Flat foot

Pathophysiology of Flat Foot

The pathophysiology of flatfoot, step by step, involves a number of complex mechanisms that can vary depending on the type of flatfoot (flexible, rigid) and individual factors. Here is a simplified explanation of the main stages of the pathophysiology of flat foot:

1. Resting Arch Failure: The normal arch of the foot exhibits a slight curvature when an individual is in a standing position. In the case of flat foot, this arch is collapsed, even when resting, resulting in a flatter appearance under the sole of the foot.
2. Collapse of the Arch during Loading: When body weight is applied to the foot, the arch of the foot can collapse further. In flexible flatfoot, this sagging may be temporary, and the arch may return to its normal shape when the pressure is removed.
3. Muscle Weakness: Strength in the muscles of the foot and ankle, particularly the tibialis posterior muscle, is essential for maintaining the arch of the foot. Muscle weakness can contribute to arch collapse.
4. Ligament Laxity: Excessive laxity of the ligaments can allow abnormal movement of the joints of the foot, thereby contributing to arch collapse.
5. Hyperpronation: When the arch of the foot collapses excessively, it can lead to hyperpronation, which is excessive inward rolling of the foot when walking or running.
6. Change in Load Distribution: Due to the change in the structure of the foot, the load distribution during walking may be altered, leading to increased pressure on certain parts of the foot.
7. Impact on Adjacent Joints: Changes in the structure of the foot can impact adjacent joints, such as the ankle, knees and hips, contributing to pain and mobility issues.
8. Development of Complications: Over time, untreated flat foot can lead to the development of complications, such as plantar fasciitis, joint problems and premature shoe wear.

The pathophysiology of flat foot is influenced by genetic, anatomical, muscular and environmental factors. Treatment will depend on the severity of symptoms and may include conservative interventions, such as wearing supportive shoes, orthotics, muscle strengthening exercises, or in some cases, surgery.

A Day in the Life of Someone Suffering from Having Flat Foot

7:00 AM: Waking Up with Stiffness

Mark, a 35-year-old office worker, wakes up with a familiar sense of stiffness and discomfort in his feet. For someone with flat feet, the mornings often start with pain, as his arches provide inadequate support. As he gets out of bed, Mark carefully stretches his feet, hoping to alleviate some of the tightness that has accumulated overnight. The condition, known as flat foot or pes planus, means that the arches of his feet are lower than usual, leading to discomfort and imbalance.

8:00 AM: Navigating the Morning Routine

Getting ready for work is a calculated process for Mark. He chooses footwear with extra support and custom orthotics, which help to reduce the strain on his arches. Even with these adjustments, standing for prolonged periods can be challenging. In the shower, Mark uses a mat to provide extra cushioning, and while preparing breakfast, he sits on a stool to avoid standing too long. These small changes make a significant difference in managing the pain.

9:00 AM: The Commute

Mark’s daily commute involves a short walk to the bus stop. This seemingly simple task becomes more arduous because of his flat feet. Walking on hard surfaces without proper arch support can lead to pain that radiates up his legs, affecting his knees and lower back. He’s learned to pace himself, walking slowly and deliberately to minimize discomfort. Mark’s backpack is packed lightly, as additional weight can exacerbate the pain.

10:00 AM: Office Challenges

Upon arriving at the office, Mark faces the first challenge of his workday: sitting at his desk for long periods. Though sitting relieves some pressure from his feet, staying in one position too long can lead to stiffness and discomfort. To manage this, Mark takes regular breaks to stretch and walk around. His ergonomic desk chair provides additional lumbar support, helping him maintain proper posture and alleviate back pain.

12:00 PM: Lunchtime Relief

Lunch offers a welcome break from sitting. Mark takes this opportunity to walk to a nearby park, where he can stretch his legs and get some fresh air. He practices specific exercises recommended by his physiotherapist to strengthen his foot muscles and improve flexibility. These exercises help manage his condition and prevent the pain from worsening. While others might overlook such routines, they are essential for Mark’s well-being.

3:00 PM: Afternoon Fatigue

As the afternoon progresses, fatigue sets in. The constant strain on Mark’s feet and legs makes it difficult to maintain focus. He experiences pain that shoots up his shins, a common symptom for those with flat feet. Mark employs techniques such as seated calf raises and foot massages to manage his discomfort, knowing that self-care is crucial in preventing further issues.

