"My child has flat feet — do they need insoles, or special shoes for sport?" is one of the most common questions about children's feet, and it tends to arrive just as a child gets serious about a sport. The commercial answer and the clinical answer are not the same thing. The commercial answer is arch-support insoles, corrective footwear and shoes sold by arch type, and it comes from companies with a financial interest in the diagnosis. The clinical answer is what the published research says.
This article is the clinical answer.
Where flat feet start
Briefly, because it explains everything after it: almost every child starts out with flat feet. A footprint survey cited in the orthopaedic literature found nearly all two-year-olds flat-footed, against 4% of ten-year-olds. A young child has a pad of fat under what will become the arch, and ligaments loose enough that the foot flattens under their weight. In an Austrian study that scanned the feet of 835 children, 54% of three-year-olds had flat feet and 24% of six-year-olds.
The arch then forms through childhood, usually somewhere between the ages of three and ten according to the NHS, and it does so without help. A 2017 review of 34 studies from 19 countries put the point plainly: a flat foot is "a normal finding at specific ages".
What that means for a school-age child
By the time a child is playing organised sport, most arches have formed. A flat-looking foot is still common, though, and how common depends on who is measuring. Published figures for 8-to-13-year-olds run from 4% to 19%. We could not find a published study of flat feet in UAE children. The closest is from Saudi Arabia, where a study of 403 children aged 7 to 14 found flat feet in 29.5% by footprint measurement. Nearly all of them (96.6%) were the flexible kind, and flat feet showed no significant link with taking part in sport or with pain after activity.
There is Dubai data on athletes, though. When 230 male athletes aged 14 to 35 were screened at Al-Ahli club before competing, 26.1% had flat feet. All of them were playing organised sport.
A flexible flat foot is a normal foot shape. A survey of 441 people aged one to eighty summed it up: flat feet are "usual in infants, common in children, and within the normal range" in adults.
Does it hold them back in sport?
This is the worry underneath the question, and it has been tested.
Researchers in Croatia scanned the feet of 218 children aged 11 to 15 and put them through 17 tests of the skills sport depends on, among them jumping and hopping on a force plate, speed and coordination, and balance. Arch height made no difference to any of them, even when the flattest feet were compared with the highest arches. Their conclusion: there is "no need for treatment of flexible flat feet with the sole purpose of improving athletic performance".
A Japanese study of 196 eight-year-olds found the same for sprinting and jumping, although the children with flatter feet were less steady in balance tests. One study disagrees: among 208 primary-school boys, those with flat feet were slightly behind in jumping, hopping, balance and sprinting. The gaps were small.
Injuries are harder to judge, because the evidence comes from runners and military recruits, most of them adults. A 2014 review of 21 studies found that a foot that rolls inwards is a risk factor for shin splints, but a small one. The evidence for kneecap pain was very limited, and for other overuse injuries the review found no link. An earlier review found both flat and high-arched feet associated with leg injuries, and called the relationship weak. One study of military recruits even found fewer stress fractures in those with flat feet than in those with average or high arches.
Taken together: where studies find a difference at all, it is small, and nothing here is a reason to keep a child with pain-free flat feet out of sport.
The research on insoles
In 1989, a trial at Texas Scottish Rite Hospital in Dallas randomly assigned 129 young children with flat feet, aged one to six, to one of four groups: no treatment, corrective orthopaedic shoes, a heel cup, or a custom-moulded plastic insert. Treatment ran for at least three years. All four groups improved, the untreated children included, with no significant difference between them. The authors concluded that "wearing corrective shoes or inserts for three years does not influence the course of flexible flatfoot in children."
In 2022 a Cochrane review, among the most rigorous kinds of evidence summary, examined 16 trials covering 1,058 children from 11 months to 19 years old. It is careful: the evidence is of low certainty at best, and whether insoles change pain or function is uncertain. For children with no pain it is plainer. In the one trial that studied them, insoles made "little or no difference" to how many were pain-free a year later, and the review concluded that for healthy children with flexible flat feet and no pain, expensive custom insoles have "no supporting evidence".
The guidance follows the evidence. The American Academy of Pediatrics' orthopaedics section and the Pediatric Orthopaedic Society of North America advise doctors not to order custom orthotics or shoe inserts for a child whose flat feet cause few or no symptoms. The NHS is as direct: "Insoles do not change the shape of feet or form arches."
