Flat feet
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Flatfoot, medically referred to as pes planus or pes planovalgus, refers to a lowering of the medial longitudinal arch of the foot, which is often accompanied by valgus alignment of the heel bone, forefoot abduction, and increased pronation. Pronation is a complex movement that enables the foot to absorb loads during walking. Clinically significant flatfoot is primarily considered when the altered foot alignment causes pain, fatigue, limitation of activity, or disrupts the mechanics of the entire lower limb. In young children, a flexible flattened arch is a common stage of development. In adults, the deformity may be persistent from childhood or develop as a result of overloading the structures stabilizing the foot. Management depends on age, the type of deformity, presenting symptoms, and coexisting conditions.
Flat feet - what is it
A properly shaped foot has a medial longitudinal arch, a lateral longitudinal arch, and a transverse arch. This structure enables weight-bearing, shock absorption, and the transformation of a flexible foot into a stable lever during push-off. The bones, ligaments, plantar fascia, intrinsic foot muscles, tibialis posterior muscle, and the calf muscle-tendon complex are collectively responsible for maintaining the medial arch.
Flatfoot is diagnosed based on a clinical examination in a standing position and during movement. Arch height alone has limited diagnostic value. Symptoms, joint mobility, and limb weight-bearing patterns are also of importance.
A specialist assessment may include:
- visual inspection of the feet from the front, side, and back;
- evaluation of heel alignment and the course of the Achilles tendon;
- examination of the arch while standing on both feet and on one leg;
- the heel-raise test, which evaluates the reversibility of heel valgus and the function of the tibialis posterior muscle;
- assessment of the range of ankle dorsiflexion;
- analysis of gait, balance, and lower limb control;
- examination of muscle strength and tissue flexibility;
- evaluation of footwear wear patterns and plantar pressure distribution.
Imaging studies are used in the event of pain, stiffness, progressive deformity, trauma, or surgical planning. The primary method is weight-bearing foot radiography. Ultrasound and magnetic resonance imaging help evaluate tendons, ligaments, and soft tissues. Computed tomography is used when tarsal coalition, bone changes, or complex deformities are suspected.
Flat feet - types
The most important clinical classification includes flexible and rigid flatfoot.
Flexible flatfoot is characterized by a lowering of the arch while standing and its restoration upon foot non-weight-bearing or when rising onto the toes. This type frequently occurs in children and usually represents a developmental variant. In some patients, it is associated with pain, rapid leg fatigue, shortening of the gastrocnemius muscle, or reduced functional capacity.
Rigid flatfoot refers to a permanent flattening of the arch present during both weight-bearing and non-weight-bearing. It may be accompanied by restricted mobility, pain, and abnormal adaptation of the foot to the ground. This form requires orthopedic evaluation, as it can be caused by tarsal coalitions, bony deformities, consequences of trauma, or inflammatory diseases.
Based on the time of onset, the following are distinguished:
- pediatric flatfoot, most commonly flexible and associated with the maturation of the musculoskeletal system;
- flatfoot persistent since the developmental period, also present in adulthood;
- adult-acquired flatfoot, currently also described as progressive flatfoot-valgus deformity.
Progressive deformity in adults can develop in stages. Initially, there is pain on the medial side of the foot and weakness of the posterior tibial tendon. Subsequently, hindfoot valgus, forefoot abduction, and arch collapse worsen. In advanced stages, stiffness and joint degenerative changes develop.
The term transverse flatfoot describes the lowering of the anterior transverse arch and widening of the forefoot. This condition has different biomechanics from classic longitudinal flatfoot, although both deformities may coexist.
Flat feet - causes
In children, a low foot arch is associated with the natural presence of fat tissue under the arch, ligamentous laxity, and the maturation of neuromuscular control. The arch of the foot develops gradually during the first decade of life. Clinical significance increases with pain, asymmetry, stiffness, gait disturbances, or marked progression of the deformity.
Factors predisposing to flatfoot include:
- genetic predisposition and generalized joint laxity;
- shortening of the gastrocnemius muscle or the Achilles musculotendinous complex;
- weakness of the intrinsic foot muscles and the muscles controlling limb alignment;
- abnormal neuromuscular coordination;
- excessive body weight increasing the load on the arch;
- prolonged standing work and repetitive strain;
- injuries to the foot and ankle joint;
- connective tissue, neurological, and rheumatological diseases;
- congenital bony abnormalities, including tarsal coalitions;
- degeneration or injury of the posterior tibial tendon;
- weakness of the spring ligament supporting the head of the talus;
- diabetes, neuropathy, and conditions affecting tissue quality.
