Subtalar arthroereisis is widely used to treat flexible flatfoot in growing patients. Metallic implants have historically been standard, whereas bioabsorbable devices have emerged as an alternative that may reduce implant-related symptoms and avoid elective hardware removal. We systematically compared clinical and radiographic outcomes, complication rates, and patient-reported satisfaction between metallic and bioabsorbable implants. We performed a PRISMA-compliant systematic review and meta-analysis. PubMed, Embase, the Cochrane Library, and Web of Science were searched to December 2024. We included clinical studies of subtalar arthroereisis using metallic and/or bioabsorbable implants in pediatric and adolescent flexible flatfoot. Primary outcomes were complication rates (complications, non-routine implant removal, persistent sinus tarsi pain), radiographic parameters, and patient-reported outcomes. Two reviewers independently screened studies, extracted data, and assessed risk of bias. Random-effects models were used for quantitative synthesis. Thirty-nine studies, mostly involving pediatric patients, reported consistent clinical and radiographic improvement after subtalar arthroereisis irrespective of implant material. Pooled single-arm analyses showed persistent sinus tarsi pain in 8.0% of metallic-implant cases and 6.3% of bioabsorbable-implant cases, and non-routine implant removal/revision in 7.7% and 5.2%, respectively. In the two comparative studies, metallic implants showed a trend toward higher odds of non-routine implant removal (pooled OR 2.20; 95% CI, 0.97-5.00) and significantly higher odds of persistent sinus tarsi pain (pooled OR 1.77; 95% CI, 1.03-3.03) compared with bioabsorbable devices. Radiographic correction and patient satisfaction were high in both groups, with no consistent evidence of superiority of either material. Subtalar arthroereisis with metallic or bioabsorbable implants yields substantial clinical and radiographic improvement in pediatric flexible flatfoot. Available data suggest that bioabsorbable devices may be associated with lower rates of implant-related symptoms, but comparative evidence, limited to two non-randomized studies, is of low-to-moderate certainty. High-quality randomized trials with standardized, long-term outcome reporting are needed to define the optimal implant choice.

Flexible flatfoot is a prevalent musculoskeletal deformity characterized by partial or complete loss of the medial longitudinal arch. It can modify lower-limb kinematic and kinetic parameters during walking. Fatigue may further impair gait patterns, potentially aggravating the deformity and increasing injury susceptibility. However, despite substantial research on fatigue and flatfoot separately, integrative evidence on fatigue-related gait biomechanics in individuals with flexible flatfoot remains limited. This study was conducted as a systematic review and meta-analysis following PRISMA guidelines. A comprehensive literature search was conducted from January 2000 to August 2025 in databases including PubMed, Scopus, Web of Science, and Embase. The methodological quality of the included studies was assessed using the Newcastle-Ottawa checklist, and data extraction was independently performed by two reviewers. Statistical analyses were carried out using RevMan software version 5.4.1, and the I² test was used to assess data heterogeneity. A total of 14 studies were included. Meta-analysis results showed that fatigue had a significant effect on certain kinematic variables in individuals with flexible flatfoot. "Regarding kinematic outcomes, pooled analyses revealed that fatigue significantly affected several lower-limb joint angles. Specifically, significant reductions were observed in knee external rotation (SMD = - 0.79, 95% CI: -1.50 to - 0.08; p = 0.03) and ankle dorsiflexion (SMD = - 0.60, 95% CI: -0.97 to - 0.22; p = 0.002), while a borderline significant decrease was noted for knee internal rotation (SMD = - 0.48, 95% CI: -0.96 to - 0.00; p = 0.05). In contrast, changes in ankle inversion, ankle eversion, hip external rotation, and hip internal rotation were not statistically significant (p > 0.05). When all kinematic outcomes were pooled, fatigue was associated with an overall significant reduction in joint angles (SMD = - 0.40, 95% CI: -0.64 to - 0.17; p = 0.0008), with moderate heterogeneity across studies (I² = 44%). In contrast, The Meta-analysis of kinetic variables such as center of pressure (MD = 0.97, 95% CI: -0.92 to 2.87; p = 0.31; I² = 0%), peak pressure (MD = 1.19, 95% CI: -6.81 to 9.20; p = 0.77) and Peak force (MD = 0.07, 95% CI: -0.68 to 0.83; p = 0.85) showed no statistically significant differences before and after fatigue. However, some single studies reported significant changes in plantar pressure, joint moments, and ground reaction forces. In conclusion, fatigue appears to significantly disrupt gait kinematics in individuals with flexible flatfoot, potentially compromising postural stability and increasing the risk of musculoskeletal injury. While kinetic parameters remained largely unaffected in the meta-analysis, the findings underscore the importance of implementing targeted corrective interventions to mitigate the functional consequences of fatigue in this population.

