Flat foot, also known as pes valgus, is a condition in which the arch of the foot is less pronounced, leading to increased contact of the foot with the ground.

Introduction

Flat feet, also known as pes valgus, is a common podiatric condition characterized by a decrease or absence of the longitudinal arch of the foot. It can occur in early childhood or develop over time in adults. Flat feet can be hereditary or result from factors such as injury, obesity or underlying medical conditions.

One of the main concerns with flat feet is insufficient arch support, which can lead to problems such as foot pain, knee pain, hip pain, and back pain. People with this condition may also experience increased fatigue when walking or running.

Treatment for flat feet depends on the severity of the symptoms and the underlying cause. Non-invasive options include wearing appropriate shoes with good arch support and using orthotic insoles. Foot and ankle muscle strengthening exercises may also be recommended to improve stability.

In some more serious cases, surgery may be considered to reconstruct or repair the ligamentous structures that support the arch of the foot. However, most people with flat feet can manage their symptoms with conservative measures.

It is essential to raise awareness about flat feet and promote preventive practices such as wearing appropriate shoes from a young age. Parents should be alert to signs of flat feet in their children, such as rapid fatigue when walking or complaints of foot pain.

Classification

Flexible flat foot (correctable)


Flexible flatfoot, also called correctable flatfoot, is a condition in which the arch of the foot collapses when there is pressure placed on the foot, but it can usually return to its normal shape when the weight is removed. Unlike the rigid flatfoot which maintains a flat arch at all times, the flexible flatfoot allows some flexibility of the arch depending on the movements and loads applied.

Here are some features of the flexible flat foot:

  1. Temporary Sagging: When the person stands or walks, the arch of the foot may sag, giving the appearance of a flat foot. However, it can return to its normal shape when the weight is removed.
  2. Flexibility: The flexible flat foot is associated with a certain flexibility in the arch of the foot, which allows the foot to adapt to the different pressures exerted during walking or running.
  3. Absence of Pain: In many cases, people with flexible flatfoot do not experience pain associated with the condition. However, some people may experience mild discomfort or increased fatigue.
  4. Common in Children: Flexible flatfoot is common in children due to the continued development of musculoskeletal structures. In some children, the arch of the foot fully develops as they grow.
  5. Can Be Temporarily Corrected: Using supportive shoes, orthotics, or muscle-strengthening exercises can help temporarily correct the arch of the foot during activities.

Rigid flat foot (non-correctable)

Rigid flatfoot, also called uncorrectable flatfoot, is a condition in which the arch of the foot is permanently flat and cannot be straightened or corrected, even when the foot is lifted off the ground. Unlike the flexible flat foot, where the arch of the foot can collapse when weight is removed from the foot, the rigid flat foot maintains a flat position regardless of the pressure placed on the foot.

Here are some characteristics of the rigid flat foot:

  1. Absence of Plantar Arch: The plantar arch remains flat at all times, even when no pressure is exerted on the foot.
  2. Rigidity: Unlike the flexible flat foot which can sometimes show an arch when sitting or standing on the toes, the rigid flat foot remains rigid in all circumstances.
  3. Discomfort or Pain: People with a rigid flat foot may experience discomfort or pain in the foot, ankle, or even leg area, due to the lack of arch support.
  4. Mobility Issues: Arch stiffness can lead to mobility and balance issues, affecting gait and foot stability.
  5. Underlying Conditions: Rigid flatfoot can sometimes be associated with underlying conditions, such as bone abnormalities, joint problems, or neuromuscular disorders.
  6. Management: Management of rigid flat foot may include measures to relieve pain and improve stability, such as wearing supportive shoes, using custom orthotics, and in some cases, corrective surgical procedures.

Rigid flatfoot develops in adults (adult acquired flatfoot) due to weakening of the tendon of the posterior tibial muscle (major support structure of the arch of the foot). The fall of the arch of the foot will be gradual and will lead to pain and swelling in the ankle which can eventually lead to arthritis of the joints of the foot and ankle.

Acquired flat foot

Acquired flatfoot, also called adult-acquired flatfoot, refers to a condition where the arch of the foot that was normally present becomes collapsed over time, usually in adulthood. Unlike congenital flatfoot, where the person is born with an underdeveloped arch of the foot, acquired flatfoot develops later in life.

