Flat feet

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Flat feet
Other namesPes planus, fallen arches
Flatfoot.jpg
Specialty Orthopedics Podiatry

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. Sometimes children are born with flat feet (congenital). 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 so that a majority of the forces incurred during weight bearing on the foot can be dissipated before the force reaches the long bones of the leg and thigh. [1]

Contents

In pes planus, the head of the talus bone is displaced medially and distal from the navicular bone. As a result, the plantar calcaneonavicular ligament (spring ligament) and the tendon of the tibialis posterior muscle are stretched to the extent that the individual with pes planus loses the medial longitudinal arch (MLA). If the MLA is absent or nonfunctional in both the seated and standing positions, the individual has "sigma" 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 is often treated with arch supports. [1]

Children

Foot with a typical arch Male Right Foot 1.jpg
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. Flat feet steps lk.jpg
Flat feet of a child are usually expected to develop into high or proper arches, as shown by feet of the mother.

Studies have shown flat feet are a common occurrence in children and adolescents. The human arch develops in infancy and early childhood as part of normal muscle, tendon, ligament and bone growth. [2] Flat arches in children usually become high arches as the child progresses through adolescence and into adulthood. Children with flat feet are at a higher risk of developing knee, hip, and back pain. A 2007 randomized controlled trial found no evidence for the efficacy of treatment of flat feet in children either from expensive prescribed orthotics (i.e. shoe inserts) or less expensive over-the-counter orthotics. [3] As a symptom itself, flat feet usually accompany genetic musculoskeletal conditions such as dyspraxia, [4] ligamentous laxity or hypermobility.

Diagnosis

Since children are unlikely to suspect or identify flat feet on their own, it is important for adult caregivers to check on this themselves. Besides visual inspection of feet and of the treadwear pattern on shoe soles, caregivers should notice when a child's gait is abnormal, or the child seems to be in pain from walking. Children who complain about calf muscle pains, arch pain, or any other pains around the foot area may be developing or have developed flat feet. A systematic review and meta-analysis study by Xu, et.al., found that urban sedentary boys, aged 6–9, were frequently diagnosed with flatfeet. The researchers also explored and listed additional risk factors that played a role in diagnosing flatfeet. [5]

Treatment

Training of the feet, utilizing 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. 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 child's foot. [7] In children with few symptoms orthotics is not recommended. [8]

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, [9] 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. [10] Flat feet can also occur in pregnant women as a result of temporary changes due to increased elastin (elasticity) during pregnancy; if developed by adulthood, flat feet generally remain flat permanently.

A woman in her thirties dorsiflexes, showing an absence of arches, over-pronated navicular and hallux valgus in the toes typically associated with flat feet. Flat feet soles.jpg
A woman in her thirties dorsiflexes, showing an absence of arches, over-pronated navicular and hallux valgus in the toes typically associated with flat feet.
Flatfoot in a 55-year-old female with ankle and knee arthritis. Adult Flatfoot.JPG
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 plantarflexes, 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 is helpful and will often result in increased arch height regardless of age.[ citation needed ]

Pathophysiology

Research has shown that tendon specimens from people who have 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. [10]

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.[ citation needed ]

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.[ citation needed ]

On plain radiography, flat feet can be diagnosed and graded by several measures, the most important in adults being the talonavicular coverage angle, the calcaneal pitch, and the talar-1st metatarsal angle (Meary's angle). [11] The talonavicular coverage angle is abnormally laterally rotated in flat feet. [11] It is normally up to 7 degrees laterally rotated, so a greater rotation indicates flat feet. [11] Radiographies generally need to be taken on weightbearing feet in order to detect misalignment. [12]

Treatment

Most flexible flat feet are asymptomatic and do not cause pain. In these cases there is usually no cause for concern. 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.[ 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 orthotics will enhance selective activation of the tibialis posterior muscle, thus acting as an adequate treatment for the undesirable symptoms of pes planus. [14]

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. [15] [16] 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. Such a condition can cause severe pain and considerably reduced ability to walk, even with orthoses. Ankle fusion is usually recommended. [17]

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 foot gymnastics or other exercises as recommended by a podiatrist 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 acclimatize to the sensation of wearing orthoses. 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. [18] A minimally invasive surgical intervention involving a small implant is also available. The implant is inserted into the sinus tarsi and prevents the calcaneus and talus from sliding relative to each other. This prevents the sinus tarsi from collapsing and thus prevents the external symptom of the fallen arch from occurring. [19]

Athletic performance

Acquired Flat foot deformity with clinical soft tissue swelling. Acessory Navicular Bone 3.jpg
Acquired Flat foot deformity with clinical soft tissue swelling.