Pediatric flexible flatfoot (PFF) is a common condition affecting children's foot biomechanics. While various conservative treatments exist, their relative effectiveness remains unclear. The objective was to compare the effectiveness of non-surgical interventions-orthotic devices, active exercise-based interventions, and neuromuscular electrical stimulation (NMES)-for managing PFF. A systematic review and network meta-analysis of randomized controlled trials was conducted and registered in PROSPERO (CRD42024539990). Eleven trials encompassing 761 children with flexible flatfoot were included. Non-surgical interventions included orthotic devices (traditional insoles, talus control insoles, corrective shoes, heel cups) and active exercise-based physical therapist interventions (corrective exercises, core stabilization exercises, and NMES combined with corrective exercises). Outcome measures included the Staheli index (static footprint measurement), barefoot radiological measures (anterior-posterior and lateral talocalcaneal angles, calcaneal pitch angle), pain scores, and treatment discontinuation rates. NMES combined with corrective exercises demonstrated significant improvement in the Staheli index compared to no intervention (mean difference [MD] = -0.28, 95% CI = -0.35 to -0.22; certainty of evidence [CoE]: moderate). Talus control insoles showed significant improvements in radiological outcomes compared to conventional flat footwear, including lateral talocalcaneal angle (MD = -5.56°, 95% CI = -9.81 to -1.30; CoE: low) and calcaneal pitch angle (MD = 2.74°, 95% CI = 0.41 to 5.06; CoE: low). Traditional insoles effectively reduced pain scores compared to flat insoles (MD = -2.92 points, 95% CI = -3.73 to -2.11; CoE: very low). Pain outcomes were not assessed in exercise or NMES studies, preventing comparative effectiveness conclusions across intervention types. No significant differences in treatment discontinuation rates were observed among orthotic interventions. Both active exercise-based and orthotic interventions demonstrated beneficial effects. NMES with corrective exercises improved standing foot alignment by static footprint analysis, while orthotic interventions enhanced radiological alignment (talus control insoles) and pain relief (traditional insoles) compared to conventional footwear. Outcome measurement differences between intervention types limited direct comparisons. Ten studies measuring gait, functional, or developmental outcomes were excluded due to insufficient outcome overlap. This network meta-analysis provides evidence-based guidance for selecting conservative PFF interventions based on primary treatment objectives.

This study proposes a finite element (FE) framework to quantitatively evaluate customized insole designs for pediatric flexible flatfoot. Validated subject-specific FE models from nine pediatric cases were analyzed under static weight-bearing to assess the effects of arch support height, arch support area, and medial heel wedge height on plantar loading. Results revealed that arch support height and medial heel wedge height dominantly influence load transfer, with arch height facilitating midfoot loading and the heel wedge correcting hindfoot mechanics, whereas arch support area has limited impact. This quantitative approach demonstrates the potential of FE analysis to guide patient-specific orthotic prescriptions.

