Medically reviewed by Dr. Tom Biernacki, DPM
Board-certified podiatric surgeon | Balance Foot & Ankle, Howell & Bloomfield Hills, MI
Last reviewed: May 2026
The most important clinical decision with Children’s Foot Problems: What’s Normal and What Needs Treatment isn’t which treatment to choose — it’s identifying which subtype you have first. Our podiatrists see patients treated for the wrong subtype for months before the correct diagnosis leads to full resolution. Call (810) 206-1402 — expert podiatric care across Michigan.
| Condition | Age Group | Key Signs | Normal vs. Abnormal | When to Act |
|---|---|---|---|---|
| Flexible flatfoot | Toddler to age 8 | No arch when standing; arch reappears when standing on tiptoe | Normal in toddlers; most resolve by age 6–8 | If painful, causing gait compensation, or persistent beyond age 8–10 |
| In-toeing (pigeon toe) | Toddler to age 7 | Feet turn inward when walking; tripping is common | Physiologic in-toeing resolves in 90%+ without treatment by age 8 | If asymmetric, worsening after age 5, or affecting sports participation |
| Out-toeing | Infant to age 2 | Feet turn outward; common after first steps | Usually resolves naturally by age 2–3 | If persists after age 3 or associated with hip pain |
| Sever’s disease (calcaneal apophysitis) | Ages 8–14 (active children) | Heel pain during or after sports; bilateral in 60%; squeeze test positive | NOT normal — growth plate inflammation from activity | Immediately — treatable with heel lifts, stretching, activity modification |
| Kohler’s disease | Ages 3–7 (more in boys) | Medial midfoot pain; limping; avascular necrosis of navicular on X-ray | NOT normal — idiopathic avascular necrosis | Immediately — short leg cast typically required |
| Tarsal coalition | Ages 10–16 | Rigid flatfoot; recurrent ankle sprains; peroneal spasm; bar on CT/MRI | NOT normal — congenital fusion between tarsal bones | If symptomatic — conservative or surgical resection |
| Juvenile hallux valgus (bunion) | Ages 10–18 | Medial prominence at 1st MTP; more common in girls; family history | NOT normal — progressive deformity | Footwear modification first; surgery deferred until skeletally mature if possible |
| Plantar warts | School-age children | Painful lesion with black dots on sole; skin lines interrupted; contagious | Common but NOT normal — HPV infection | If painful or spreading; multiple treatment options available |
| Sever’s Disease Feature | Detail |
|---|---|
| What it is | Inflammation of the calcaneal apophysis (growth plate in the heel) from repetitive traction by the Achilles tendon during rapid bone growth |
| Who gets it | Active children ages 8–14; peak at 10–12 in boys, 8–10 in girls; 60% bilateral |
| Classic presentation | Heel pain after or during sports (soccer, basketball, gymnastics); squeeze test: pain with medial-lateral compression of heel; no swelling |
| X-ray findings | Normal or fragmentation of apophysis (not diagnostic; apophysis normally looks irregular) |
| Treatment | Heel lifts (silicone, 6–8mm) reduce Achilles tension immediately; Achilles stretching 3x daily; activity modification (not rest — modification); ice after activity; NSAIDs short-term |
| Prognosis | Resolves completely once growth plate closes (typically age 14–15); no long-term damage if managed correctly |
| Return to sport | Same week in most cases with heel lifts in cleats or athletic shoes; season-ending rest is rarely required |
Common Foot Problems in Children
Children’s foot problems fall into two categories: developmental variations that are normal at certain ages and resolve without treatment, and true pathology that requires intervention. The most common mistake parents make is treating normal developmental variants (flexible flatfoot in toddlers, mild in-toeing) as problems requiring bracing or orthotics, while sometimes missing genuinely abnormal conditions (Sever’s disease, tarsal coalition, Kohler’s disease) that are treatable and important to address early.
Flatfoot in Children: When to Treat and When to Watch
Flatfoot (pes planus) is the most common reason parents bring children to a podiatrist. The majority of cases in children under age 8 are flexible flatfoot — the arch is absent when standing but reappears when the child stands on tiptoe or sits with feet dangling. This is a normal developmental pattern; arch development typically completes by age 6–8. Studies following children with asymptomatic flexible flatfoot into adulthood have not shown increased rates of pain or disability compared to children with normal arches, and routine treatment is not recommended by most pediatric orthopedic guidelines.