5:00 PM: Heading Home

The journey home is much like the morning commute, a test of patience and resilience. Mark stops by a grocery store, mindful of the weight he carries. Choosing ingredients for a simple dinner, he focuses on maintaining a balanced diet that supports his overall health. The walk back home, though brief, serves as a reminder of the continuous battle he faces against flat foot pain.

6:30 PM: Evening Exercise

In the evening, Mark heads to the local gym for a workout tailored to his condition. He focuses on low-impact exercises such as cycling and swimming, which strengthen his leg muscles without putting undue pressure on his arches. The gym provides a sense of accomplishment, reminding Mark that, despite his flat feet, he can still lead an active lifestyle. Exercise is a vital component of his routine, offering both physical and mental benefits.

9:00 PM: Relaxation and Reflection

As the day winds down, Mark finds solace in relaxing at home. He practices mindfulness meditation to manage the stress and anxiety associated with chronic pain. This time for reflection helps him maintain a positive outlook despite the challenges. Mark is hopeful about the future, knowing that with consistent care and attention, he can manage his condition effectively.

11:00 PM: Preparing for Rest

Mark prepares for bed, knowing that restful sleep is crucial for his recovery. He elevates his feet with pillows to reduce swelling and reviews his daily routine, considering any adjustments needed for tomorrow. Despite the difficulties, Mark remains resilient, understanding that his flat feet do not define him but rather highlight his strength and determination.

Complications of Flat Foot: A Chain Reaction

Flat foot, or pes planus, not only affects the foot itself but can lead to a series of biomechanical complications throughout the body. The collapse of the foot’s arch disrupts the alignment of the legs, pelvis, and spine, triggering a chain reaction that can affect joints, muscles, and tendons from the tibia to the occiput. The key to understanding these complications lies in the interconnectedness of the musculoskeletal system and how a problem in one area, such as the feet, can cascade upward, impacting other structures.

Internal Tibial and Femoral Torsion

When the arches of the foot collapse, it causes the foot to pronate, meaning the ankle rolls inward. This inward rotation of the foot alters the alignment of the tibia (shinbone), leading to internal tibial torsion. This torsion creates abnormal stress on the knee joint, forcing it to compensate for the misalignment. As the tibia twists inward, the femur (thigh bone) follows suit, resulting in internal femoral torsion. This rotation at both the tibial and femoral levels places considerable strain on the knee, which can lead to patellofemoral pain syndrome (pain around the kneecap), and wear down the cartilage, potentially contributing to osteoarthritis over time.

Knee Complications

The abnormal inward rotation of the tibia and femur causes the knee joint to experience excessive pressure and mechanical imbalance. This misalignment shifts the load away from the knee’s natural shock-absorbing mechanisms, leading to strain on the ligaments and tendons around the joint. Over time, this can cause issues such as medial knee pain and meniscal damage, increasing the risk of injury and degenerative changes. The knee’s altered biomechanics can also lead to iliotibial (IT) band syndrome, a painful condition in which the IT band, a thick band of tissue running along the outside of the thigh, becomes irritated due to the changes in leg alignment.

Hip and Pelvic Misalignment

The torsional effects of flat foot extend upwards to the hip joint, which is now forced to rotate internally as the femur follows the twisting tibia. This internal rotation affects the positioning of the pelvis, which can become misaligned as a result. The pelvic misalignment may cause hip pain and dysfunction, particularly affecting the muscles around the hips, such as the gluteus medius, which plays a key role in stabilizing the pelvis. Over time, these compensatory changes can lead to trochanteric bursitis, a condition where the bursa (fluid-filled sac) near the hip becomes inflamed due to altered movement patterns.

Lombosacral Tension

As the pelvis tilts and rotates to accommodate the changes in leg alignment, the lower spine is next to be affected. The lumbar region experiences increased tension, particularly at the lumbosacral junction (where the lumbar spine meets the sacrum). The flattening of the feet causes the pelvis to tilt anteriorly (forward), increasing the lordotic curve (inward curve) of the lumbar spine. This exaggerated curve places strain on the vertebral discs and muscles of the lower back, leading to lumbosacral pain, sciatica, and the risk of disc herniation over time.