Flatfeet involve a collapse of the medial longitudinal arch, hindfoot valgus, and forefoot abduction. Flexible flatfoot is the most common type and can often be corrected with physiotherapy or orthotics. While some individuals remain asymptomatic, others develop symptoms for reasons that are not fully understood. This cross-sectional study compared plantar pressure distributions in 16 adults with asymptomatic and 16 with symptomatic flexible flatfeet (FPI-6 > 6; navicular drop > 5 mm), using a resistive-sensor-equipped pressure plate during walking and heel-strike running. During walking, symptomatic participants showed significantly higher total and peak forces at metatarsal 5 (p ≤ 0.003), and the midfoot (p ≤ 0.02146). The medial heel had significantly lower peak force (p = 0.00147), and metatarsal 4 showed higher peak force (p = 0.02539). Force ratios indicated a more lateralized pressure distribution in the symptomatic group. During heel-strike running, the symptomatic group exhibited higher total and peak forces at the fifth metatarsal, the midfoot, and the first metatarsal, with shorter time to peak force in the midfoot and the medial part of the heel. No significant ratio differences were found during running. Symptomatic individuals adopted a lateralized pressure distribution pattern, contrasting the traditional expectation of medial overload in flatfoot conditions.

Subtalar arthroereisis with calcaneal stop screw for symptomatic flexible flatfoot in children A prospective case series

Paediatric flexible flatfoot (PFF), though common, lacks universally accepted diagnostic and management protocols. There is ongoing debate regarding whether it represents a pathological condition or a physiological variant. Whilst many children remain asymptomatic, evidence suggests that even those without overt symptoms may experience reduced functional capacity. This narrative review aims to summarise the current understanding of paediatric flexible flatfoot, focusing on factors influencing arch development and the various clinical approaches used in managing symptomatic children. Many treatment strategies have been described in literature for symptomatic children, including non-operative measures such as orthotic support and functional re-education, as well as surgical procedures such as lateral column lengthening and subtalar arthroereisis (SA).Obesity has been identified as a significant contributing factor to paediatric flexible flatfoot. With the expected rise in childhood obesity, the prevalence of flatfoot is likely to increase, highlighting the need for clear and standardised management guidelines. Paediatric flexible flatfoot remains a debated condition with no clear consensus regarding its clinical significance or optimal management. While most children remain asymptomatic, symptomatic cases should initially be managed with activity modification and functional re-education. Surgical procedures such as subtalar arthroereisis show promising short-term outcomes in selected patients, though further long-term studies are required to establish clear treatment guidelines.

Background: Flatfoot is a condition brought on by trauma, persistent foot stress, obesity, and poor biomechanics. These factors result in the development of a flat foot, collapse of the foot arch, and malfunction of the posterior tibial tendon. This study aimed to assess the immediate effects of Kinesio Tape on static plantar foot pressure and force in young females with flexible flatfoot. Methods: A pilot study (pre-experimental study design) with a convenience sample of 20 female subjects from a university with flexible flatfoot (age = 20.1 ± 1.3 years, weight = 91.8 ± 14.4 kg, height = 162.2 ± 6.3 cm, BMI = 34.9 ± 5, foot posture index (FPI) = 8.8 ± 2.1) was selected. The TekScan MatScan® system was used to measure the static plantar forces and pressures, foot contact area, and the mediolateral displacement of COF over time while standing (Boston, MA, USA) before and immediately after the application of Kinesio Tape (KT). Results: While there were no statistically significant changes in the foot peak or total pressure, paired-sample t-tests showed a statistically significant reduction in foot contact area (p < 0.05) and a statistically significant increase in midfoot maximum force (p < 0.05) following the application of KT. Furthermore, after applying KT, there was a statistically significant decrease in the mediolateral COF velocity, indicating greater lateral displacement of COF (p < 0.05). Conclusions: The results of this study concluded that Kinesio Tape was a useful intervention method for immediately redistributing pressure and forces in young females with flexible flat feet.