Treatment is appropriate when flatfoot is: (1) painful — arch or heel pain with activity; (2) causing compensatory gait changes (knee pain, in-toeing, easy fatigue); (3) rigid rather than flexible (arch does not reconstitute on tiptoe — suggests tarsal coalition or congenital rigid flatfoot requiring further evaluation); or (4) progressive after age 10. Custom orthotics for symptomatic pediatric flatfoot reduce pain effectively and may support normal arch development in growing feet, though evidence for altering the natural history is limited.
Sever’s Disease: The #1 Cause of Heel Pain in Active Children
Sever’s disease (calcaneal apophysitis) is the most common cause of heel pain in children ages 8–14, and the diagnosis parents and coaches most often miss because the heel appears normal and the child “walks it off” once warmed up. The condition results from the Achilles tendon’s attachment pulling on the still-open calcaneal growth plate during the rapid growth phase of early adolescence — particularly during soccer, gymnastics, and basketball seasons when running volume is high.
Sever’s does not require rest from sports in most cases. Silicone heel lifts inserted into cleats or athletic shoes immediately reduce Achilles tension on the apophysis, and most children can return to full activity within the same week. Achilles stretching (three times daily, holding 30 seconds) and calf strengthening are added to address the underlying tightness. The condition resolves completely when the growth plate closes — there is no permanent damage. Parents can be reassured that Sever’s is not an injury to the bone’s permanent structure, but management does matter for season participation.
Tarsal Coalition: The Diagnosis Behind Recurrent Ankle Sprains
Tarsal coalition — an abnormal bony or fibrous bridge between two tarsal bones (most commonly calcaneonavicular or middle facet talocalcaneal) — presents subtly in children and is often dismissed as recurrent ankle sprains. The key clinical findings: a rigid or semi-rigid flatfoot that does not fully reconstitute on tiptoe, involuntary peroneal muscle spasm when the subtalar joint is stressed, and recurrent sprains from a foot that cannot accommodate uneven ground. X-ray may be normal or show the anteater sign (calcaneonavicular coalition) or C-sign (TC coalition); CT scan is the diagnostic standard. Conservative management (orthotics, immobilization) is tried first; surgical resection of the coalition is highly effective in symptomatic younger patients before secondary arthritis develops.
At Balance Foot & Ankle, Dr. Tom Biernacki and Dr. Carl Jay evaluate and treat children’s foot and ankle conditions at both the Howell and Bloomfield Hills offices. Call (810) 206-1402.
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For a complete clinical overview: Heel Pain Causes & Treatment Guide — every cause of foot and heel pain diagnosed
📋 Dr. Tom Biernacki, DPM, FACFAS answers:
The foot conditions I evaluate most commonly in children fall into distinct age-related patterns. In toddlers and young children under 6, flat feet and intoeing (pigeon-toed gait) are the most frequent concerns parents bring in. Most cases are developmental and resolve naturally, but persistent intoeing with tripping or asymmetric flat feet warrant evaluation to rule out structural causes. In school-age children 8 to 14, calcaneal apophysitis (Sever disease) is by far the most common diagnosis — it produces posterior heel pain during and after sports that is often mistaken for a sprain. In teenagers, I see more adult-pattern conditions including plantar fasciitis, stress fractures from competitive sport overload, and bunion development in girls who begin wearing fashion footwear early.
The red flags that prompt urgent evaluation regardless of age are: limping that does not resolve within a few days, refusal to bear weight, a single joint that is swollen and warm (which could indicate septic arthritis or juvenile idiopathic arthritis), and foot pain that is present at rest and not just with activity. For general developmental concerns — in-toeing, flat feet, mild toe-walking — evaluation by 3 to 4 years of age gives enough time for intervention during the most responsive developmental window if treatment is indicated.
Dr. Tom Biernacki, DPM is a board-certified foot & ankle surgeon (ABFAS & ABPM) at Balance Foot & Ankle Specialists in Southeast Michigan. With over a decade of clinical experience, he specializes in heel pain, bunions, diabetic foot care, sports injuries, and minimally invasive surgery. Dr. Biernacki is a member of the APMA and ACFAS, and his patient education content on MichiganFootDoctors.com and YouTube has made him one of the most-followed foot & ankle educators on YouTube.