In adult-acquired flatfoot, several mechanisms usually interact. Insufficiency of the tibialis posterior muscle limits dynamic arch support, and overloaded ligaments gradually lose their stabilizing capacity. The calcaneus assumes a valgus position, the head of the talus displaces medially and plantarward, while the forefoot abducts. A biomechanical vicious cycle develops, increasing the load on the medial structures of the foot.
Flat feet - effects of lack of treatment
The course of flat feet depends on its form. A flexible, painless child's foot usually maintains normal function and requires observation of development. Symptomatic or progressive deformity can lead to the overloading of many structures of the musculoskeletal system.
The most common consequences include:
- pain in the medial arch, heel, ankle joint, or the posterior tibial tendon area;
- faster fatigue of the feet and calves during walking;
- inflammation or tendinopathy of overloaded tendons;
- overloading of the plantar fascia;
- calluses and local complaints related to altered pressure distribution;
- reduced stability when standing on one leg;
- decreased efficiency in walking, running, and jumping;
- fixation of hindfoot valgus;
- contracture of the gastrocnemius muscle and limited dorsiflexion;
- development of degenerative changes in the hindfoot and ankle joints;
- difficulty selecting footwear.
The relationship between flat feet and knee, hip, or back pain remains complex. Excessive pronation can affect tibial rotation and lower limb mechanics, but the occurrence of symptoms is also determined by muscle strength, anatomy, body weight, type of activity, and tissue load tolerance. Therefore, treatment should be based on a comprehensive functional examination rather than solely on the appearance of the foot.
Urgent consultation is required for the sudden development of deformity, unilateral swelling, severe pain, loss of the ability to rise onto the toes, progressive stiffness, sensory disturbances, and skin lesions in a person with diabetes.
Flat feet - exercises and treatment
The goal of treatment is to reduce pain, improve function, increase load tolerance, and slow down the progression of the deformity. In children with flexible, asymptomatic flatfoot, observation and periodic developmental assessment form the basis of management. Active intervention is implemented in the presence of pain, fatigue, activity limitation, calf contracture, or progressive foot malalignment.
An exercise program is tailored by a physical therapist based on an examination. The most commonly used include:
- the short foot exercise, which consists of bringing the head of the first metatarsal bone closer to the heel without curling the toes;
- controlled calf raises while maintaining heel alignment;
- strengthening of the posterior tibialis muscle with resistance;
- exercises for the peroneal muscles, gluteal muscles, and pelvic stabilizers;
- stretching of the gastrocnemius and soleus calf muscles;
- balance and proprioception training;
- learning the proper weight distribution across the three support points of the foot;
- graded training of walking, running, and functional activities.
The exercises require regularity, proper technique, and load progression. Short series performed over many weeks usually bring more benefits than sporadic, intensive training.
Orthopedic insoles can reduce pain and improve comfort in selected patients with symptomatic flatfoot. They are selected based on anatomy, footwear, type of activity, and patient tolerance. Their main task is to modify load and support function, rather than permanently reshape the developing arch. Stable footwear, temporary activity modification, and gradual reduction of excess body weight can also be helpful.
At Ambasada Urody, supportive methods for the conservative management of functional disorders associated with flatfoot are available:
- physical therapy and manual therapy, including functional assessment, work on joint mobility, tissue flexibility, neuromuscular control, and weight-bearing patterns;
- therapeutic and rehabilitation massage, used supportively in cases of muscle overload in the calf, plantar tissues, and other elements of the myofascial chain.
Manual methods can relieve secondary tension and facilitate the performance of exercises. The foundation of lasting functional improvement lies in active rehabilitation, appropriately dosed load, and the patient's own work.
Surgical treatment is considered in cases of persistent pain, significant functional limitation, progression of the deformity, or rigid flatfoot despite properly conducted conservative treatment. The scope of the surgery depends on age and the anatomy of the deformity. Techniques used include calcaneal osteotomies, lateral column lengthening, ligament reconstruction, tendon transfers, gastrocnemius lengthening, and arthrodesis of selected joints in advanced degenerative changes.
