Pronation and flat feet

The Pediatric Insider

© 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.

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21 Comments on “Pronation and flat feet”

  1. Lucy Pan Says:

    Dr. Benaroch,

    Thanks for your information on kid’s flat feet and pronation.
    I have two questions:
    1.Does the child with pronation need have orthosis in all his life ? The orthosis is used to cure pronation or only used to adjust his gait ?
    2.How old the child can start to have orthosis ?



  2. Dr. Roy Says:


    Orthoses are typically used in younger kids for a few years– as they age, ligaments tighten up and at least sometimes they start to develop a firmer arch. There is some thought, though, that starting them early may prevent foot adaptation. So younger orthotics may make it more likely that the child will continue to need them. Teens in orthotics, who really need them, continue to need them as adults.

    I have seen little toddlers with muscular problems in orthotics. They can be started at any age. But only severe mechanical problems are treated so early with orthotics.


  3. Lucy Says:

    Thanks for your explanation, Dr. Roy.
    My son is 16 months now and just starts to walk. I notice he put his weight on the inside of feet, which looks like a curve on the edge of inside of feet, also it looks that his ankle turns out. I guess this is the reason for him to be a late walker and lack of balance. My husband has flat feet and over pronation. So I pay extra attention on my son’s feet and worry that he may be inherited from his dad.
    You said “Almost all toddlers, learning to walk, have ankles that turn out… All of this is normal…Feet and ankles and knees all grow and adapt, and these things improve with time.”, which comforts me a lot. However, for our case, do I need treat my son’s pronation, or just waiting for the grow and adapt by himself ? Is it helpful to alleviate the over-pronation if I give his feet some massage everyday since now ? Any suggestion is very appreciated.


  4. Dr. Roy Says:

    16 mos olds almost always walk like that– on the inside edges of the feet. At that age, we’d almost always just leave it alone and give it time to improve. Ask your pediatrician to observe your child’s walk to be sure there’s nothing that needs to be done now.


  5. Lucy Says:

    Thanks for your answers. They are very helpful !


  6. Kim N Says:

    Do you have some recommendations of reputable websites where I can buy inserts for my 27 month old who was just diagnosed with pronated feet?


  7. Dr. Roy Says:

    Kim, I don’t. That’s pretty unusual for a 27 m/o to need inserts. I’d suggest you work w/ a podiatrist w/ pediatric experience to get these made if needed.


  8. Erin Faxel Says:

    My daughter is 4 and for a year now has complained of knee pain when walking, running, or riding a bike. Her feet are pronated and has “knock knee”. I was told to get her better shoes with support, which I did. I’m curious though, how do I correct the imbalance? Will she just have to wear orthotics forever?


  9. Dr. Roy Says:

    Erin, I’ve not seen so many children this young with these symptoms. I think you ought to see a pediatric orthopedist or podiatrist to confirm the diagnosis and suggest treatment options.


  10. amanda Says:

    Dr Roy,
    My 8yr old has the pronated ankles/flat feet, she has been complaining of major pain her ankle bone I am” guessing the lateral malleolus by the picture on web md” she says just touching it hurts. Does she need to be taken to the orthopedic? What would they do to treat it?


  11. Dr. Roy Says:

    Amanda: Major pain, hurts just to touch it– that ought to be evaluated by a physician or podiatrist.


  12. Melissa Says:

    My 6-year-old just got her first pair of orthotics for pronation. Do we need to remove the shoe lining (innersole) before putting them in? Also, can you recommend a good brand/style of tennis shoes for her?


  13. Dr. Roy Says:

    Melissa, you typically remove the insert that came with the shoe, but it would be best to ask whoever made the orthotic. I don’t have any brands to recommend. Best of luck!


  14. Karsen Says:

    Dr. Roy,
    My daughter is an extreme athlete. She just turned 12. We have noticed she is knock kneed and did get a physical therapist that confirmed the diagnosis. Please tell me there is a way to correct this at this age? Should we see a specialist?


  15. Dr. Roy Says:

    A degree of knock knees is considered normal. You may wish to ask at her pediatrician’s office, or if you’d like, by all means see an orthopedist. I would typically refer if there are symptoms (like pain) or if there were a large angle at the knee.


  16. Karsen Says:

    Does it sometimes correct itself after puberty?


  17. Christine Says:

    Do these general rules about leaving it alone apply for hypotonic kids as well? My 16 month old with hypotonia and hip dysplasia is starting to “walk” while holding my hands. Her physical therapist has stated she has severe pronation and in-toeing and will likely need orthotics. Is that just old-school thinking, or are the variables different in kids with low tone?


  18. Dr. Roy Says:

    Christine, with hypotonia and hip dysplasia the general advice in this column does not apply. I’d rely on in put from the PT and perhaps an orthopedist to help decide in your individual case.


  19. Dr. Roy Says:

    Karsen: yes, everything tends to tighten with puberty.


  20. Nancy Says:

    Hi Doctor,

    My daughter is a volleyball play, formally a competitive gymnast. She typically has no pain however, her feet are flat and her ankles a bowed in, which I am reading now is call over pro-nation. the orthopedist saw her and said we should leave it alone as she is not experiencing any foot pain. My concern is if a problem develops will it be too late to do anything about it. She is 13 now.


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