The study
This is a clinical guideline and consensus statement rather than a single trial: a panel reviewed the available evidence on paediatric flexible flatfoot and agreed a set of recommendations.
The central recommendation is that structured conservative management is the mainstay of treatment, and that a child should have at least a six-month trial of conservative care before anyone starts talking about a surgical referral. In other words, surgery sits a long way down the road, and only after non-surgical care has had a real chance.
What they found
A couple of specifics are worth pulling out. First, foot orthoses earn their place when there is pain or a functional limitation. They are a tool for the symptomatic foot, not a default for every flat foot that walks through the door. Second, and this is the part clinicians sometimes skip, exercise programs may do more than orthoses alone for actually normalising the foot, which tells you the device should be one part of a plan rather than the whole plan.
Taken together, the guideline draws a clear line between feet that look flat and feet that hurt or do not work properly. The first group mostly needs monitoring. The second group needs an active plan.
What it means for your practice
Most children with flexible flat feet do not need much from you beyond a good assessment and honest reassurance. A flat-looking foot in a child who runs around, plays sport and never complains is, in the great majority of cases, a normal developing foot. Saying that clearly is treatment in itself, because it takes a real worry off the parents.
Reserve active treatment for the feet that are genuinely painful or limiting what the child can do. When you do step in, build a combined plan rather than reaching only for an orthotic. That means supportive footwear, orthoses where they are indicated, strengthening and mobility work, some monitoring over time, and clear goals you can show the parent so they can see progress. Lead with the exercise side, because the evidence suggests it does more for the foot itself than a device used on its own.
There is a secondary benefit to this approach. When you only prescribe orthoses where they are genuinely indicated, and you explain why, parents trust you more, and so do the referrers who send you their patients. That trust brings far more long-term value to a clinic than selling a device to every flat foot you see.
The way I put it to parents is that we treat how the foot feels and how it works, not how it looks in a photo, and that we will know it is improving because their child will tell us.
Bottom line
With kids’ flexible flat feet, the strongest message is to treat symptoms and function rather than the shape of the arch. Reassure the feet that are fine, and give the painful or limited ones a proper plan built around footwear, exercise and selective orthotic use, with surgery only considered after a long conservative trial.