Flat feet

"Flatfoot" redirects here. For the 1973 Italian film, see Flatfoot (film). For the
play by David Williamson, see Flatfoot (play).

Flat feet

Flatfoot.jpg
A flat foot.

Classification and external resources

ICD-10
M21.4, Q66.5

ICD-9
734

DiseasesDB
4852

MedlinePlus
001262

eMedicine
Orthoped/540

MeSH
D005413

Flat feet (also called pes planus or fallen arches) is a postural deformity in
which the arches of the foot collapse, with the entire sole of the foot coming
into complete or near-complete contact with the ground. Some individuals
(an estimated 2030% of the general population) have an arch that simply
never develops in one foot (unilaterally) or both feet (bilaterally).

There is a functional relationship between the structure of the arch of the

foot and the biomechanics of the lower leg. The arch provides an elastic,
springy connection between the forefoot and the hind foot. This association
safeguards that a majority of the forces incurred during weight bearing of the
foot can be dissipated before the force reaches the long bones of the leg and
thigh.[1]

In pes planus, the head of the talus bone is displaced medially and distal
from the navicular. As a result, the spring ligament and the tendon of the
tibialis posterior muscle are stretched, so much so that the individual with
pes planus loses the function of the medial longitudinal arch (MLA). If the
MLA is absent or nonfunctional in both the seated and standing positions, the
individual has rigid flatfoot. If the MLA is present and functional while the
individual is sitting or standing up on their toes, but this arch disappears
when assuming a foot-flat stance, the individual has supple flatfoot. This
latter condition can be correctable with well-fitting arch supports.[1]

Three studies (see citations below in military section) of military recruits

have shown no evidence of later increased injury, or foot problems, due to
flat feet, in a population of people who reach military service age without
prior foot problems. However, these studies cannot be used to judge possible
future damage from this condition when diagnosed at younger ages. They
also cannot be applied to persons whose flat feet are associated with foot
symptoms, or certain symptoms in other parts of the body (such as the leg
or back) possibly referable to the foot.

Flat feet in children

foot with a typical arch

Flat feet of a child are usually expected to develop into high or proper
arches, as shown by feet of the mother.
The appearance of flat feet is normal and common in infants, partly due to
"baby fat" which masks the developing arch and partly because the arch has
not yet fully developed. The human arch develops in infancy and early
childhood as part of normal muscle, tendon, ligament and bone growth.
Training of the feet, especially by foot gymnastics and going barefoot on
varying terrain, can facilitate the formation of arches during childhood, with a
developed arch occurring for most by the age of four to six years. Flat arches
in children usually become proper arches and high arches while the child
progresses through adolescence and into adulthood.

Because young children are unlikely to suspect or identify flat feet on their
own, it is a good idea for parents or other adult caregivers to check on this
themselves. Besides visual inspection, parents should notice whether a child
begins to walk oddly or clumsily, for example on the outer edges of the feet,
or to limp, during long walks, and to ask the child whether he or she feels
foot pain or fatigue during such walks. Children who complain about calf
muscle pains or any other pains around the foot area may be developing or
have flat feet. Pain or discomfort may also develop in the knee joints. A
recent randomized controlled trial found no evidence for the efficacy of
treatment of flat feet in children either for expensive prescribed orthoses
(shoe inserts) or less expensive over-the-counter orthoses.[2]

Treatment

Going barefoot, particularly over terrain such as a beach where muscles are
given a good workout, is good for all but the most extremely flatfooted, or
those with certain related conditions such as plantar fasciitis. Ligament laxity
is also among the factors known to be associated with flat feet. One medical
study in India with a large sample size of children who had grown up wearing
shoes and others going barefoot found that the longitudinal arches of the
bare footers were generally strongest and highest as a group, and that flat
feet were less common in children who had grown up wearing sandals or

slippers than among those who had worn closed-toe shoes. Focusing on the
influence of footwear on the prevalence of pes planus, the cross-sectional
study performed on children noted that wearing shoes throughout early
childhood can be detrimental to the development of a normal or a high
medial longitudinal arch. The vulnerability for flat foot among shoe-wearing
children increases if the child has an associated ligament laxity condition.
The results of the study suggest that children be encouraged to play
barefooted on various surfaces of terrain and that slippers and sandals are
less harmful compared to closed-toe shoes. It appeared that closed-toe shoes
greatly inhibited the development of the arch of the foot more so than
slippers or sandals. This conclusion may be a result of the notion that
intrinsic muscle activity of the arch is required to prevent slippers and
sandals from falling off the childs foot.[3]

Flat feet in adults

Flat feet can also develop as an adult ("adult acquired flatfoot") due to injury,
illness, unusual or prolonged stress to the foot, faulty biomechanics,[4] or as
part of the normal aging process. This is most common in women over 40
years of age. Known risk factors include obesity, hypertension and diabetes.
[5] Flat feet can also occur in pregnant women as a result of temporary
changes, due to increased elastin (elasticity) during pregnancy. However, if
developed by adulthood, flat feet generally remain flat permanently.

