Definition
- Physiological variants referred with parental concern that resolve without treatment
Clinical Features
Common variants
- Flexible flatfoot, arch develops through the first decade
- Metatarsus adductus, flexible forefoot adduction with neutral hindfoot
- Calcaneovalgus foot of the newborn from intrauterine position
- In toeing from internal tibial torsion or femoral anteversion
- Out toeing in infants from external rotation contracture of the hip
- Curly toes, usually third and fourth toes
- Overriding fifth toe
- Toe walking in early walkers
Assessment
- Staheli rotational profile with foot progression, thigh foot angle and hip rotation
- Tiptoe test and Jack test confirm a flexible arch
- Full neurological examination and spine inspection
Red flags
- Pain, night pain or systemic symptoms
- Rigid or stiff foot
- Unilateral or progressive deformity
- Neurological signs or developmental delay
Investigations
- No imaging for painless flexible variants
- Standing radiographs only for pain, rigidity or red flags
Management
- Reassurance and education of parents
- Normal footwear, barefoot activity encouraged
- Shoe inserts do not change arch development (Wenger 1989 RCT)
- Stretching for flexible metatarsus adductus in infants
- Serial casting for metatarsus adductus that is stiff and persists
- Discharge without follow up when no red flags
Prognosis
- Most flexible metatarsus adductus resolves in the first years
- Internal tibial torsion corrects by about age 4
- Femoral anteversion corrects by about age 8 to 10
- Curly toes often improve, flexor tenotomy if symptomatic
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.