Objectives Paediatric flatfoot is a common presentation with prevalence estimates of 15%. Some flatfeet can result in pain and altered gait. No optimal strategy, nor consensus, for non-surgical management of paediatric flat feet has been identified. The efficacy of common practice in interventions for paediatric flatfeet require objective evaluation.

Method We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE (to 12 March, 2018), including all randomised and quasi-randomised trials of non-surgical interventions for paediatric flatfeet. The primary outcomes were pain reduction and adverse events; secondary outcomes included disability involving the foot, goniometric measurements, quality of life and patient comfort. Two authors independently extracted data, assessed the risk of bias of included trials, and assessed the quality of the body of evidence for the main outcomes, with a third author using GRADE. A fourth author arbitrated any dissent.

Results There are 12 studies (912 children) which overall compared shoes to foot orthoses and the effects over 2 months to 5 years on foot posture, pain, gait function, and quality of life. There were four distinct diagnostic groups of children included across the 12 trials: • JIA: 2 trials, n=100, ages 5–19 years, duration of trials were three to six months. • Immediate effects for a) flatfeet/pain: 1 trial, n=21, ages 8–13 years; b) flatfeet/no pain: 1 trial, n=50, mean age 7.76 years • DCD: 1 trial, n=14, ages 6–11 years (only boys), duration of trial was 7 weeks. • asymptomatic flatfeet in healthy children: 7 trials, n= 505, ages 11 months - 15 years, trial durations 8 weeks - 5 years. The main outcomes reported were: pain, gait and function, health-related quality of life, foot x-rays. The updated version at Cochrane Library is ‘in progress’: DOI: 10.1002/14651858.CD006311.pub2

Conclusions The evidence from randomised controlled trials is inconsistent and limited. In the absence of overt symptoms, the use of expensive, customised foot orthoses has no strong evidence to support this intervention. The meta-analysis for children with JIA and painful flatfeet shows that the effectiveness of mechanical and physical therapies for lower limb problems in JIA remains unclear.