Flatfoot in a 55 year-old female with ankle and knee arthritis.

If a youth or adult appears flatfooted while standing in a full weight bearing
position, but an arch appears when the person dorsiflexes (stands on heel or
pulls the toes back with the rest of the foot flat on the floor), this condition is

called flexible flatfoot. This is not a true collapsed arch, as the medial
longitudinal arch is still present and the windlass mechanism still operates;
this presentation is actually due to excessive pronation of the foot (rolling
inwards), although the term 'flat foot' is still applicable as it is a somewhat
generic term. Muscular training of the feet, while generally helpful, will
usually not result in increased arch height in adults, because the muscles in
the human foot are so short that exercise will generally not make much
difference, regardless of the variety or amount of exercise.[citation needed]
However, as long as the foot is still growing, it may be possible that a lasting
arch can be created.

Pathophysiology

Research has shown that tendon specimens from people who suffer from
adult acquired flat feet show evidence of increased activity of proteolytic
enzymes. These enzymes can break down the constituents of the involved
tendons and cause the foot arch to fall. In the future, these enzymes may
become targets for new drug therapies.[5]

Diagnosis

Many medical professionals can diagnose a flat foot by examining the patient
standing or just looking at them. On going up onto tip toe the deformity will
correct when this is a flexible flat foot in a child with lax joints. Such
correction is not seen in adults with a rigid flat foot.

An easy and traditional home diagnosis is the "wet footprint" test, performed
by wetting the feet in water and then standing on a smooth, level surface
such as smooth concrete or thin cardboard or heavy paper. Usually, the more
the sole of the foot that makes contact (leaves a footprint), the flatter the
foot. In more extreme cases, known as a kinked flatfoot, the entire inner
edge of the footprint may actually bulge outward, where in a normal to high
arch this part of the sole of the foot does not make contact with the ground
at all.

Treatment

Most flexible flat feet are asymptomatic, and do not cause pain. In these
cases, there is usually no cause for concern, and the condition may be
considered a normal human variant. Flat feet were formerly a physical-health
reason for service-rejection in many militaries. However, three military
studies on asymptomatic adults (see section below), suggest that persons
with asymptomatic flat feet are at least as tolerant of foot stress as the
population with various grades of arch. Asymptomatic flat feet are no longer
a service disqualification in the U.S. military.[citation needed]

In a study performed to analyze the activation of the tibialis posterior muscle

in adults with pes planus, it was noted that the tendon of this muscle may be
dysfunctional and lead to disabling weightbearing symptoms associated with
acquired flat foot deformity. The results of the study indicated that while
barefoot, subjects activated additional lower-leg muscles to complete an
exercise that resisted foot adduction. However, when the same subjects
performed the exercise while wearing arch supporting orthotics and shoes,
the tibialis posterior was selectively activated. Such discoveries suggest that
the use of shoes with properly fitting, arch-supporting orthics will enhance
selective activation of the tibialis posterior muscle thus, acting as an
adequate treatment for the undesirable symptoms of pes planus.[6]

Rigid flatfoot, a condition where the sole of the foot is rigidly flat even when
a person is not standing, often indicates a significant problem in the bones of
the affected feet, and can cause pain in about a quarter of those affected.[7]
[8] Other flatfoot-related conditions, such as various forms of tarsal coalition
(two or more bones in the midfoot or hindfoot abnormally joined) or an
accessory navicular (extra bone on the inner side of the foot) should be
treated promptly, usually by the very early teen years, before a child's bone
structure firms up permanently as a young adult. Both tarsal coalition and an
accessory navicular can be confirmed by X-ray. Rheumatoid arthritis can
destroy tendons in the foot (or both feet) which can cause this condition, and
untreated can result in deformity and early onset of osteoarthritis of the
joint.[9] Such a condition can cause severe pain and considerably reduced

ability to walk, even with orthoses. Ankle fusion is usually recommended.

[citation needed]

Treatment of flat feet may also be appropriate if there is associated foot or

lower leg pain, or if the condition affects the knees or the lower back.
Treatment may include using orthoses such as an arch support, foot
gymnastics or other exercises as recommended by a podiatrist/orthotist or
physical therapist. In cases of severe flat feet, orthoses should be used
through a gradual process to lessen discomfort. Over several weeks, slightly
more material is added to the orthosis to raise the arch. These small changes
allow the foot structure to adjust gradually, as well as giving the patient time
to acclimatise to the sensation of wearing orthoses. Once prescribed,
orthoses are generally worn for the rest of the patient's life. In some cases,
surgery can provide lasting relief, and even create an arch where none
existed before; it should be considered a last resort, as it is usually very time
consuming and costly.[citation needed]

