Panel Discussion: Flat Feet - Structural or Functional?
Can we correct flat feet?… And if we can, how? Is this something that should be addressed during assessment, or is it an issue that we should just work around?
Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS
This Panel Discussion was originally posted on my facebook page - https://www.facebook.com/brent.brookbush - on February, 18th 2011
Shawn Fears, February 18 at 11:39am: This is an interesting topic and I can't wait to hear from others. I would like to think to some degree we can, and as a matter of fact I am working with somebody right now (coworker) who has flat feet. When he walks it looks like he's been on a horse for a year, he's pretty bowlegged. Hips externally rotated with very limited range of motion, feet pointed out externally greater than 45 degrees and FLAT feet with no transverse movement in the ankle at all. He said it wasn't that bad when he was a kid and he thinks its due to the way he was taught to squat in high school by his football coach (an argument for two discussions ago about squatting feet out).
He has what I feel is an SI issue now and we are working on hip mobility and lumbo-pelvic stability and ankle mobility.
Up until I started working with this guy I would have said yes its correctable. Now I am just not sure because this guy is 180lbs and in good shape so there are a lot of external/internal factors that come into play.
So I am going to have to say yes and no, it can be corrected if the cause for it is not genetic and the external cause is not during early in adolescence. In accordance with Wolf's Law, bone remodeling due to heavy lifting with incorrect technique during adolescence can possibly be irreversible. If flat feet are developed after maturation then yes there is the possibility it is a movement pattern issue and it can be addressed.
Melissa Reynolds Hatton, February 18 at 12:03pm: I'm not sure if flat feet can be corrected or not. My brother has flat feet and can "fake" arches if he tries (that's how he got into the Army!) His daughter also has flat feet, but hers was a skeletal issue that was improved with a surgical procedure. I would be interested in seeing if corrective exercise would allow the foot arch to be what is considered "normal".
Shawn Fears, February 18 at 12:28pm: I missed a couple of your questions…lol
Should we pay attention to it during assessments? Yes, seeing flat feet and asking some questions on the clients history will tell a lot about if it is possibly a compensation pattern that is "worth" addressing.
On other side of this topic, if the feet flatten out during a movement assessment we NEED to address that for sure.
The more I learn about the body the more I am realizing the importance of healthy ankles and the effects of lack of mobility in ankles have on the kinetic chain.
Shawn Fears, February 18 at 1:20pm: This is a very narrow article but pretty much statest that if you catch it in children it may be corrected with orthotics and there is a type that happens in adult hood that if not treated can lead to rigid flat foot that can be debilitating enough to limit rising to ones toes (most common in women 45-60) Then there is something called flexible flat foot where the arches collapse when standing but return to normal when in a non weight bearing position. I mention this one last because I think this is the only one we can address in our scope of practice as Fitness Professionals.
Practice Guideline Published to Treat Flat Feet in Adults. O&P Business News . May 2005;14(9):49. Available from: SPORTDiscus with Full Text, Ipswich, MA.
This study shows that kids show favorable improvements in arch improvements.
Elena M, Gabriel C, Roxana E, Sandu E. THE ROLE OF PHYSICAL TRAINING REGARDING THE KINETICALLY IMPROVEMENT AND RECOVERY TO CHILDREN HAVING PHYSICAL DEFICIENCY, THE FLAT FOOT. Ovidius University Annals, Series Physical Education & Sport/Science, Movement & Health . September 2010;10(2):309-312. Available from: SPORTDiscus with Full Text, Ipswich, MA.
These were done in a quick search and by no means an exhaustive search on the subject, but the common theme I saw was in kids it can be corrected and in adults orthotics are the treatment to prevent debilitation.
Brent Brookbush, February 18 at 2:41pm: I believe part of the question is whether we believe that having flat feet is a structural problem (having to do with the shape of bones) or a functional problem (arising from neuromuscular inefficiency)?
Shawn Fears, February 18 at 5:28pm: That’s a case by case question and answer from what I have read. If I were to generalize an answer flat feet start out as a neuromuscular inefficiency and lead to structural changes.
Mikal Payne, February 18 at 5:50pm: Don't know enough about it.
Kristina Rathod, February 18 at 9:34pm: Walk bare feet in a forest.. (pine cones, rocks.. ouch!) That was the advice from my doctor in Latvia. It worked!
Brent Brookbush, February 19 at 8:40pm: Some interesting comments… I have an issue with assuming that this problem is structural, or a genetic abnormality that must be corrected in someone’s youth. Most abnormalities including a type 3 acromion, genu varus, genu valgus, scoliosis, etc… happen in a fairly small portion of the population (less than 5%)…. However, the occurrence of lower leg dysfunction is higher than 50%. I would agree that some individuals do have structural abnormalities that require surgery, orthotics, or require specialized footwear, however, most dysfunction is musculoskeletal and could be resolved using a corrective exercise program. Anyone want to take a shot at the solutions table?
Mikal Payne, February 20 at 7:28am: I'll give it a try been looking up things about flat feet all week, I'll get back to ya. Thanks, now the brains going,dang! it Sunday all I wanted to do was watch the all-star game, LOL. Be Back
Brent Brookbush, February 20 at 2:03pm: I'll give you a bit of hint… you have to start with the tibia and tibio-talor joint, but there is also dysfunction leading to dysfunctional movement of the talus itself, the talo-metatarsal joints, and even the toes….