This study evaluated tibiofemoral loading and medial meniscal stress distribution in individuals with flexible flatfoot (FFF) during walking under different foot progression angle (FPA) conditions. This study analyzed the gait of 28 FFF patients (16 males, 12 females) under three FPA conditions (neutral, toe-in, toe-out). Kinematic (Vicon) and kinetic (Kistler) data were used to estimate tibiofemoral forces in OpenSim. Subsequently, joint angles and muscle forces at peak tibiofemoral forces were used to drive a finite element (FE) model of the knee, enabling the comparison of meniscal von Mises stress, maximum shear stress, and contact pressure across FPA conditions. Tibiofemoral force increased during early stance (9-11%) in the toe-in condition with this increase reaching statistical significance in males (p = 0.008, mean partial within the SPM-identified cluster). FE analysis showed that peak stresses and contact pressure were primarily localized in the anterior region of the medial meniscus. A consistent directional response to FPA was observed with the lowest peak values occurring in the toe-in condition and the highest values in the toe-out condition. Adjusting FPA modulates intra-articular knee loading via the kinetic chain. For FFF patients, neutral FPA provides stable loading. The toe-in condition presents a complex mechanism: despite increasing tibiofemoral force (notably in males), it reduces peak stress by altering contact mechanics and stress distribution. Therefore, FFF gait interventions must be individualized based on factors like foot morphology, sex, and functional goals.

Introduction: Flexible flat foot (FFF) is a common postural variation in which the foot's medial arch collapses during weight-bearing. It is influenced by various factors, including long-standing hours, footwear, trauma, BMI, and sex. This review explores the prevalence of flexible flat feet in adults; the effects of footwear, particularly improper or inadequate arch support, on balance and fall risk; and their association with balance and fall risk. Methodology: A narrative review was conducted by searching the PubMed, Scopus, Google Scholar, and ScienceDirect databases for studies published between 2015 and 2025. Keywords included “flat foot", “flexible flat foot", “pes planus", "footwear", "balance", and “fall risk". Studies on adults (18–35 years) assessing FFF or flat foot prevalence, the impact of footwear on flat foot and foot posture, and/or balance and falls were included in this review. Results: Available studies report variable prevalence of flat feet, ranging from 11% to 26%, and of flexible flat feet, around 13% to 15%, in adults. Footwear emerged as a key modifying factor, as studies suggest that footwear choices and prolonged use can contribute to a higher prevalence of flat feet, particularly when wearing low-arch-support shoes. Footwear has also been linked to altered balance in adults with flat feet, potentially increasing the risk of falls and injuries. Conclusion: Flexible flatfoot is a common yet under-researched musculoskeletal condition with notable functional and postural effects in adults. There is a need to raise awareness among adults about supportive footwear choices for daily use and to implement institutional-occupational reforms regarding footwear restrictions, as evidence suggests the prevalence of FFF among adults is increasing, predisposing individuals to increased fall risk. Keywords: Adult, Flatfoot, Accidental Falls, Shoes, Prevalence, Footwear, Balance.

Introduction: This study aims to assess the functional and radiological outcomes of combining minimally invasive medial displacing calcaneal osteotomy (MDCO) with subtalar arthroereisis (STA) for the treatment of symptomatic planovalgus feet in young adults. Methods: A single-centre, prospective cohort study was conducted between November 2015 and February 2022. The study included a total of 32 patients with flexible flatfoot who were treated with subtalar arthroereisis combined with medialising calcaneal osteotomy with at least three years of follow-up. Radiographic evaluation included talar coverage angle, AP talo-first metatarsal (T1MT), AP talo-calcaneal, lateral talo-first metatarsal, and calcaneal pitch angles. Function was assessed by the AOFAS score. Results: Angles and scores were compared preoperatively and at the third-year follow-up. The mean talo-navicular coverage angle TNCA reduced from 32.72° (±8.33) preoperatively to 8.84° (±5.70) at the last follow-up. The mean AP T1MT improved from 21.59° (±8.47) preoperatively to 7.78° (±4.03) at three years postoperatively. Meary’s angle decreased from 20.84° (±7.14) preoperatively to 4.78° (±3.20) following the correction. The mean preoperative AOFAS score was 62.69 (±9.26), and significantly improved to 94.19 (±3.80) at the last follow-up. Four feet experienced sinus tarsi pain (12.5%), and three patients (9.3%) needed removal of the arthroereisis implant. Conclusions: The combination of MDCO and STA holds significant promise for treating flexible flatfeet in adolescents and young adults, particularly in cases of moderate to severe deformity. This combination demonstrates a synergistic interaction, with the STA implant providing internal bracing to support MDCO and reducing stresses over the medial arch by preventing hyper-pronation. Simultaneously, the MDCO reinforces the reconstruction, achieving the necessary increased correction in moderate to severe flatfoot cases, while also reducing stresses over the STA implant.