Running

It is generally accepted by professionals that a person with flat feet tends to

overpronate in his or her running form.[10] However, persons with flat feet
may also have a neutral or underpronating gait. Pronation is a natural form
of shock absorption during running and walking, when the ankle rolls inward
and the weight distribution in the foot shifts medially. Overpronation is
excessive pronation; it disrupts the alignment of the leg and may result in
injuries due to over-stressing of the knee and leg. With normal, or neutral,
running shoes, a person who overpronates in his or her running form may be
more susceptible to shin splints, back problems, and tendonitis in the knee.
[11][dubious ] Running in shoes with extra medial support or using special
shoe inserts, orthoses, may help correct one's running form by reducing
pronation and may reduce risk of injury.[12]

Military studies

Studies analyzing the correlation between flat feet and physical injury in
soldiers have been inconclusive, but none suggests that flat feet are an
impediment, at least in soldiers who reached the age of military recruitment
without prior foot problems. Instead, in this population, there is a suggestion
of more injury in high arched feet. A 2005 study of Royal Australian Air Force
recruits that tracked the recruits over the course of their basic training found
that neither flat feet nor high arched feet had any impact on physical
functioning, injury rates or foot health. If anything, there was a tendency for
those with flat feet to have fewer injuries.[13] Another study of 295 Israel
Defense Forces recruits found that those with high arches suffered almost
four times as many stress fractures as those with the lowest arches.[14] A
later study of 449 U.S. Navy special warfare trainees found no significant
difference in the incidence of stress fractures among sailors and Marines with
different arch heights.[15]

See also

Arches of the foot

Marfan syndrome
Ehlers-Danlos syndrome

References

1.^ a b Franco, Abby Herzog (1987). "Pes Cavus and Pes Planus Analyses and
Treatment.". Physical Therapy 67 (5): 688694.
2.^ Whitford D., Esterman A. (2007). "A randomized controlled trial of two
types of in-shoe orthoses in children with flexible excess pronation of the
feet". Foot and Ankle International (University of South Australia, Spencer

Gulf Rural Health School) 28 (6): p. 71523. doi:10.3113/FAI.2007.0715. PMID

17592702.
3.^ Rao UB, Joseph B (1992). "The influence of footwear on the prevalence of
flat foot. A survey of 2300 children" (PDF). J Bone Joint Surg Br 74 (4): 5257.
PMID 1624509. quoted in http://www.unshod.org/pfbc/pfmedresearch.htm
4.^ http://www.eatmoveimprove.com/2009/11/shoes-sitting-and-lower-bodydysfunctions/[unreliable medical source?]
5.^ a b "Advance toward treatment for painful flat feet". ScienceDaily. 201201-11.
6.^ Kulig, Kornelia et al. (2005). "Effect of foot orthoses on tibialis posterior
activation in persons with pes planus.". Med Sci Sports Exerc 37 (1): 2429.
doi:10.1249/01.mss.0000150073.30017.46.
7.^ "Fallen Arch". Health A to Z. Aetna InteliHealth(R). 2007-12-18. Retrieved
2008-05-27. Unlike a flexible flatfoot, a rigid flatfoot is often the result of a
significant problem affecting the structure or alignment of the bones that
make up the foot's arch.
8.^ "Flatfoot". Orthopedics: Conditions Treated. Children's Hospital and
Regional Medical Center. Retrieved 2008-05-27. About one in four people
with rigid flatfoot has pain and disability.
9.^ http://www.everydayhealth.com/rheumatoid-arthritis/arch-nemesisrheumatoid-arthritis-and-flat-feet.aspx |accessdate= 2015-04-08
10.^ "Pronation, Explained." Runner's World Aug 2004.
11.^ Mata. "Best Running Shoes for Your Feet"
(www.thebestrunningshoestoday.com/choose-best-running-shoes-flat-feet/).
12.^ Hintermann, Beat, and Benno Niggs. "Pronation in Runners: Implications
for Injuries." Sports Medicine 26.3 (1998)
13.^ Esterman A, Pilotto L. (July 2005). "Foot shape and its effect on
functioning in Royal Australian Air Force recruits. Part 1: Prospective cohort
study". Military Medicine 170 (6): p. 6238. PMID 16130646.
14.^ Giladi M, Milgrom C, Stein M, et al. The low arch, a protective factor in
stress fractures: a prospective study of 295 military recruits. Orthop Rev
1985;14:824.

15.^ Jones, Bruce H.; Thacker, Stephen B.; Gilchrist, Julie; Kimsey, Jr., C.
Dexter; Sosin, Daniel (2002). "Prevention of Lower Extremity Stress Fractures
in Athletes and Soldiers: A Systematic Review". Epidemiologic Reviews 24
(2): 228247. doi:10.1093/epirev/mxf011. PMID 12762095.

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