Here are some factors that can contribute to the development of acquired flat foot:

  1. Age: Aging can cause tendons and ligaments to have less flexibility, which can contribute to a sagging arch.
  2. Joint Wear: Normal wear and tear on joints from physical activity, repetitive movements or medical conditions can weaken the supporting structures of the foot.
  3. Injuries: Injuries to the feet, ankles, or legs can affect the supporting structures of the foot and contribute to the development of acquired flatfoot.
  4. Ligament Laxity: Increased laxity of the ligaments can lead to sagging of the arch of the foot.
  5. Arthritis: Certain types of arthritis can affect the joints of the foot, leading to a weakening of the arch of the foot.
  6. Obesity: Excess weight can put extra pressure on the feet, contributing to a sagging arch.
  7. Intense Physical Activities: Certain strenuous physical activities or participation in high-impact sports can increase the risk of developing acquired flatfoot.

Sign of excess toes

The “excess toes sign” is a clinical observation which is sometimes involved in the evaluation of the degree of pronation of the foot and the possible presence of a flat foot. To spot this sign, we usually examine the foot from behind, focusing on the number of toes visible on the lateral (outer) side compared to the medial (inner) side. This observation may indicate excessive pronation and highlight possible problems with the arch of the foot.

“Too many toes” sign. Notice how the right foot curves inward, exposing more of the side toes (circle) along the outer edge of the leg.

In normal alignment of the foot, when viewed from the rear, we should normally see the fourth toe and sometimes the fifth. The presence of more toes, especially the first and second, suggests excessive pronation, that is, excessive inward movement of the foot. This increased pronation may be associated with conditions such as flat foot.

In summary, the “excess toes sign” is based on observing the number of toes visible when looking at the foot from behind. If more than the fourth and fifth toes are distinguishable, especially the first and second toes, this may indicate excessive pronation and a lower arch characteristic of flat feet.

It is crucial to emphasize that although the “excess toe sign” can provide useful guidance, it is only one component in diagnosing flat foot or other foot conditions. A comprehensive evaluation by a healthcare professional, such as a podiatrist or orthopedic specialist, including a thorough physical examination, gait analysis, and possibly imaging studies, remains essential for an accurate diagnosis and appropriate treatment recommendations.

Causes of flat foot

Flat feet can be caused by a variety of factors, including genetic, anatomical, muscular, or related to health conditions. Here are some of the common causes of flat foot:

  1. Genetics: A genetic predisposition can play an important role in the development of flat feet. If family members have flat feet, there is an increased risk of developing this condition.
  2. Insufficient Muscle Development: Insufficient muscle development in the foot and ankle region can contribute to flat feet. The muscles of the foot and leg play a crucial role in maintaining the arch of the foot.
  3. Injuries or Strain: Repeated injuries or strain to the feet, ankles, or legs can weaken the muscles that support the arch of the foot, contributing to the development of flat feet.
  4. Growth Issues: Certain growth issues in childhood can influence foot development. For example, abnormal bone growth can affect the structure of the foot.
  5. Arthritis: Some forms of arthritis, such as rheumatoid arthritis, can affect the joints of the foot, leading to deformity and eventually flat feet.
  6. Ehlers-Danlos Syndrome: It is a genetic disorder of the connective tissue that can influence the structure of the feet, among other symptoms.
  7. Obesity: Excess weight can put extra pressure on the feet, weakening the muscles and contributing to the development of flat feet.
  8. Age: Flat feet can develop with age as ligaments and tendons lose their natural elasticity.
  9. Neurological Conditions: Neurological conditions, such as cerebral palsy, can affect muscle tone and contribute to the development of flat feet.

It is important to note that flat feet can be asymptomatic in many people and do not always require treatment.

Symptoms of flat foot

Flat feet, also known as pes valgus, can be asymptomatic in many people, but some people may experience symptoms associated with this condition. Symptoms of flat foot can vary in intensity and may include:

  1. Pain: Pain is one of the most common symptoms associated with flat feet. It can appear on the inside of the ankle, along the arch of the foot, the heel or even in the calf. The pain can be mild to severe, especially after physical activity.
  2. Foot and Leg Fatigue: People with flat feet may experience increased fatigue in their feet and legs, especially after a long period of walking or standing.
  3. Discomfort or Heavy Feeling: Some individuals may experience a feeling of discomfort or heaviness in the feet, particularly towards the end of the day.
  4. Instability or Twisting Sensation: People with flat feet may experience a feeling of instability or twisting in their feet, especially when walking or standing for long periods of time.
  5. Difficulties Finding Comfortable Shoes: People with flat feet may have difficulty finding comfortable shoes that provide adequate arch support.
  6. Calluses or Corns: Due to increased pressure on certain parts of the foot, calluses or corns may develop, especially on the soles of the feet.
  7. Heel Pain (Plantar Fasciitis): People with flat feet have an increased risk of developing plantar fasciitis, which can lead to heel pain, especially when taking their first steps in the morning.
  8. Posture Issues: Flat feet can also contribute to posture issues, which can lead to pain in the knees, hips, and back.

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.

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.

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