Biomechanical effects of varying arch support hardness in foot orthosis for adults with flexible flatfoot: A comprehensive Bayesian statistical analysis.

Flatfoot is one of the most common clinical presentations in orthopedic practice. When symptomatic flexible flatfoot fails to respond to nonoperative measures, surgical intervention may be necessary. Surgical options include soft tissue and bony procedures. However, deformity correction often requires bony procedures, as soft tissue interventions alone are rarely successful. Evans and Hintermann calcaneal osteotomies are the most commonly used techniques for lateral column lengthening. Despite being performed under fluoroscopic guidance, these osteotomies carry the risk of calcaneal articular surface invasion. Therefore, a more precise and accurate method is needed. This study describes the use of 3D printed patient specific guide for lateral column lengthening osteotomy (LCLO). A CT scan of the affected foot was used for image segmentation via DICOM files to produce a 3D visualization of the calcaneus using 3D Slicer software. A patient specific osteotomy guide designed with anatomic curves to fit the lateral calcaneal surface at the level of the sinus tarsi is 3D printed. The guide directs the osteotomy precisely to the desired direction based on patient calcaneal facet anatomy to avoid articular surface violation. Both Evans and Hintermann osteotomies can be accurately performed using these 3D-printed guides. Postoperative CT scans revealed that the osteotomy was performed as planned, without violation of the articular facets. Patient specific 3D printed guide for lateral column lengthening osteotomy may be a safer and more accurate method to avoid articular surface violation during this demanding osteotomy. Level of Evidence: Diagnostic Level 5.

Biocompatible screw-based biomechanical alignment technique for improving surgical effect in adolescent flexible flatfoot

BACKGROUND: Flexible flatfoot with Achilles tendon shortening represents a distinct form of rigid flatfoot. Conservative treatment of this condition includes stretching of the triceps surae muscle to increase ankle dorsiflexion. The authors hypothesized that the effectiveness of stretching in children with flatfoot may depend on the correctness of exercise performance. AIM: This work aimed to analyze the relationship between the effectiveness of stretching in children with flexible flatfoot and Achilles tendon shortening and the correctness of home exercise performance. METHODS: This was a prospective, comparative, observational study that included 43 children aged 7–17 years with flexible flatfoot and Achilles tendon shortening. All patients were advised to perform stretching exercises according to a standard protocol. Parents were asked to record a video of the exercises being performed to monitor the correctness of exercise performance. Based on treatment outcomes, patients in the main group were divided into two subgroups depending on clinical effectiveness. RESULTS: The most frequent protocol violations were related to foot position, including external rotation (60.5% of patients) and hyperpronation (41.9%). Knee flexion during the exercise was observed in 27.9% of patients, whereas knee hyperextension was observed in 20.9%. A significant association was found between the quality of exercise performance and the clinical effectiveness of conservative treatment. Patients with regular and persistent violations of the stretching protocol demonstrated less pronounced positive trends in both ankle dorsiflexion range and FPI-6 (Foot Posture Index) scores. Based on the obtained data, the most typical exercise performance errors were identified, which allowed developing a more precise protocol for instructing parents and patients. CONCLUSION: Detailed instruction and careful monitoring of exercise performance may improve the overall effectiveness of conservative treatment in children with flatfoot.

Subtalar arthroereisis has been reported to be an effective treatment technique for flexible flatfoot (FF) in children. Although many devices for this procedure exist, arthroereisis using screws is still globally used. Therefore, this study aims to revisit subtalar screw arthroereisis (SSA) and investigate its outcomes. We retrospectively reviewed 353 flexible flatfeet in 178 pediatric patients who underwent SSA between 2007 and 2020. Clinical and radiological assessments were conducted pre-implantation and pre-explantation. Radiographic angles were measured to quantify correction. Statistical analyses included chi-squared tests and Student's t-tests to evaluate clinical improvement and the impact of variables on outcomes. The mean patient age at implantation was 11.96years. 96.31% of feet showed clinical improvement postoperatively. Radiographic analysis demonstrated significant correction in most (83.33%) angular measurements, with the calcaneal pitch showing the strongest effect size. Postoperative complications occurred in 41.08% of FF, predominantly pain, and were mainly (84.13%) resolved with non-surgical treatment. 4.25% required implant revision, which was significantly more frequent in the younger age and female group. SSA for treatment of FF in children showed favorable results regarding improved clinical aspects and radiographic measurements. Nevertheless, an accurate indication for surgical treatment is necessary. Clinical retrospective research-Level III.