Thoracic Spine and Occiput

As the lumbar spine compensates for pelvic misalignment, the ripple effect continues up the spine to the thoracic region (mid-back). The muscles in this area become overworked as they try to stabilize the body, leading to stiffness and pain. Furthermore, the misalignment can extend all the way to the cervical spine (neck) and occiput (base of the skull). Flat feet, through this upward chain reaction, can contribute to tension headaches and neck pain due to increased tension in the muscles and ligaments connecting the head to the cervical and thoracic regions.

Stages of Compensatory Changes

1. Foot and Ankle: The collapse of the arch leads to overpronation, internal tibial torsion, and ankle instability.
2. Knee: Internal tibial torsion causes abnormal rotation at the knee joint, increasing stress on ligaments and cartilage.
3. Hip and Pelvis: Internal femoral torsion leads to pelvic misalignment, increasing strain on hip muscles and joints.
4. Lumbosacral Spine: Pelvic tilt and compensatory changes in the lumbar spine result in increased lumbar lordosis and potential lower back pain.
5. Thoracic and Cervical Spine: As compensations continue upward, tension develops in the thoracic spine and cervical spine, potentially leading to headaches and upper back pain.

Recommendation

1. Medical Consultation: The first step is to consult a healthcare professional, such as a podiatrist or orthopedist, to obtain an accurate diagnosis. This will help determine the underlying cause of flat foot and develop a suitable treatment plan.
2. Proper Footwear: Wearing supportive, well-fitting shoes is essential. Shoes with good arch support and adequate cushioning can help reduce symptoms.
3. Orthotics: Custom orthotics or orthotic insoles may be recommended to provide additional arch support and correct excessive pronation.
4. Muscle Strengthening Exercises: Targeted exercises aimed at strengthening the muscles of the foot and ankle can help stabilize the arch of the foot. A healthcare professional can recommend specific exercises.
5. Weight Control: If being overweight is a contributing factor, losing weight can reduce pressure on the feet and improve flatfoot symptoms.
6. Pain Treatment: Methods to relieve pain, such as application of ice, non-steroidal anti-inflammatory drugs (NSAIDs) on medical advice, may be used to manage discomfort.
7. Avoid High-Impact Activities: Limiting high-impact activities can reduce strain on the feet. Low-impact alternatives such as swimming can be considered.
8. Surgical Correction (as a last resort): In cases that are severe and resistant to conservative treatment, surgery may be considered to correct the underlying structural or joint abnormalities.

Osteopathy

It is important to note that osteopathy does not aim to structurally correct a flat foot, but rather to treat the associated symptoms by working on the mobility and balance of the body. Here are some osteopathic techniques that can be used to address the symptoms of flat foot:

1. Work on Muscles and Tendons: The osteopath can use myofascial release techniques to relax the muscles of the foot, particularly the posterior tibial muscle, which is crucial for maintaining the arch of the foot.
2. Ankle Mobilization: Mobilization techniques can be applied to the ankle to improve the flexibility and mobility of this joint, which can impact posture and function of the foot.
3. Work on the Posterior Chain: The osteopath can also work on other parts of the body, such as the knees, hips and lower back, because these areas are interconnected. By treating the posterior chain, the osteopath can help reduce tensions that could influence flat foot.
4. Education and Postural Advice: The osteopath can provide advice on posture, walking and ergonomics to help the patient better manage the symptoms of flat foot on a daily basis.

However, it is important to note that osteopathy cannot necessarily structurally correct a flat foot. Structural changes, such as bone abnormalities, often cannot be changed by osteopathic techniques.

Before choosing osteopathy as a treatment approach for flat foot, it is recommended to consult a healthcare professional who specializes in foot disorders, such as a podiatrist or orthopedist. These experts can assess the situation thoroughly, provide an accurate diagnosis and recommend appropriate treatment approaches, which may include osteopathy in addition to other interventions.

Work on muscles and tendons in osteopathy

Working on muscles and tendons is an important component of the osteopathic approach to treating symptoms associated with flat foot. Here are some specific osteopathic techniques that can be used to target the muscles and tendons of the foot in the context of flat foot:

1. Myofascial Release: The osteopath can use myofascial release techniques to release tension in the muscles of the foot. This involves applying gentle, continuous pressure to tight areas to release restrictions in the fascia, the membrane that surrounds the muscles.
2. Calf Muscle Stretching: Specific stretches of the calf muscles, such as the gastrocnemius complex and soleus, may be prescribed to improve the flexibility of these muscles. These stretches can help relieve tension on the arch of your foot.
3. Trigger Point Techniques: The osteopath can identify and treat trigger points, which are areas of localized muscle tension. By applying precise pressure to these points, the osteopath seeks to release tension and improve muscle function.
4. Work on the Posterior Tibial Muscle: The posterior tibial muscle is crucial for supporting the arch of the foot. The osteopath can apply specific techniques to release tension in this muscle, thus promoting its correct function.
5. Muscle Strengthening Exercises: In addition to osteopathic techniques, specific muscle strengthening exercises can be prescribed. This may include exercises to strengthen the tibialis posterior, hallucis flexor muscles, intrinsic muscles, and other muscles that support the arch of the foot.
6. Self-Management Education: The osteopath can provide advice on self-management, including self-massage techniques, home exercises, and advice on posture and walking.

Exercise and stretching for those with flat feet

Exercises and stretches can help strengthen muscles, improve stability, and alleviate symptoms associated with flat feet. However, it is important to consult a healthcare professional before beginning any exercise program, especially if you have any pre-existing health conditions. Here are some exercises and stretches that may benefit those with flat feet:

Muscle Strengthening Exercises

1. Heel Raise:
   • Standing, slowly lift your heels off the floor, standing on your tiptoes.
   • Hold the position for a few seconds, then lower your heels.
   • Repeat the movement to strengthen your calf muscles.
2. Foot Puppet:
   • Sitting or standing, imagine that your big toe is a puppet.
   • Slowly raise your big toe while keeping the other toes on the ground.
   • Lower the big toe and raise the others.
   • Alternate between movements to strengthen the intrinsic muscles of the foot.
3. Resisted Plantar Flexion:
   • Sit with an elastic band around the top of your foot and hang it on a stationary surface.
   • Slowly flex the foot inward against the resistance of the band.

Stretching

1. Calf Stretch against the Wall:
   • Place your hands against a wall, one leg bent forward, the other extended backwards.
   • Keep your back heel on the floor and bend your front knee slightly to stretch your calf.
   • Hold the position for 20 to 30 seconds and repeat on the other side.
2. Achilles Tendon Stretch:
   • Get into a lunge position, with your front foot bent and your back foot extended.
   • Keep the back heel on the ground and lean forward slightly to stretch the Achilles tendon.
   • Hold the position for 20 to 30 seconds and switch sides.
3. Stretching the Anterior Tibial Muscle:
   • On your knees, sit back on your heels.
   • Bend one knee forward, keeping the other leg tucked under you.
   • You should feel the stretch on the top of your foot and ankle.
   • Hold the position for 20 to 30 seconds and switch sides.

These exercises and stretches can help strengthen foot muscles, improve stability, and alleviate flat foot symptoms. However, it is crucial to do them regularly and properly.

Conclusion

Flat feet, or pes valgus, is a common condition that can range from being a benign anatomical variation to causing significant discomfort and mobility issues. The condition can stem from a variety of causes, including genetic predispositions, muscular imbalances, or acquired factors such as aging, injury, and obesity. Understanding the specific type of flat foot—whether flexible, rigid, or acquired—is crucial for determining the most effective treatment approach.

Managing flat feet often involves a combination of interventions tailored to the individual’s needs and the severity of their condition. Non-invasive measures such as wearing supportive footwear, using custom orthotics, and engaging in muscle strengthening exercises can significantly improve symptoms and enhance foot stability. Osteopathy offers additional support by focusing on muscle and tendon work, promoting better foot alignment and relieving associated symptoms through targeted techniques.

While conservative treatments are effective for many, surgical options may be considered in severe cases where other measures fail. Importantly, early intervention and preventive practices, like proper footwear from a young age, can help mitigate the development and progression of flat feet.

Ultimately, a multidisciplinary approach that includes consultation with healthcare professionals, such as podiatrists and orthopedic specialists, is essential for a comprehensive assessment and personalized treatment plan. By addressing the underlying causes and symptoms of flat feet, individuals can improve their quality of life and reduce the risk of related complications, such as knee, hip, and back pain.

References

Books

1. Coughlin, M. J., Saltzman, C. L., & Anderson, R. B. (2007).Mann’s Surgery of the Foot and Ankle (9th ed.). Philadelphia, PA: Elsevier Saunders.
   • This comprehensive book covers various foot and ankle conditions, including flat foot, and provides detailed surgical and non-surgical treatment options.
2. Nigg, B. M., & Emery, C. (2016).Biomechanics of the Musculoskeletal System (3rd ed.). Wiley-Blackwell.
   • A detailed examination of the biomechanics of flat feet, this book includes insights into the causes and potential treatments for the condition.

