7815 7816 All children (<3 years) have flat feet with a fat pad obscuring 7817 the arch. Over time, the longitudinal arch develops but 15% 7818 of adults have flat feet influenced by familial and racial factors. 7819 7820 All flat feet have a flattened medial arch with a valgus heel 7821 but two types are distinguishable (Table 44.3). The painless, 7822 flexible flat foot needs no treatment. Orthoses do not alter the 7823 natural history but can alleviate symptoms if they are present. 7824 7825 The symptomatic, rigid flat foot is due to inflammation or 7826 a tarsal coalition and requires investigation and medical or sur- 7827 gical management (Figure 44.4). 7828 7829 7830 ![A line graph plots \"Varus\" versus \"Age\" with a shaded blue area, labeled \"Knee angle (tibiofemoral angle).\"](https://cdn.orris.care/cdss_images/d367a16f7532be1f89bb0eebf7282786dcde824415af474ae8131c477faa0ebd.png) 7831 7832 *Figure 44.3 Graph to show the normal tendency of limb alignment to 7833 change from varus to valgus with growth; normal is slight valgus after 7834 the age of 7–8 years.* 7835 7836 7837

Type	Characteristics
Flexible	On tiptoe the arch returns and the heel corrects into varus Subtalar joint movements are full and pain free
Rigid	On tiptoe the arch fails to return and the heel remains in valgus Subtalar joint movements are restricted and often painful

7838 7839 7840 ![A radiograph displays a foot with a white arrow pointing toward the ankle joint.](https://cdn.orris.care/cdss_images/cbdd7c978b419adc39a65062298dee9b3e8f66b036ba44b3009bc4b2a5f68a82.png) 7841 7842 *Figure 44.4 Oblique radiograph of the foot that shows the most 7843 common form of tarsal coalition: an incomplete calcaneonavicular bar 7844 (arrow).* 7845 7846 7847 ## Summary box 44.2 7848 7849 7850 ## Normal variants 7851 7852 Legs are often bowed until age 2 years and then knock-kneed until age 6–7 years 7853 7854 Neuromuscular pathology must be excluded in toe walkers, particularly when the onset is late