Pes planus involves the collapse of the medial longitudinal arch, altering gait and plantar pressure and leading to pain and injury. This review aimed to evaluate the effects of conservative interventions on plantar pressure in flatfoot patients. Four databases were searched from inception to 20 February 2025. Two reviewers screened studies using predefined criteria and the Downs and Black scale. Eligible designs included randomized controlled trials, quasi-experimental, and observational studies. Mean differences with 95% CIs were synthesized using a random-effects model, and evidence strength was graded using modified van Tulder criteria. Twenty-eight studies (5–80 participants; total n = 815) involving young to middle-aged adults with flexible flatfoot were included, and most showed moderate methodological quality. Exercise significantly reduced medial-heel pressure (MD − 12.61; 95% CI − 21.23 to − 3.98; strong evidence; 2 RCTs) but showed no significant change in midfoot pressure (MD 0.62; 95% CI − 4.41 to 5.65; 2 RCTs). Taping reduced medial-forefoot peak pressure (MD − 3.40; 95% CI − 5.78 to − 1.03; strong evidence; 5 studies) and did not change lateral-heel pressure (MD -1.26 ; 95% CI -5.11 to 2.58; strong evidence; 5 studies). Taping increased second-toe pressure by 28.2% (MD 3.69; 95% CI 1.64 to 5.75; 2 studies) and third-to-fifth-toe pressure by 34.7% (MD 3.21; 95% CI 1.85 to 4.56; 2 studies), while reducing middle forefoot by 18.2% (MD − 6.33; 95% CI − 8.95 to − 3.71; moderate evidence; 2 studies) and lateral forefoot by 12.4% (MD − 1.24; 95% CI − 2.14 to − 0.34; moderate evidence; 3 studies). Insoles increased medial-midfoot pressure by 61% (MD 29.15; 95% CI 17.23 to 41.06; 2 studies) but did not significantly change first-metatarsal (MD 8.79; 95% CI − 11.75 to 29.33; 2 studies) and lateral-midfoot pressures (MD 5.93; 95% CI − 26.31 to 38.16; 2 studies). Overall, conservative interventions may modify plantar-pressure distribution and provide short-term relief (primarily from acute/single-session taping and insole studies, with exercise effects observed over periods up to 8 weeks), but long-term efficacy remains unclear. Protocol registration: CRD42024621107.

ABSTRACTIntroductionFoot progression angle affects gait and lowerlimb alignment. Altered angles may increase knee and ankle loading and produce tissue loading patterns previously linked to musculoskeletal injury. This study investigates how different foot progression angles modify knee and ankle biomechanics in young adults with flexible flatfoot.Methods28 participants (aged 18–35 years) with flexible flatfoot completed gait trials under three foot progression angle conditions. Kinematic and kinetic variables were analyzed using one‐dimensional statistical parametric mapping. A 1D convolutional neural network was applied to classify progression angle patterns based on flexible flatfoot severity and gait biomechanics.ResultsDecreasing foot progression angle reduced the ankle eversion/inversion range and knee abduction and external rotation (p < 0.05). Increasing foot progression angle lowered early stance ankle plantarflexion and increased knee abduction/external rotation (p < 0.05). Kinetically, a smaller foot progression angle reduced peak ankle plantarflexion moment and knee extension moment but increased the first peak of the knee adduction moment and rotational moment fluctuations (p < 0.05). A larger foot progression angle reduced rotational fluctuations and terminal stance knee extension moment (p < 0.05). The convolutional neural network model was most accurate for moderate flexible flatfoot cases, and ankle coronal and knee transverse biomechanics showed the strongest discriminative power.ConclusionModifying the foot progression angle can meaningfully alter knee and ankle loading in young adults with flexible flatfoot. Neutral or mild toe‐in angles may help mitigate excessive eversion and rotational stress, suggesting a simple noninvasive adjustment that clinicians can incorporate during gait retraining or orthotic prescription. Because biomechanical responses vary across individuals, FPA modification may be the most effective when tailored to patient‐specific gait characteristics. In addition, deep‐learning‐based gait classification shows promise for supporting personalized monitoring and guiding clinical decision‐making during rehabilitation.

