Flat Feet: What the Research Says About Lifestyle, Geography, and Why It Matters

Flat feet, or a lowered medial arch, are incredibly common—especially in children—and researchers have been piecing together why some people develop them while others don’t. The science points to a mix of lifestyle, mechanical load, environment, and geography. In other words: how we grow up, how we move, and even where we live may all play a role.

One factor that repeatedly shows up in research is body weight. Increased body mass places more pressure on the structures that support the arch, and over time that load can contribute to the arch flattening. In an Ethiopian study of school-aged children, those who were overweight or obese were significantly more likely to have flat feet compared to children with lower body weight. Source: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-023-07082-6

Activity level also matters. A meta-analysis reviewing multiple studies found that children who were less physically active had a higher chance of developing flat feet. The inference is simple: movement strengthens the tissues that stabilize the foot, and less movement means less stimulation for arch development. Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9319536/

Footwear plays a surprisingly large role as well. The same meta-analysis reported that children who wore rigid sports shoes were nearly three times more likely to be diagnosed with flat feet than those wearing more flexible footwear (OR ≈ 2.97). One explanation is that stiff shoes restrict natural foot muscle development compared to barefoot time or lightly structured footwear. Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9319536/

Age and gender also factor in. Younger children naturally have a higher prevalence of flat feet because the arch hasn’t fully developed yet; it often improves with age. Several studies note that flat feet decrease over time, particularly after age six or seven. Boys also tend to show a higher prevalence than girls, with one analysis finding being male increased the odds of flatfoot (OR ≈ 1.33). Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9319536/

From a biomechanics standpoint, the arch acts like a spring that helps store and return energy while also absorbing shock during walking and running. When the arch collapses, the foot tends to roll inward (pronation), the heel may tilt outward (hindfoot eversion), and pressure spreads differently across the foot. Research comparing flat feet and high arches shows clear differences in gait patterns and in how pressure is distributed across the foot. Over time, that shift can contribute to dysfunction or pain in the ankles, knees, hips, and even the lower back. Source example: https://arxiv.org/abs/1012.3816

While lifestyle plays a role, geography and living environment appear to matter more than people expect. One study in Ethiopia found children living in high-altitude highland regions were dramatically more likely to have flat feet than those living in lowland areas (OR ≈ 8.83). The researchers suggested that vitamin D deficiency (linked to sunlight exposure and altitude) might influence bone and arch development. Source: https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-023-07082-6

Urban versus rural living is another major difference. A systematic review and meta-analysis by Xu et al. (2022) found that children living in urban environments were roughly twice as likely to have flat feet as those in rural settings (OR ≈ 2.10). The Ethiopian study reached a similar conclusion, finding urban children were about 2.4 times more likely to exhibit flat feet. Researchers speculate this may be related to more time indoors, less barefoot exposure, more rigid footwear, and less unstructured outdoor play. Source: https://pmc.ncbi.nlm.nih.gov/articles/PMC9319536/ and https://bmcmusculoskeletdisord.biomedcentral.com/articles/10.1186/s12891-023-07082-6

Footwear and terrain patterns differ across regions too. In many rural or lower-income environments, children spend far more time barefoot or in flexible sandals on natural ground surfaces. In urban settings, children often wear stiff closed-toe shoes from a young age and walk mostly on hard pavement—conditions that may limit natural arch development. The Ethiopian research specifically found that wearing closed shoes was associated with higher flat-foot prevalence. Source: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0238001

Prevalence also varies widely by country. For example, one study reported about 29.5% of children in Saudi Arabia had flat feet, while the Ethiopian sample mentioned earlier found about 17.6%. Nutrition, sun exposure, and general growth patterns may shape these differences, especially given the connection between vitamin D, bone formation, and foot structure. Source example: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0238001

Taken together, the research suggests that flat feet are not just a structural issue someone is “born with.” They’re shaped by early childhood environment, movement behavior, footwear choices, body weight, and the surfaces people grow up on. In other words, the body adapts to the world it experiences.

Do Flat Feet Increase Injury Risk? And Can Training Help?

People often assume that having flat feet automatically leads to injuries, but the scientific research isn’t that straightforward. Some studies suggest a connection, while others show little to no relationship between arch height and injury rates.

One study that followed 196 collegiate athletes found that flat feet did not significantly predict lower-extremity injuries when compared to athletes with normal arches.

https://pubmed.ncbi.nlm.nih.gov/12146774/

Another review in the Journal of Orthopaedic & Sports Physical Therapy found that both flat feet and high arches can be associated with injuries, but the strength of the evidence is weak and inconsistent.

https://www.jospt.org/doi/10.2519/jospt.2013.4225

More recently, a 2025 study found that young females with flexible flat feet performed worse on functional movement testing, balance, agility, and core strength, suggesting there may be meaningful performance differences when flat feet impact movement control or stability.

https://www.nature.com/articles/s41598-025-89364-8

So, the risk picture is mixed: flat feet alone do not guarantee problems, but when they appear alongside instability, poor control, or pain, they may contribute to issues further up the chain.

Can Training or Orthotics Improve Flat Feet?

Research is much clearer when it comes to intervention. Multiple studies show that targeted exercises and arch supports can improve arch structure, muscle strength, and alignment in people with flexible flat feet.

A 6-week exercise program focusing on intrinsic foot muscles, posterior tibialis strength, and hip/core stability showed significant improvements in arch height and alignment.

https://pubmed.ncbi.nlm.nih.gov/36526555/

A 2024 network meta-analysis found that combining posterior tibialis strengthening, iliopsoas stretching, and trunk exercises produced the greatest improvements.

https://www.nature.com/articles/s41598-024-72149-w

The well-known “short-foot exercise” has been shown to strengthen intrinsic foot muscles and improve alignment across several trials.

https://www.mdpi.com/1660-4601/19/19/11994

Arch supports can help too. A 9-week study on young soccer players showed measurable increases in intrinsic foot muscle size with orthotic use.

https://bmcsportsscimedrehabil.biomedcentral.com/articles/10.1186/s13102-022-00590-3

My Personal Conclusion

The truth is the jury is still out. Some research suggests flat feet contribute to dysfunction and injury risk, while other studies show minimal impact. What is clear is that structure alone doesn’t tell the whole story—how someone moves, controls load, and manages fatigue may matter far more.

We have a lot more to learn about how flat feet relate to performance and long-term injury risk. In the meantime, each person has to decide what feels right for them: ignore it if there are no symptoms, or explore strengthening, or movement retraining if there’s pain, fatigue, or instability.

Your body is always giving you feedback. Listen to it, experiment, and take responsibility for your own path forward.