The effects of flat feet fall under two categories, which are asymptomatic and symptomatic. Individuals with rigid flat feet tend to exhibit symptoms such as foot and knee tendonitis and are recommended to consider surgical options when managing symptoms. Individuals with flexible flat generally exhibit asymptomatic effects in response to their flat feet. [2]

According to AAP news and journal gateway, being flexibly flat-footed does not impede athletic performance in children 11-15. [20]

It is generally assumed by running professionals (primarily including some physical trainers, podiatrists, and shoe manufacturers) that a person with flat feet tends to overpronate in the running form. [21] However, some also assert that persons with flat feet may have an underpronating if they are not in a neutral gait. With standard running shoes, these professionals claim, a person who overpronates in his or her running form may be more susceptible to shin splints, back problems, and tendonitis in the knee. [22] 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. [23]

Military performance

Studies analyzing the correlation between flat feet and physical injuries 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.

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 capability, injury rates or bipedal aptitude, although there have been results of military trials that have shown those with flat feet to have fewer injuries. [24]

No current studies have been successful in fully ascertaining the long-term detriments to health caused by the overexertion (necessary for athletes/soldiers performing with flat feet) and other compensating measures commonly enacted by the body during bipedal movement.

Another divergent study of 295 Israel Defense Forces recruits found that those with high arches had almost four times as many stress fractures as those with the lowest arches. [25]

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. [26]

See also

Related Research Articles

<span class="mw-page-title-main">Charcot–Marie–Tooth disease</span> Neuromuscular disease

Charcot–Marie–Tooth disease (CMT) is a hereditary motor and sensory neuropathy of the peripheral nervous system characterized by progressive loss of muscle tissue and touch sensation across various parts of the body. This disease is the most commonly inherited neurological disorder, affecting about one in 2,500 people. It is named after those who classically described it: the Frenchman Jean-Martin Charcot (1825–1893), his pupil Pierre Marie (1853–1940), and the Briton Howard Henry Tooth (1856–1925).

<span class="mw-page-title-main">Foot</span> Anatomical structure found in vertebrates

The foot is an anatomical structure found in many vertebrates. It is the terminal portion of a limb which bears weight and allows locomotion. In many animals with feet, the foot is a separate organ at the terminal part of the leg made up of one or more segments or bones, generally including claws and/or nails.

<span class="mw-page-title-main">Human leg</span> Lower extremity or limb of the human body (foot, lower leg, thigh and hip)

The leg is the entire lower limb of the human body, including the foot, thigh or sometimes even the hip or buttock region. The major bones of the leg are the femur, tibia, and adjacent fibula.

<span class="mw-page-title-main">Bunion</span> Deformity characterized by lateral deviation of the big toe

A bunion, also known as hallux valgus, is a deformity of the MTP joint connecting the big toe to the foot. The big toe often bends towards the other toes and the joint becomes red and painful. The onset of bunions is typically gradual. Complications may include bursitis or arthritis.

<span class="mw-page-title-main">Achilles tendon</span> Tendon at the back of the lower leg

The Achilles tendon or heel cord, also known as the calcaneal tendon, is a tendon at the back of the lower leg, and is the thickest in the human body. It serves to attach the plantaris, gastrocnemius (calf) and soleus muscles to the calcaneus (heel) bone. These muscles, acting via the tendon, cause plantar flexion of the foot at the ankle joint, and flexion at the knee.

<span class="mw-page-title-main">Pes cavus</span> Medical condition

Pes cavus, also known as high arch, is an orthopedic condition that presents as a hollow arch underneath the foot with a pronounced high ridge at the top when weight bearing.

<span class="mw-page-title-main">Plantar fasciitis</span> Connective tissue disorder of the heel

Plantar fasciitis or plantar heel pain is a disorder of the plantar fascia, which is the connective tissue that supports the arch of the foot. It results in pain in the heel and bottom of the foot that is usually most severe with the first steps of the day or following a period of rest. Pain is also frequently brought on by bending the foot and toes up towards the shin. The pain typically comes on gradually, and it affects both feet in about one-third of cases.

<span class="mw-page-title-main">Diseases of the foot</span> Medical conditions affecting the human foot

Diseases of the foot generally are not limited, that is they are related to or manifest elsewhere in the body. However, the foot is often the first place some of these diseases or a sign or symptom of others appear. This is because of the foot's distance from the central circulation, the heart and its constant exposure to pressures from the ground and the weight of the body.

<span class="mw-page-title-main">Tibialis posterior muscle</span> Muscle in the most central of all the leg muscles

The tibialis posterior muscle is the most central of all the leg muscles, and is located in the deep posterior compartment of the leg. It is the key stabilizing muscle of the lower leg.

