children with flat foot need special shoes or insoles, and NHI that the vast majority do not need treatment [1][3].

When does a child's foot arch become normal?

NHI states that small children normally have some degree of flat foot until about 3 to 4 years, and the Journal that the majority develop a normal arch before the age of 10 [1][3].

What is the difference between flexible and rigid flat foot?

With flexible flat foot the foot regains a normal shape when unloaded, for example on tiptoe. With rigid flat foot the foot is always flat, and it can cause symptoms and require further assessment [1][2].

Do insoles help with flat feet in children?

The evidence is limited. One review found better radiographic measures and less pain in older children, but with few and small studies [4], while another review could not conclude that orthoses are useful [5]. NHI writes that the effect of custom-made insoles is not firmly documented [1].

What are good shoes for children with flat feet?

The Journal describes stable shoes with a stiff heel counter, the right size, and laces or Velcro that hold the foot back. The sole should not twist [3].

The page about Sever's disease describes heel pain in children and adolescents. You can find more articles in the overview of articles.

This article was written by Dr.Dropin Fysikalske and is based on the sources listed below. It gives general information and does not replace an examination by a healthcare professional.

The websites were accessed and read on 22 October 2026.

1. Plattfot (Flat foot). NHI.no, based on Legehåndboka. Last updated 2 April 2025. Link

2. Wong C, Larsen EP. Platfod (pes planus). Lægehåndbogen, sundhed.dk. Professionally updated 18 August 2025, edited 7 April 2026. Link

3. Liyanarachi S, Fevang JM. Paediatric flat foot and good shoes (Plattfot og den gode barnesko). Tidsskr Nor Legeforen. Published 9 April 2025. Link

4. Liu C, Zhang H, Li J, Li S, Li G, Jiang X. The effects of foot orthoses on radiological parameters and pain in children with flexible flat feet: a systematic review and meta-analysis. Front Pediatr. 2024;12. Link

5. Oerlemans LNT, Peeters CMM, Munnik-Hagewoud R, Nijholt IM, Witlox A, Verheyen CCPM. Foot orthoses for flexible flatfeet in children and adults: a systematic review and meta-analysis of patient-reported outcomes. BMC Musculoskelet Disord. 2023;24:16. doi:10.1186/s12891-022-06044-8. Link

6. Betennelse i hælsenefestet (Severs sykdom) (Inflammation at the heel tendon attachment, Sever's disease). NHI.no, based on Legehåndboka. Last updated 13 January 2023. Link