Flat Feet (Pes Planus)
Background & Etiology (Cause)
There are over 30 joints in the foot, including the subtalar, talonavicular, calcaneocuboid, metatarsocuneiform joints, and the metatarsophalangeal joints. The precise movement of these joints as they work together is what enables us to run, walk, and jump. The arch of the foot depends of the proper development of the bone, ligaments, tendons and muscles of the foot. Ligaments are formed by fibrous connective tissue that joins bone to bone. Weak or lax ligaments can compromise the structure of the arch of the foot. Tendons are connective tissues that attach muscle to bone. They are strong, fibrous structures that transfer the forces generated by the muscle to the bone, producing movement at the joint. These tendons allow the joint to move, but also serve a secondary supportive function to the arch of the foot. When tendons and muscles in the foot are weak they can be less effective in their supportive role.
Flat Feet is a condition where the foot does not have a normal raised arch when standing. Poor bone structure, laxity of ligaments and weakness of the supporting muscle and tendons can cause the arch of the foot to be flat. An indication that an individual has this condition is to look at the feet while standing and see if the instep comes into contact with the ground. There are two types of flat feet, flexible and rigid.
- Flexible Flat Feet: If a person can lift their toes up, and an arch forms, the flat foot is flexible, and will not require further treatment.
- Rigid Flat Feet: If the arch of the foot does not form when an individual lifts their toes up and stands on heels, the condition is considered rigid. If the flat foot is rigid or if there is pain, further testing and evaluation of the foot may be necessary to determine any underlying pathology of the condition.
Flat feet are common in young children (infants and toddlers), and with normal development do not require treatment because the condition will typically right itself as the child develops. However, in some cases this condition does not improve on its own. As an adult if flat feet do not improve, symptoms may start to develop. Flat feet can also occur as a result of damage to the tendons over time, causing the condition to occur in older individuals.
In young children flat feet can occur normally, and as the tendons tighten over time the condition will go away on its own. However, there are other ways that a person can develop flat feet.
- Normal occurrence through child development
- Condition that does not correct itself as an individual develops in adulthood
- Injuries or prolonged stress to the bone, ligaments, muscles, and tendons that compromise the arch of the foot
- Tarsal Coalition, a condition where two or more bones in the foot fuse or grow together. This is typically seen in children.
- During pregnancy women can develop flat feet because their ligaments become more lax.
- A fallen arch or flat feet may develop as part of the aging process.
- Pain in the foot, ankle or lower leg
- A tired or achy feeling in the feet or legs after standing or walking for prolonged periods of time.
- Pain that occurs after participating in sports or other physical activities
- Reduction in the range of motion of the foot
While normal flat feet often do not require treatment, a medical professional should still evaluate the condition to ensure that it is in fact a normal aspect of development. If pain occurs (particularly in children) it is important to have the condition checked out by a physician to look for any underlying abnormalities. CT scans, MRI’s or an X-ray of the foot can be used to assess the state of the bones and tendons in the foot. If a doctor evaluates the foot and determines that everything is normal, no further treatment will be needed unless pain or symptoms start to occur.
In cases of flat feet where there are pain or other symptoms orthotic devices (shoe inserts) that support the arch may be recommended. With rigid flat feet or cases of flat feet where there is underlying pathology (like tarsal coalition) more involved treatment may be necessary. In the most severe cases this can include surgery and physical therapy.
Physical Therapy Interventions
Physical Therapists are professionals, educated and trained to administer interventions. As stated in The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and goal of the patient or client. Common interventions in the treatment of Flat Feet include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, deep friction massage, manual stretching and joint mobilization by a physical therapist to regain mobility and range of motion of the foot and tendons.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to regain range of motion and strengthen the foot and effected muscle.
- Neuromuscular Reeducation (NMR) to restore stability, retrain the lower extremity, and improve movement technique and mechanics (for example, running, jumping, kicking, or stepping) in daily use of the involved lower extremity.
- Modalities that can include the use of ultrasound, electrical stimulation, ice, cold laser and others to decrease pain and inflammation at the foot and tendon.
- Home program that includes strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Procedures that your physician may recommend and perform in addition to physical therapy may include:
- REST and ICE
- Pain medication to reduce the discomfort and allow the patient to perform the recommended exercises
- Surgery to correct underlying pathology or the cause of the flat feet
- Orthotic devices or special shoes
- Taping to support affected structures may be indicated
Most people recover full function following a course of conservative care that includes orthotics foot support, taping, physical therapy, and pain relief. It is important that once the pain is reduced, and motion and strength are restored, the patient gradually returns to full activities. Instruction in daily activities or sport performance is helpful for reducing a reoccurrence of symptoms caused by flat feet.