New ‘benchmarks’ for paediatric feet


A very helpful research article was published a few months ago that provides useful ‘benchmarks’ for clinicians when assessing paediatric foot posture.

Establishing normative foot posture index values for the paediatric population: a cross-sectional study.

Gijon-Nogueron GMontes-Alguacil JAlfageme-Garcia P Cervera-Marin JAMorales-Asencio JMMartinez-Nova A.
J Foot Ankle Res. 2016 Jul 26; 9:24.
doi: 10.1186/s13047-016-0156-3.

This cross-sectional study assessed FPI in 1,762 Spanish children, aged between 6-11 years, and to date provides the most comprehensive reference values for this age group.

The findings:

  • The mean (SD) FPI values from this study were: 3.74 (SD 2.93) right foot, 3.83 (SD 2.92) left foot.
  • Clinically, this means – for children aged between 6 and 11 years – the average FPI is +4, and may be expected to fall within a normal range of: +1 to +7. This applies to both genders and both left and right feet.
  • Foot posture was seen to change with age – as expected, findings showed that feet were ‘less flat’ in older children – but not by very much, for this age group.
  • The normative FPI value for children was +4 at 6 years, reducing to +3 at 11 years (50th percentile).
  • FPI scores outside the bounds of -1 (4th percentile): to +6 (85th percentile): in children aged 6 to 11 years can be considered abnormal.
  • Interestingly, there was very little detectable change in foot posture before age 9 years. Unfortunately, this study had access to a limited age range of paediatric participants, and not applicable to the often clinically relevant teenage years when growth is considerable.

These findings help to identify children who may need further consideration or analysis of their gait and in future may provide part of a wider understanding of children who have ‘flat feet’ and symptoms, versus those who are ‘flat’ and pain-free. The need to better determine the difference between physiological or pathological foot posture in childhood is relevant for many areas of clinical practice, research, and is important for parents.


What about treatment?

The best current evidence from a Cochrane Library systematic review found that customised foot orthoses were better than flat cushioning insoles or athletic footwear alone in reducing pain and improving function in children with foot pain and JIA.

There is no evidence to support the use of customised foot orthoses in healthy children with asymptomatic flexible flat feet.

The Cochrane Library systematic review for non-surgical interventions for paediatric flatfeet is currently being updated, and there are a number of RCTs to be included, which will widen the overall knowledge base for both flatfoot interventions in children with JIA, and in otherwise healthy cases.

In the meantime, a recent literature review (not a systematic review) has concluded:

“The pediatric flexible flatfoot (FFF) remains poorly defined, making the understanding, study, and treatment of the condition extremely difficult. Pediatric FFF is often unnecessarily treated. There is very little evidence for the efficacy of nonsurgical intervention to affect the shape of the foot or to influence potential long-term disability for children with FFF. The treatment of tarsal coalition remains challenging, but short-term and intermediate-term outcome studies are satisfactory, whereas long-term outcome studies are lacking. Management of the associated flatfoot deformity may be as important as management of the coalition itself. The management of CVT is still evolving; however, early results of less invasive treatment methods seem promising.”

An assessment tool that will help to clarify the need for concern and/or treatment of paediatric flatfoot (also in-toeing gait, knee alignment) is the ‘3qq’ (3 quick questions), which will be published in a summarized form in The Journal of Paediatric and Child Health later this year, and will be fully available in a Series 2 monograph of Evidence Essentials – available mid-2017. An abstract can be found here.


Evidence Essentials – Series 3, will dedicate specific monographs to paediatric flatfoot, to present the best available evidence in a useable format for clinicians. This is important not only for diagnosis, and considerations around intervention, but for discussion with parents and other medical and health colleagues.



Series subscribers will have received the Evidence Essentials ‘Quarterly’ – a seasonal paediatric foot ‘round up’ – the ‘Summer’ edition features 13 recent paediatric foot journal article commentaries, e-links. In the style of Evidence Essentials, the ‘Quarterly’ is pithy and pertinent – a quick read and you glean the latest.


Evidence Essentials has three objectives:

  1. Evidence Essentials funds ‘Walk for Life’ – the sustainable clubfoot project in Bangladesh

‘Walk for Life’ recently won the BMJ South Asia Healthcare Award for Excellence in Delivering Primary Care

Everyone who purchases Evidence Essentials simultaneously pays for a child to receive FREE treatment of their clubfoot deformity, enabling them to walk, to go to school and have a hopeful future – thank you, what a gift!

You may like to review our latest results.

  1. APERF (Australasian Podiatric Education and Research Foundation) also benefit from Evidence Essentials
  1. Evidence Essentials brings best evidence to paediatric podiatry practice around the world, advancing your professional development.

Please keep an eye out for the Evidence Essentials blogs – every month or so.


Thank you for supporting Evidence Essentials. A second series is planned, as is a third! Your suggestions and feedback are welcome!


Kind regards everyone and Happy New Year!

Angela Evans


Dr Angela Evans    PhD, FFPM RCPS(Glasg)