by: Scott Kilberg DPM
Flat feet are universally known to have a bad reputation for causing discomfort and pain. Although this is generally true, flat feet are extremely common and there are entire populations of people around the world with flat feet who have no problems with walking or standing. Within our population in the western world, shoe use is common and feet do not become acclimated to functioning with flat feet well as in other parts of the world where shoes are not worn much from an early age. In essence, while flat feet do cause their fair share of foot problems, it is quite normal to have them and under other biological circumstances flat feet would not pose an issue. It would seem that the combination of our shoe use (albeit necessary in modern life), relatively sedentary lifestyle, and the hard surfaces we must walk upon all give rise to issues associated with flat feet.
Flat feet are usually the result of one’s own genetics inherited from their family. Flattening is a normal part of the walking cycle of the foot, and in fact this is how the body disperses much of the shock forces created with walking. However, in some individuals, the foot flattens outward too much. This changes the way certain muscles in the foot and leg have to function, which causes numerous changes to the feet over time. These changes can include chronic straining of ligaments and tendons, as well as the development of deformities that rely on structural imbalance like bunions and hammertoes. Some people may live their entire lives without having any problems, while some people may have pain starting in childhood.
Because of extra demand on foot and leg muscles, people with flat feet become fatigued easier, with leg pain or cramping after activity. The vast majority of the time, a general discomfort or even pain is felt to the bottom of the feet, primarily in the arches. Severely flattened feet may cause hip, knee, or back pain, as the strain endured by the foot eventually transfers to the ligaments of joints further up the leg. In the most severe cases, early arthritis may develop in a number of joints in the feet. As stated above, individuals with flat feet may develop bunions and hammertoes over time, and are more susceptible to injuring their heel and arch. The most common condition I see in my office related to flat feet is plantar fasciitis, which involves damage to the plantar fascia, a ligament that attaches to the heel and runs along the arch. Often misunderstood to be caused by a heel spur (which may be present but almost never causes pain), plantar fasciitis is nearly always directly related to arch strain caused by flat feet, and has little to do with the heel itself. High arches can cause plantar fasciitis, but for completely different reasons.
Many people have flat feet, but assume their foot is normal arched as they can see an arch when they sit and examine their feet. The foot naturally curves inward into an arched position while seated, even in people with flat feet; misleading one into thinking the arch is higher. Flat feet need to be assessed when one is standing and placing body weight on the feet. Sometimes, the flattening is not obvious, but still affects the function of the foot nonetheless. X-rays taken while one is standing on their feet provide the most insight into the foot’s true structure, as the bones show obvious changes in position not always seen outside the body.
There are numerous ways to treat flat feet. Some are more effective than others. Prescription shoe inserts are effective for the vast majority people with flat feet. Many people start with over-the-counter inserts to build up arch support. For people with more than just a mild amount of flattening, this will not likely be supportive enough. Most over-the-counter inserts rely on padding to push into the arch to decrease its flattening. Padded material will significantly compress when the body’s weight is applied to it, leaving the support level decreased. Some over-the-counter insert designs are composed of a plastic or composite material that are more supportive, but are poorly tolerated since they are not customized to a person’s specific foot, and can cause further irritation. In order to truly support the arch to the fullest degree, one must use inserts not only made from a mold of their foot, but from a mold made while the foot is held in a specific position that eliminates flattening. These types of inserts are called orthotics, and are used medically across the country to stabilize flat feet. When properly made, orthotics will eliminate over-flattening. If made from a mold in which only the shape of the foot was captured but no adjustment was made to correct the flattening, the insert will simply reflect the flat foot and will be much less effective. This is seen sometimes when orthotics are fabricated through those who have poor training in foot mechanics. There are also many instances now in which retail locations have entered the ‘orthotic fad’, and provide inserts they claim to be orthotics. In actuality, many of these inserts are simply over-the-counter devices that are pulled off the shelf using rudimentary measurements that these stores are claiming to be a custom process. Don’t be fooled by these lesser devices and pay large sums of money unnecessarily. True orthotics are a prescription product that requires a detailed foot exam by a foot specialist (usually a podiatrist), along with a written prescription plan and insert modification specific to a person’s foot (alot of angles and adjustment go into the process of making orthotics beyond simply obtaining a mold of the foot to be condition-specific). Treatment with prescription orthotics is generally successful in controlling many symptoms associated with flat feet and the conditions that are due to flat feet, as long as the foot is still flexible. If the flat foot is rigid, or stiff, orthotics will not help. Orthotics realign the foot to allow it to function properly, and over time will help prevent further progression of associated problems like bunions and hammertoes, and conditions linked to foot strain like tendonitis and plantar fasciitis. However, orthotics will not cure these conditions if they have fully developed, as deformities require surgery to fix and inflammation from foot strain requires medication and rest. Orthotics function as long-term maintenance devices for more serious conditions, most importantly eliminate the fatigue associated with flat feet. Properly supportive shoes are also a necessity in this equation, as without stiffer soled more supportive shoes, orthotics have to fight with the shoe to function properly, reducing their effectiveness.
Unfortunately, severe cases of flat feet where there is a severe deformity, or where the foot is fixed in a flattened position, require surgery to reform the foot into a more functional shape. In these cases, orthotics and supportive shoes are insufficient in stabilizing the foot. Even leg bracing is usually not enough to control the abnormal forces acting on the foot in these cases. Reconstruction is often the only answer in these relatively uncommon situations. There are a multitude of different types of procedures to correct a flat foot, each addressing a specific component of flat feet in order to provide the most effective relief. Since the deformity in a flat foot involves numerous directions of motion, the surgical correction of the deformity has to take all this into account, and be planned based on the specific mechanics of the foot’s abnormal motion. Recovery from these procedures generally involves a period of non-weightbearing, and can take several months depending on the complexity of the reconstruction. This surgery is performed by podiatrists and some orthopedic surgeons trained in the foot and ankle, and can be quite successful in many cases.
As you can see, many factors go into the identification and treatment of flat feet. Usually only a simple prescription devise is needed in the shoes to counteract the foot’s tendency to collapse the arch, which helps to prevent many of the foot problems associated with flat feet. Surgery is needed in advanced cases, which is generally very successful. Although many people with flat feet have no problems, it is simply a matter of time before they eventually develop, as our western feet are not well conditioned to function with flat feet overall.
Dr. Olga Garcia Luepschen and the Gentle Foot Care Center are located 2 Ryant Blvd (on US27) can be reached 314-9255(walk). Check us out at www.gentlefootcarecenter.com
Gentle Foot Care Center 