<span class="mw-page-title-main">Sever's disease</span> Medical condition

Sever's disease, also known as calcaneus apophysitis, is an inflammation at the back of the heel growth plate in growing children. The condition is thought to be caused by repetitive stress at the heel. This condition is benign and common and usually resolves when the growth plate has closed or during periods of less activity. It occurs in both males and females. There are a number of locations in the body that may get apophysitis pain. Another common location is at the front of the knee which is known as apophysitis of the tibial tuberosity or Osgood–Schlatter disease.

<span class="mw-page-title-main">Calcaneal spur</span> Medical condition of the heel

A calcaneal spur is a bony outgrowth from the calcaneal tuberosity. Calcaneal spurs are typically detected by x-ray examination. It is a form of exostosis.

<span class="mw-page-title-main">Accessory navicular bone</span> Accessory bone of the foot that occasionally develops abnormally in front of the ankle

An accessory navicular bone is an accessory bone of the foot that occasionally develops abnormally in front of the ankle towards the inside of the foot. This bone may be present in approximately 2-21% of the general population and is usually asymptomatic. When it is symptomatic, surgery may be necessary.

The Hubscher maneuver is a method of evaluating the flexibility of a pes planus or flat foot type. The test is performed with the patient weight bearing, with the foot flat on the ground, while the clinician dorsiflexes the hallux and watches for an increasing concavity of the Arches of the foot. A positive result results from the flatfoot being flexible. A negative result results from the flatfoot being rigid. In a Jack's test, the patient raises the rearfoot off the ground, thus passively dorsiflexing the hallux in Closed Kinetic Chain. This will result in an increase of the arch height in cases of Dynamic (Flexible) Flat Foot. If the deformity is a Static (rigid) Flat foot, the height of the arch will be unaffected by raising up the heel on the forefoot.

<span class="mw-page-title-main">Orthotics</span> Medical specialty that focuses on the design and application of orthoses

Orthotics is a medical specialty that focuses on the design and application of orthoses, sometimes known as braces, calipers, or splints. An orthosis is "an externally applied device used to influence the structural and functional characteristics of the neuromuscular and skeletal systems." Orthotists are medical professionals who specialize in designing orthotic devices such as braces or foot orthoses.

<span class="mw-page-title-main">Tarsal coalition</span> Abnormal tissue connection between bones of the foot

Tarsal coalition is an abnormal connecting bridge of tissue between two normally-separate tarsal (foot) bones, and is considered a sort of birth defect. The term 'coalition' means a coming together of two or more entities to merge into one mass. The tissue connecting the bones, often referred to as a "bar", may be composed of fibrous or osseous tissue. The two most common types of tarsal coalitions are calcaneo-navicular and talo-calcaneal, comprising 90% of all tarsal coalitions. There are other bone coalition combinations possible, but they are very rare. Symptoms tend to occur in the same location, regardless of the location of coalition: on the lateral foot, just anterior and below the lateral malleolus. This area is called the sinus tarsi.

Children's feet are smaller than those of adults, not reaching full size until the ages of 13 in girls and 15 in boys. There are correspondingly small sizes of shoes for them. In poor populations and tropical countries, children commonly go barefoot.

Haglund's syndrome is a group of signs and symptoms consisting of Haglund's deformity in combination with retrocalcaneal bursitis. It is often accompanied by Achilles tendinitis.

<span class="mw-page-title-main">Calcaneal pitch</span>

The calcaneal pitch is an angle used mainly in the diagnosis and severity grading of flat feet and pes cavus.

Posterior tibial tendon dysfunction is the dysfunction of the posterior tibial tendon. It is a progressive disease that has four stages and is the most common cause of adult flatfoot.

Subtalar arthroereisis is a common treatment for symptomatic pes planus, also known as flatfoot. There are two forms of pes planus: rigid flatfoot (RFF) and flexible flatfoot (FFF). The symptoms of the former typically necessitate surgical intervention. The latter may manifest fatigue or pain, but is typically asymptomatic.

