Flat feet, knock knees and other anomalies- what is "normal"?

I am regularly asked by parents, be it in clinic or the school run to check their child’s feet or legs, worrying whether their limb position is ‘normal’.  Parents have anxiety over knock knees, bow legs, flat feet, and toes turning in during walking. Most of the time these are not issues at all but a normal part of development.

I’ll explain over the next few blogs a little more about what to expect, what is normal and when to be more concerned and get limbs and feet checked out…


·        Flat feet (known as pes planus, over pronation, pes valgus, fallen arches.)





Most ‘normal’ feet have an arch along the inside of the foot. You can see this more easily if your child stands on their tip toes. A ‘flat foot’ is described when the arch disappears or reduces in standing.

All children under the age of 3 have flat feet.

The bones in the feet are held together by ligaments and children also have baby fat pads between the bones. Most flat feet in children are associated with loose ligaments and sometimes tight muscles.

Even in an older child most flat feet do not need any treatment. However, if there are complaints of pain in the feet, ankles, knees or back, poor stamina in walking or poor balance they would benefit from an assessment.


What can we do?

No exercises will improve flat feet, or make them worse, however, children can have tight muscles particularly their calves that need stretching.  A children’s physio can assess this and show you stretches and exercises that will help. Your child may also need an orthotic which can be put in their shoe, again this will not cure the problem but correct the foot positioning, allowing a better position. We very rarely put an orthotic in a child under 5 and even when we do it is usually very flexible.

As I will keep coming back to, a good quality, well-fitting shoe is essential.



·        In toeing gait (‘pigeon toes’)

Children walking with their toes turned in is very common, it can result in tripping when running and can be exacerbated by tiredness and in children with hypermobility.


There are 3 main causes, depending on a child’s age.


1.       Metatarsus adductus- When the forefoot curves in. This is evident from birth often due to positioning in utero. It usually resolves spontaneously but in some cases may need extra  stretching.



2.       Tibial torsion . This is more common in children up to 4-5 years and presents with the shin bones turning inwards with the knee caps still facing forwards. After this age the bones tend to straighten with a more mature gait pattern.



3.       Femoral anteversion – the whole thigh bone rotates inwards and knees and feet will turn inwards. Seen in children around 2-4 years and usually spontaneously resolves by 10 years. It is more common in girls and is often hereditary.

fem ant.jpg


What can we do?

Most of the time there is little indication for treatment. It won’t affect a child running or walking in the long term. Splints and special shoes are not shown to make any difference. However a good pair of well-fitting shoes is recommended. Children can present with tight muscles particularly their calf and  hamstrings and also weakness in specific muscles that can make the problem worse. A full assessment can reveal these weaknesses and an exercise program can help maintain strength as the child grows. Doctors and physios often keep an eye on intoeing gait that isn’t resolving. A very tiny percentage may need an operation when they are older.