Pronation and flat feet
© 2012 Roy Benaroch, MD
Allison wrote in: “My (almost) 8 year old son has pronated feet. It’s pretty clear when you look at the wear pattern on his sneakers. What, if anything, do we need to do about it for now?”
Pronated feet means that the ankle is rotated outwards, so most of the person’s weight is over the instep of the foot. Most of the time, kids with pronated ankles have relatively flat feet when they stand. Some pronation is normal—it helps cushion walking, when the foot absorbs some of the impact of each step. When the foot flattens out too much and the ankle stays rotated, that’s sometimes called “overpronation” or “overly pronated feet”. I don’t have a public-domain photo to post, but this google image search will bring up plenty of pictures of pronated feet.
In adults, especially runners, over-pronation seems to be considered a bad thing. There are a lot of stores that sell special shoes and inserts for over-pronators, and entire lines of sneakers are designed to help over-pronators avoid problems like injuries and chronic pain.
With kids, as usual, the story is different. All babies are born with flat pudgy feet, and little baby arches can’t support any weight. Almost all toddlers, learning to walk, have ankles that turn out, and pigeon-toes, and a waddly, bowlegged stance. All of this is normal. In the past, great efforts were made with special shoes and corrective cables and crazy braces to fix how legs and feet looked. Just ask Grandma. She’ll tell you about all of the money and worry spent on fixing Junior’s feet. All of that was a Waste of Time. Feet and ankles and knees all grow and adapt, and these things improve with time. Some adults continue to walk with a little turn or bowlegs or knock-knees, but it turns out that all of this is pretty much normal anyway.
So: ordinary, flexible flat feet that allow the foot to over-pronate do improve, at least some, with time. In most cases, kids with ankle pronation don’t need any kind of treatment. The exception is if there’s pain or an abnormal or clumsy gait. Some pronating kids will complain of foot or ankle or knee pain that’s worse with activity. For these kids, treatment is a good idea—otherwise, they figure out that it’s more comfortable to be a couch potato than a limping child.
If you do need to treat a child’s foot pronation, the most effective approach is with a shoe insert that supports the instep. The insert should be fairly stiff to provide good support. Most over-the-counter drug store inserts are soft and floppy, and don’t offer much actual support (they also wear out very quickly.) Good shoe inserts, called “orthotics” can be fashioned with the help of a podiatrist a sports-medicine orthotist. Your pediatrician should know the best local resources. Keep in mind that children grow, so an orthosis may need adjustment every 4-5 months or so.