References

  1. 1 2 Franco AH (May 1987). "Pes cavus and pes planus. Analyses and treatment". Physical Therapy. 67 (5): 688–694. CiteSeerX   10.1.1.1018.2649 . doi:10.1093/ptj/67.5.688. PMID   3575426.
  2. 1 2 Harris EJ (January 2010). "The natural history and pathophysiology of flexible flatfoot". Clinics in Podiatric Medicine and Surgery. 27 (1): 1–23. doi:10.1016/j.cpm.2009.09.002. PMID   19963167.
  3. ↑ Whitford D, Esterman A (June 2007). "A randomized controlled trial of two types of in-shoe orthoses in children with flexible excess pronation of the feet". Foot & Ankle International. 28 (6): 715–723. doi:10.3113/FAI.2007.0715. PMID   17592702. S2CID   33684466.
  4. ↑ "Dyspraxia in Adults". www.dyspraxiafoundation.org.uk. 3 October 2013.
  5. ↑ Xu L, Gu H, Zhang Y, Sun T, Yu J (July 2022). "Risk Factors of Flatfoot in Children: A Systematic Review and Meta-Analysis". International Journal of Environmental Research and Public Health. 19 (14): 8247. doi: 10.3390/ijerph19148247 . PMC   9319536 . PMID   35886097.
  6. ↑ Zhou B, Tang K, Hardy M (December 2014). "Talocalcaneal coalition combined with flatfoot in children: diagnosis and treatment: a review". Journal of Orthopaedic Surgery and Research. 9 (1): 129. doi: 10.1186/s13018-014-0129-9 . PMC   4276075 . PMID   25499625. S2CID   16663986. (CC BY 4.0)
  7. ↑ Rao UB, Joseph B (July 1992). "The influence of footwear on the prevalence of flat foot. A survey of 2300 children". The Journal of Bone and Joint Surgery. British Volume. 74 (4): 525–527. doi:10.1302/0301-620X.74B4.1624509. PMID   1624509 – via (quoted in) www.unshod.org/pfbc/pfmedresearch.htm.
  8. ↑ "Five Things Physicians and Patients Should Question" (PDF). Choosing Wisely. Retrieved 15 February 2018.
  9. ↑ "Flat feet: MedlinePlus Medical Encyclopedia". medlineplus.gov. Retrieved 2022-11-18.
  10. 1 2 "Advance toward treatment for painful flat feet". ScienceDaily. 2012-01-11.
  11. 1 2 3 4 5 6 "Pes Planus". University of Washington, Department of Radiology. Last modified: 14 August 2016
  12. ↑ Bell DJ, Weerakkody Y. "Pes planus". Radiopaedia . Retrieved 2018-03-01.
  13. ↑ Detailed explanations and references are located in the Calcaneal pitch article.
  14. ↑ Kulig K, Burnfield JM, Reischl S, Requejo SM, Blanco CE, Thordarson DB (January 2005). "Effect of foot orthoses on tibialis posterior activation in persons with pes planus". Medicine and Science in Sports and Exercise. 37 (1): 24–29. doi: 10.1249/01.mss.0000150073.30017.46 . PMID   15632663.
  15. ↑ "Fallen Arch". Health A to Z. Aetna InteliHealth(R). 2007-12-18. Archived from the original on 2008-08-03. 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.
  16. ↑ "Flatfoot". Bone, Joint and Muscle Conditions: Flatfoot. Seattle Children's Hospital. 2008-07-29. Retrieved 2008-05-27. About one in four people with rigid flatfoot has pain and disability.
  17. ↑ "Rheumatoid Arthritis in Feet - Academic Association of Medicine". aaom.org. 27 February 2018.
  18. ↑ "Flat Feet – Everything You Should Know – The Shoes For Me". theshoesforme.com. 16 October 2015.
  19. ↑ "Can The HyProCure Implant Provide The Answer For Hyperpronation?". podiatrytoday.com.
  20. ↑ Tudor A, Ruzic L, Sestan B, Sirola L, Prpic T (March 2009). "Flat-footedness is not a disadvantage for athletic performance in children aged 11 to 15 years". Pediatrics. 123 (3): e386–e392. doi:10.1542/peds.2008-2262. PMID   19254974. S2CID   9891114.
  21. ↑ "Pronation, Explained." Runner's World. August 2004.
  22. ↑ "Running Shoes for Flat Feet." ShoeGuide.Org. February 2020.
  23. ↑ Hintermann B, Nigg BM (September 1998). "Pronation in runners. Implications for injuries". Sports Medicine. 26 (3): 169–176. doi:10.2165/00007256-199826030-00003. PMID   9802173. S2CID   24812917.
  24. ↑ 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 (7): 623–628. doi: 10.7205/MILMED.170.7.623 . PMID   16130646.
  25. ↑ 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; 14:82–84.
  26. ↑ Jones BH, Thacker SB, Gilchrist J, Kimsey CD, Sosin DM (2002). "Prevention of lower extremity stress fractures in athletes and soldiers: a systematic review". Epidemiologic Reviews. 24 (2): 228–247. doi: 10.1093/epirev/mxf011 . PMID   12762095.
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