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Pediatric flatfoot is ubiquitous with several etiologies, including that of being the normal shape of the child’s foot. More specifically, pediatric flatfoot can be categorized as either flexible or rigid, with the former being more common. Most flexible flatfeet are normal and do not cause pain or functional disability. They should not, in fact, be called deformities at all but, instead, anatomic shape variations. Rigid flatfeet are acquired deformities. Most are caused by tarsal coalitions which, like their flexible counterparts, are also usually asymptomatic. This fact contributes to their under-diagnosis in the general population and makes it imperative to consider the coexistence of a tarsal coalition in a child with foot pain in the setting of flatfoot. There are several etiologies for pain in pediatric feet that happen to be flat, including the association of a tendo-Achilles contracture, the aforementioned tarsal coalitions, muscle overuse in young children, inflammatory arthropathies, accessory naviculars, stress fractures, foreign bodies, infections, tumors, and chronic pain syndromes. They must be identified as such so that specific and targeted treatment can be instituted. Surgical management of symptomatic flatfoot, after failed non-operative treatment, is based on the utilization of osteotomies to correct the anatomic deformities. If the symptomatic flatfoot is associated with a tarsal coalition, surgical treatment may involve resection of the coalition with concurrent or staged deformity correction, or deformity correction alone. In the majority of cases, gastrocnemius recession or tendo-Achilles lengthening is required. Addressing other coincident deformities with the addition of concurrent osteotomies and soft tissue procedures are needed to ensure short and long-term success.