As radiographic and clinical parameters have not been found to consistently correlate with pain and disability in adolescents with flexible flatfoot deformities, there is no consensus as to why some flexible flatfeet become bothersome and others do not. The purpose of this study was to assess pedobarographic differences between adolescents with symptomatic flexible flatfoot (SFF) and those with asymptomatic flatfeet (AFF) deformities. A retrospective review of a Foot and Ankle registry identified 59 adolescents (64 feet) with SFF who underwent plantar pressure analysis. Normalized contact area (CA%), contact time (CT%) and mean force (MF%) were assessed for the medial/lateral hindfoot, midfoot, and forefoot regions. In those with SFF, patient-reported outcomes were evaluated with the Oxford Ankle Foot Measure (OxAFM) questionnaire. From a control group, 13 feet with medial midfoot CA% greater than 1 SD comprised the AFF group. The SFF group differed from controls and the AFF group in all variables across the foot, with an emphasis in the medial midfoot. Ten symptomatic patients went on to surgery and 54 were managed nonoperatively. No pedobarographic differences were found between the operative and nonoperative groups; however, the operative group reported significantly lower OxAFM for school and play ( P = 0.030) and emotional wellbeing ( P = 0.023). There is a greater medial shift in CA%, MF%, and CT% within the SFF group when compared with the AFF. Pedobarographic differences were not found between symptomatic flatfeet undergoing surgical treatment and those managed conservatively. Level of evidence is therapeutic level 3.

Background: Flexible flatfoot is a common pediatric condition. Surgical intervention is indicated for symptomatic cases unresponsive to conservative treatment. This study evaluates the outcomes of two established procedures, Grice extraarticular subtalar arthrodesis and subtalar arthroereisis, in children treated for symptomatic flatfoot. Methods: A retrospective analysis was conducted on 158 patients (286 feet) treated between 2013 and 2024. Among them, 34 underwent Grice arthrodesis and 124 underwent arthroereisis. Demographic and procedural data were collected, including age, sex, neurological impairment (cerebral palsy), laterality, and concurrent Achilles tendon lengthening. Radiographic parameters assessed pre- and postoperatively included Meary’s, Pitch, and Kite’s angles (frontal and sagittal view), uncovering of the talus, and Cyma line. Only patients with both pre- and postoperative measurements were included in paired analysis. Statistical tests included paired t-tests within groups and Welch’s t-tests for between-group comparisons. Results: Grice patients were younger (mean age 9.0 ± 3.1 years) and included all cerebral palsy cases (18/34; 52.9%), while arthroereisis patients were older (10.8 ± 2.6 years) and typically neurologically normal. Achilles tendon lengthening was performed in 100% of Grice and 48% of arthroereisis cases. Both groups showed significant radiographic improvement across all measured parameters (all p < 0.05). Grice arthrodesis produced greater reductions in Meary’s angle (right Δ = −19.8° ± 9.2 vs. −13.1° ± 7.5; p = 0.024), while arthroereisis yielded larger increases in Pitch angle (left Δ = +9.2° ± 7.2 vs. +5.5° ± 6.2; p = 0.055). Other angular improvements (Kite’s, uncovering, and Cyma line) were statistically significant within both groups but not between groups. Conclusions: Symptomatic flat-valgus foot in children remains a relevant public health issue. Treatment should be individualized, while cases secondary to unrecognized or untreated congenital conditions often require surgery to restore normal foot biomechanics.