It happens anyway. In the Austrian study one child in ten was already wearing arch supports, and the authors judged more than 90% of those treatments unnecessary.
None of this makes insoles useless. For a child whose flat feet do hurt, they are one of the standard first treatments, alongside changing activity, suitable shoes, and stretching and strengthening exercises. The NHS notes that insoles can help with pain or stiffness even though they will not change the shape of the foot. That is a decision to make with a clinician rather than at a shop counter.
Flexible or rigid: the ten-second check
Ask your child to stand on tiptoe. If an arch appears, the foot is flexible: flat under load, arched when the load comes off. That is the common kind, and without pain it needs nothing.
A rigid flat foot stays flat on tiptoe and when the foot is off the ground. It is uncommon (fewer than 1% of the Austrian children had a flat foot the researchers classed as pathological), it is usually painful, and it usually has an underlying cause, so it should be assessed.
Signs worth an opinion from a GP or a podiatrist:
- Feet that are painful, stiff or weak, or a child who doesn't want to play sport because of pain
- Only one foot is flat
- No arch appears on tiptoe
- Flat feet that weren't there before
- Frequent foot or ankle injuries, or problems with walking or balance
- In a teenager, a flat foot with a tight Achilles tendon, which one orthopaedic review singles out as the kind that causes pain in some adolescents
None of these is a reason to panic. They are reasons to have it looked at. Heel pain in an active child is often something else entirely, and we cover it in our piece on Sever's. Without any of these signs, the NHS's advice for a child with flat feet is that you do not need to do anything.
Shoes: what the evidence supports
For everyday wear, choose shoes that let the foot move. A gait-lab study of eight-year-olds found that conventional children's shoes reduced the natural movement of the arch by about 40% and the twist of the foot by about half, compared with walking barefoot. Slimmer, more flexible shoes changed foot motion far less, and the authors recommended them for healthy children generally. The NHS's practical test fits with that: a shoe should support the heel and should not bend easily in the middle. It should bend where the foot bends, at the ball. There is more on how much shoe a child needs in our piece on cushioning.
Make sure they fit. A review of 18 studies found that between 63% and 72% of people were wearing shoes that did not match the length or width of their feet, and linked badly fitted shoes with foot pain. The NHS suggests wide, comfortable shoes with a low heel. Measuring at home takes ten minutes.
Let them go barefoot when they can. In a survey of 2,300 Indian children aged 4 to 13, flat feet were three times as common in those who wore shoes (8.6%) as in those who did not (2.8%), with sandal and slipper wearers in between. A later study compared 810 children and teenagers who had grown up largely barefoot in South Africa with matched children who had grown up in shoes in Germany, and the habitual shoe-wearers had lower arches at every age. These are surveys, not trials, so they cannot prove that shoes cause flat feet. They do point the same way, and the Dubai habit of leaving shoes at the door fits the evidence well.
For sport, buy for the sport and the fit, not for the arch. Running shoes are often sold by foot type, with "motion control" models for low arches. That idea has been tested in three randomised trials with more than 7,000 military recruits. One group was given running shoes matched to their arch height and the other a standard shoe, and it made little difference to injury rates. Those were adults in basic training, and we have not found an equivalent trial in children, but it is the best evidence there is, and it gives no reason to pay extra for a shoe because of the shape of a child's arch. A boot, spike or trainer that suits the sport and fits properly is the right one. A young athlete who does have symptoms, shin pain for instance, is a different case, and worth a podiatrist's eye rather than a guess at the shop.
The practical summary
A flat foot is where children start, and most arches form by about ten. A flexible flat foot that doesn't hurt needs no treatment, and that is the NHS's advice too. In the studies that have tested it, flat feet made little or no difference to how children run and jump.
Insoles do not build arches, and the trials found no benefit for children without symptoms. For a child with pain they can help, and that is a clinician's call.
Have it looked at if there is pain, if only one foot is flat, if no arch appears on tiptoe, if the flat feet are new, or if injuries keep coming. Otherwise: everyday shoes that bend and fit, time barefoot, and sports shoes chosen for the sport rather than the arch.
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