* Corresponding Author; Address: Sports Medicine Research Center, Tehran University of Medical Sciences, No 7, Jalal ale Ahmad Highway, Tehran, P.O.Box: 14395-578, Iran E-mail: Mazaheri_md@tums.ac.ir © 2013 by Pediatrics Center of Excellence, Children’s Medical Center, Tehran University of Medical Sciences, All rights reserved. Iran J Pediatr; Vol 23 (No 3), Jun 2013 Published by: Tehran University of Medical Sciences (http://ijp.tums.ac.ir) Pediatric Flexible Flatfoot; Clinical Aspects and Algorithmic Approach Farzin Halabchi 1,2 , MD; Reza Mazaheri * 1,2 , MD; Maryam Mirshahi 2 , MD; Ladan Abbasian 2 , MD 1. Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran 2. Department of Sports & Exercise Medicine, Tehran University of Medical Sciences, Tehran, Iran Received: Sep 04, 2012; Accepted: Jan 24, 2013; First Online Available: Feb 17, 2013 Abstract Flatfoot constitutes the major cause of clinic visits for pediatric foot problems. The reported prevalence of flatfoot varies widely due to numerous factors. It can be divided into flexible and rigid flatfoot. Diagnosis and management of pediatric flatfoot has long been the matter of controversy. Common assessment tools include visual inspection, anthropometric values, footprint parameters and radiographic evaluation. Most flexible flatfeet are physiologic, asymptomatic, and require no treatment. Otherwise, the physician should treat symptomatic flexible flatfeet. Initial treatment options include activity modification, proper shoe and orthoses, exercises and medication. Furthermore, comorbidities such as obesity and ligamenous laxity should be identified and managed, if applicable. When all nonsurgical treatment options faile, surgery can be considered. Our purpose in this article is to present a clinical algorithmic approach to pediatric flatfoot. Iranian Journal of Pediatrics, Volume 23 (Number 3), June 2013, Pages: 247-260 Key Words: Flatfoot; Pes planus; Hyperpronation; Orthosis; Exercise; Algorithm; Children Introduction Deformities of the lower extremities are very frequent in children and most of the time these conditions are physiological and do not need any treatment. Ninety percent of clinic visits for foot problems are due to flatfoot (FF) [1] . Although flatfoot rarely leads to disability, it is still one of the major concerns of parents. Generally it is believed to lead to gait disorders later [2-5] . The flatfoot has two components: sagging of the medial arch and heel valgus [1] . Flattening of the medial arch is a universal finding in patients with flatfoot that is common in both pediatric and adult populations [5-12] . In the neonates and toddlers, it is known that a fat pad is present underneath the medial longitudinal arch of the infant foot while the arch develops; although this fat pad is thought to resolve between the ages of 2 and 5 years as the arch of the foot is formed [13] . Children almost universally are “flat-footed” when they start walking. Intrinsic laxity and a lack of neuromuscular control result in flattening of the foot when weight-bearing [14] . Pediatric flatfoot can be divided into flexible and rigid categories. Flexible flatfoot is characterized by a normal arch during non weight-bearing and a flattening of the arch on stance and may be asymptomatic or symptomatic. Rigid flatfoot is characterized by a stiff, flattened arch in both weight bearing and non-weight bearing positions. Most rigid flatfeet are associated with underlying pathology that requires special considerations [10,15] . Flatfoot may be an isolated pathology or as part of a larger clinical entity. These entities Clinical Approach Iran J Pediatr Jun 2013; Vol 23 (No 3), Pp: 247-260