Journal Articles

3. Van Boerum, D. H., & Sangeorzan, B. J. (2003). Biomechanics and Pathophysiology of Flat Foot. Foot and Ankle Clinics, 8(4), 659-670.
   • This article discusses the biomechanics and underlying pathophysiology of flat foot, providing insights into its development and impact on gait.
4. Degenhardt, B. F., et al. (2007). Osteopathic Treatment of Foot Pain: A Randomized Controlled Trial. Journal of the American Osteopathic Association, 107(5), 197-205.
   • This study explores the effectiveness of osteopathic treatments for foot pain, including flat feet, highlighting therapeutic approaches and outcomes.
5. Evans, A. M., & Rome, K. (2011). A Cochrane Review of the Evidence for Non-Surgical Interventions for Flexible Pediatric Flat Feet. European Journal of Physical and Rehabilitation Medicine, 47(2), 177-190.
   • This review evaluates non-surgical interventions for pediatric flat feet, including exercise and orthotics, assessing their effectiveness and impact on children.
6. Redmond, A. C., Crosbie, J., & Ouvrier, R. A. (1999). Development and Validation of a Novel Rating System for Scoring Standing Foot Posture: The Foot Posture Index. Clinical Biomechanics, 14(3), 214-220.
   • This article introduces the Foot Posture Index, a tool used to assess foot posture and evaluate flat foot, providing a standardized approach to diagnosis.

Reviews

7. Kulthanan, T., et al. (2015). Flatfoot: Epidemiology and Etiology. Journal of Orthopaedic Science, 20(6), 1024-1029.
   • A comprehensive review of the epidemiology and etiology of flat foot, exploring the prevalence and potential causes of this condition.
8. Mosca, V. S. (2010). Flexible Flatfoot in Children and Adolescents. Journal of Children’s Orthopaedics, 4(2), 107-121.
   • This review article examines flexible flatfoot in children and adolescents, discussing its natural progression and possible interventions.
9. Falter, L. B., & Menger, M. M. (2020). Flatfoot and Its Surgical Treatment: A Systematic Review. Journal of Clinical Medicine, 9(11), 3558.
   • This systematic review analyzes surgical treatment options for flatfoot, comparing outcomes and effectiveness across different procedures.

Websites

10. American Orthopaedic Foot & Ankle Society (AOFAS). Flatfoot. https://www.aofas.org/footcaremd/conditions/ailments-of-the-foot/flatfoot
    • A reliable resource providing information about flatfoot, its causes, symptoms, and treatment options, including conservative measures and surgical interventions.
11. National Health Service (NHS). Flat Feet. https://www.nhs.uk/conditions/flat-feet/
    • The NHS website offers an overview of flat feet, including symptoms, causes, diagnosis, and treatment recommendations.

Osteopathic Resources

12. Chila, A. G. (2010).Foundations of Osteopathic Medicine (3rd ed.). Lippincott Williams & Wilkins.
    • This book provides a detailed look at osteopathic principles and practices, including techniques for managing flat foot symptoms.
13. Hertling, D., & Kessler, R. M. (2006).Management of Common Musculoskeletal Disorders: Physical Therapy Principles and Methods (4th ed.). Lippincott Williams & Wilkins.
    • This book outlines various physical therapy methods and osteopathic techniques for managing musculoskeletal disorders, including flat foot.

Clinical Studies

14. Roth, S., et al. (2017). Effects of Foot Orthotics on the Treatment of Flexible Flatfoot in Children: A Randomized Controlled Trial. Journal of Pediatrics and Child Health, 53(10), 943-947.
    • A clinical study examining the effects of foot orthotics on children with flexible flatfoot, evaluating improvements in foot posture and pain reduction.
15. Cheung, R. T., & Ng, G. Y. (2014). Efficacy of Motion Control Shoes for Reducing Excessive Rearfoot Motion in Adults with Flat Foot. Journal of Foot and Ankle Research, 7(1), 19.
    • This study investigates the efficacy of motion control shoes in reducing excessive rearfoot motion in adults with flat foot, highlighting their impact on gait mechanics.