Paediatric feet – practical tips for clinicians, using best evidence in 2022



It has been great to lecture at many well attended conferences this year, and in response to those of you who have asked, here is a ‘summary’ to enable easy access to information presented.

I have collated some excerpts from lectures which have covered paediatric foot, legs, and gait, and tried to keep it clinically useful. The references provided have links to relevant sites and access.

Here are 12 main points from my feet, legs, and gait presentations:


1. Avoiding low value careful is important for both people and the planet. It is costly, wasteful, and can be harmful.

Choosing Wisely:


2. The common foot and lower limb presentations are:

    1. Flat feet
    2. Knock knees (bow legs)
    3. Intoeing gait

Triage, using three quick questions (3QQ)

Evans AM (2017), J Paediatr Child Heal 53: 1050-1053


3. For painful presentations, run the 5 I’s screen – may reduce the risk of missing something more serious, if unlikely.

Evans AM, in Neale’s Disorders  of the Foot and Ankle (9th ed.) – Ch 12, 2020.

Evans AM, Benign musculoskeletal paediatric leg – ‘just growing pains’ – or is it?
Intern Med J. 2020 Jul;50 Suppl 2:5-52.  doi: 10.1111/imj.14932


4. For wider assessment, that aligns the clinician with the child and parent/carer, try CAPER


5. Access user-friendly normative paediatric foot posture data, and use the ‘Ready Reckoner’ for paediatric flat feet

Gijon-Nogueron G et al, International normative data for paediatric foot posture assessment: a cross-sectional investigation


6. Ensure that you are familiar with the most recent best evidence for paediatric flat feet and foot orthoses, from the publicly available systematic review in the Cochrane library.

Evans et al; Cochrane Database Syst Rev, 2022 Jan 14;1(1):CD006311.

Statement of the clinical significance from the systematuic review (2022)
This review confirms that in the absence of pain, the use of high-cost Customised Foot Orthoses for healthy children with flexible flatfeet, has no supporting evidence.


7. Paediatric flat feet are more likely to become symptomatic if the ‘boomerang signs’ are present

Evans AM; J Am Podiatr Med Assoc. 2021 May 5;20-103

Unexpected findings, eg feet that are flatter than expected for age, requires consideration of wider diagnoses especially;

    • Hypermobility
    • Hypotonia
    • or something else..

Remember that gait is a great neurological assessment, and append with maneuvers, and hands-on testing of reflexes, strength, balance etc.

Evans AM, Evidence Essentials monographs 1 (7); 2(4)


8. Genu valgum – expected to maximise at approx 3 years of age.

Triage using the 3QQ

Affected cases should be painless, symmetrical, and within expected age range

van Aswegen M et al, IJERPH 2020

Genu varum after age 2 years, or if asymmetrical, or painful, is unusual.


9. Intoeing gait is a common concern, and commonly confusing for many clinicians.

Most cases will be withing normal developmental limits.

Triage using the 3QQ.

Affected cases should be painless, symmetrical, and within expected age range.


10. Most children are insufficiently physically active:

‘12% of children aged 5 – 12 years and only 2% of those aged 13 – 17 years, met both the physical activity and sedentary screen-based behaviour guidelines’

Australian Govt Institute of Health and Welfare

Refer to the WHO recommendations from: The Commission on Ending Childhood Obesity; Global Action Plan on Physical Activity 2018–2030.


11. Functional tests to use in the clinical setting include:

  1. Time to rise from floor
  2. 10 m run
  3. 10 m walk
  4. p-GALS gait assessment


12. Given the existential threat facing humanity and all life of planet earth from climate change, and especially equatorial and developing nations, green podiatry, and green healthcare are primary health priorities.

Climate change – the wider threat

    • Stop unnecessary treatments
    • Promote physical activity
    • Encourage time outside in green spaces

Some green resources:

Podiatry specific:


Kind regards, and let’s all practise good value and green health care!

Angela Evans  AM

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