FLAT FEET
Does the height of the arch affect the performance of an athlete? Does a higher arch indicate a better dancer? Let's take a look at flat feet and see if we can answer that question.
Flat foot is simply a subjective term that describes a foot with a decreased or absent arch. Flat feet are a common condition that will bring patients into a podiatrist's office or shoe store. In the majority of flat foot cases we're simply dealing with an inherited tendency to have no arch. There are a lot of bio-mechanical and developmental reasons why this occurs, but in most cases the condition is benign and will never really have significant impact on that patient over the course of their lives. Occasionally though, we see specific types of flat feet that are real trouble makers. We can talk about those in a little more detail.
How does a person get flat feet? You know that's the important question to ask when we're differentiating between the simple and the not so simple types of flat feet. Let's look at the most common example of a flat foot. This is the simple asymptomatic flat foot. This type of flat foot is present when a child first begins to walk. Many of the moms that come in the office joke that their child has their dad's feet, indicating that he also has no arch. We don't actually inherit this type of flat foot per se, but we inherit bone structure and biomechanical traits that are very similar to those of our parents. It's really no different than the way we inherit the color of our eyes or the color of our hair. We'll walk and move much like our parents do, and if they have flat feet we probably will too.
I'm a firm believer in the fact that the asymptomatic common flat foot has its origins in the leg even before we begin to walk. Let's use a simple example to illustrate how this condition develops. Let's compare the leg, ankle and foot to a nutcracker. The ankle is the nut in the middle, the foot is one of the arms of the nutcracker and the leg the other arm. For those with a physics background, this would be a class one lever arm. As we begin to walk, we try to establish a balance between the two arms of the nutcracker. If one arm proves to be more assertive or powerful, the other arm has to find ways to accommodate it. And this is the case with asymptomatic flat feet. The leg, consisting of the longer leg bones, calf and Achilles tendon, becomes too powerful. As a result they overpower the other arm of the nutcracker, the foot and ankle. The poor foot has no choice other than to flatten in its effort to maintain a sense of balance. The foot can be very accommodating in this regard.
Remember, this is the origin of most asymptomatic flat feet. There are a number of different types of flat feet and it's important to differentiate between them.
Children are often some of the most challenging patients because they don't have the ability to express themselves and tell you where or how they hurt. Most kids won't come to you and say they hurt. They'll give you indications of a problem. They'll ask to be carried or want their legs and feet rubbed. A child with the common type of flat feet that we've been discussing will have some of these types of complaints, particularly when they've been very active. These symptoms are due to the mechanical inefficiency of the flat foot. It just takes more work to walk with a flat foot. Therefore, kids with flatfeet have to exert more effort during a day to keep up with the other kids.
Although most pediatric flat feet are asymptomatic, there are several different types of pediatric flat feet that can be of significant concern. There are a number of specific congenital (from birth) deformities that we see that result in flat feet. One of the more common is called a tarsal coalition. Tarsal refers to the bones of the rear portion of the foot and coalition refers to a bridge. What happens in cases of tarsal coalition is that a coalition or bridge of bone forms between two bones, limiting the range of motion of the joints of the foot. The end result is a rigid, painful flatfoot. This is a challenging condition to diagnosis. The challenge lies in the fact that the symptoms don't become evident until the late teens. Part of the diagnostic challenge lies in the fact that the bridge of bone in young children is made of fibrous material and cannot be seen on x-ray. As the patient matures, the fibrous bridge begins to ossify (turn to bone). As this ossification progresses, the foot becomes markedly rigid and painful.
Adults, on the other hand, can have many of the same problems with flat feet that we've already discussed in children. The majority of adults with flatfeet simply complain of fatigue and an inability to get through the day comfortably. These are the same kids that we've talked about, only they've grown up.
Occasionally adult patients will develop another type of flat foot referred to as an acquired flat foot. An acquired flat foot can be due to many different reasons such as trauma, arthritis etc. Acquired flat feet can be some of the more difficult flat foot cases to manage. The most common symptomatic acquired flat foot that I see is due to a condition called posterior tibial tendon dysfunction (PTTD). The posterior tibial tendon originates up under the calf, comes down along the inside of the ankle and inserts into the arch. Its primary function is to support the height of the arch. When this tendon is damaged and becomes 'dysfunctional' the bones and joints of the arch begin to collapse. We'll see PTTD in many elderly women. One day they have an arch, the next day they don't.
Treatment of flat feet really depends upon the symptoms. Pain should be the primary motivation for treatment. Obviously we start out with a simple conservative approach in most cases.
The vast majority of children can be treated with arch support and shoes. This could be an arch support that the shoe repair shop glues into the shoe, it could be a store bought arch support or even a custom made arch support called an orthotic. The key is to try the simple tricks and see if they work. How do you know that they're working? You'll simply see a decrease in symptoms. The other consideration with kids is that they're going to grow out of things so quickly. I think it is money well spent to discuss your concerns with your podiatrist or pedorthist. They'll be able to recommend a treatment plan that may be significantly more cost effective for your child in the long run.
Treatment of the adult flat foot is much the same as we've discussed with children. Try the easy things first such as arch supports and eurocomfort shoes. You'd be amazed at what a decent pair of comfortable shoes can do to change a person's life. If the symptoms of a flat foot don't respond to conservative care, consult your podiatrist. I would also like to stress that early treatment of some of the conditions that we've discussed, like PTTD, is very important. We've discussed the fact that PTTD is due to failure of the posterior tibial tendon. In the early stages of this condition, the tendon is inflamed and can be corrected. If the condition is allowed to progress, the tendon will eventually rupture leading to a surgical correction that can be quite extensive.
Relatively few flatfeet require surgery considering the number of flatfeet that are out there. Once again, treatment depends upon the symptoms that each patient experiences. Are they able to complete a day at work or are they able to walk around the mall? We really need to look at the social issues that are affected by a flat foot.
At first glance, flatfoot surgery would seem fairly simple; raise the arch. But in actuality it's much more complex than that. Much of the stability of the foot comes from the bones of the rear foot. If a house has a bad basement, the rest of the house is in jeopardy. The same holds true for the foot. A faulty rear foot jeopardizes the stability of the rest of the foot.
In addition to correcting the arch, we also need to consider how to restore the center of gravity over the foot. How do we center the weight of the body over the foot? Quite often in flatfoot cases we see the arch collapse and the foot rolls in forcing the center of gravity to be carried somewhere out over the inside of the foot. That's a very important consideration when repairing flat feet. We also discussed the impact of a tight Achilles tendon in children and its affect on the development of the foot. Quite often I'll lengthen the Achilles tendon in flat foot repair cases.
Some procedures involve a wedge resection of the arch. As the wedge is closed, a new arch is formed. Other procedures require fusion of the joint to created needed stability. Many of these cases require prolonged casting to allow for proper healing.
Another type of procedure involves placing a small implant in the side of the ankle to 'wedge' the foot and ankle into a more stable position. This procedure is referred to as arthroeresis. Arthroeresis is not as invasive as other forms of surgical arch reconstruction, but may only be used in select cases.
So can the height of the arch affect the ability to dance? In most cases, no. But an abrupt change in the arch should be a sign to seek medical care.
Dr. Oster is a board certified podiatrist and pedorthist. Dr. Oster practices in Granville, Ohio and is medical director of Myfootshop.com, an on-line resource for foot care information and products.