Mikal Payne, February 21 at 5:52am: Oh, Thanks! ok, rethink I am almost there. 1 question-If babies are born flat footed and stay ff till the 2 or 3 year of life, when does it become a bad thing?
Mikal Payne February 21 at 6:44am: OK, here are the leg/ankle exercises and stretches I do with my classes it's a start
Curl and extend
Ab and Add
flex and point (extend leg)
Ankle roll in and out
Toe stretch
ankle stretch
Lunges and lunge to hold
Gastro/solues stretch(2 different wall stretches). Not a bad start ah?
All are body weight exercises.
Brent Brookbush, February 21 at 12:27pm: Your warm-up looks pretty good. I am not sure what all the exercises are (not your fault, there is no official naming of exercises) but is looks sound. I would save the lunges for the end, and move the calve stretch up a bit.
Brent Brookbush, February 21 at 12:35pm: Some thoughts on common dysfunction… " Flat footedness" is often pronation distortion of the lower leg. This is not a structural problem, but a functional one. Generally, restriction resulting in an inability to adequately dorsi-flex leads to compensation during gate mechanics, including tibiofemoral external rotation, ankle eversion, excessive dorsi flexion of the forefoot (talometotarsal joints), adduction and a reduction in both flexion and extension of the first metatarsal phalangeal joint (the big toe). Next will look at the muscles
Mikal Payne, February 21 at 2:11pm: Thanks and Ahhhhhh gotcha, so the babies flat feet have nothing to do with the effect(s) that adult will suffer. It's a growing and learning thing in the baby's case.
So the flat feet in a baby offers/gives them a wider base to learn the walking thing?
Now for a client. This one I am not sure of.
SMR-
Lateral G/s
Peroneals
Bicep Femoris
T FL
Static Stretching-
Wall G/S
Bicep Fem
Tensor FL
Iso Strength-
Toe Towel Scrunch
Ant./Post. Tibi
Toe/heel raises
Lunges after Ab and add?
Brent Brookbush, February 21 at 8:37pm:
Hey Mikal,
I have to be honest… I am not sure what normal baby movement is. Pediatrics is a realm of the corrective exercise/rehabilitation spectrum I am not even remotely familiar with. I will have to do a clinical in pediatrics in my second year of DPT school. Maybe you can ask me again then…
Mikal Payne, February 22 at 6:57am: Ahhhh OK, no problem just curious, so keep me in the loop let me know what you find out or I can bug you to death (find out, find out) and in the mean time I'll do some asking' and let you know what I find out.
Brent Brookbush A simple corrective exercise strategy for lower leg dysfunction.
SA Static Release:
Calves
Peroneals
Bicps Femoris
TFL
Stretch:
Calves w/ inersion (pigeon toed)
Bicep Femoris
TFL Stretch
Activation:
Tibialis Anterior
Tibialis Posterior
Gluteus Medius
Integration:
Single-Leg Balance with Excursion
Mikal Payne, February 24 at 6:54am: Holy cow,dang!
Brent Brookbush, February 24 at 2:26pm: It get's deeper… Just think that the EHL, becomes synergistically dominant for a inhibited tibialis anterior and this alone has a huge effect on foot mechanics.
Matthew Bleistein, February 24 at 4:21pm: depends on the cause of flat fleet, though I think that in most cases it can be corrected, but not with orthotics
Scott Pullen, February 24 at 8:05pm; If it is acquired, most likely it can be fixed. If it is "from the factory", nope. Totally matters though. In both instances I address it as if it can be fixed…worst case scenario it minimizes the potential downsides of flatfeet.
Brent Brookbush, February 24 at 8:45pm: Thanks for mentioning the point about minimizing the dysfunction regardless of cause… Really great point.
Mikal Payne, February 25 at 5:55am: No orthotics Why? It would seem a good place to start they a training weak muscles, every little bit helps. Is that not our job?
Brent Brookbush, February 25 at 11:10am: Orthotics do not strengthen weak muscles; in fact they do quite the opposite. You could think of orthotics in the same way you think of a weight belt contributing to Core Dysfunction and weakening the TVA. Essentially orthotics is a cast for your arch. With orthotics your flexor hallucis longus, flexor digitorum longus and brevis, lumbricals, and a host of other supporting musculature no longer need to work to maintain the arch of the foot. These muscles are normally lengthened and weak in postural distortion, so orthotics only exacerbates the problem. Further, no strength in the flexors of the foot means the extensors start to tighten, leading to over-activity, synergistic dominance of the EHL, eventual weakness of the tibialis anterior, a reduction in dorsi flexion, adaptive shortening or the gastroc/soleus complex, etc, etc, etc…..
Matthew Bleistein, February 25 at 12:22pm I’m speaking from personal experience, I’ll admit it. Orthotics only made my foot pain worse, again my problem was structural, not muscular.
Brent Brookbush, February 25 at 4:01pm Has anyone had any experience with release, stretching, or activation exercises for the muscles of the feet?