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| Ref: https://health.clevelandclinic.org/ |
The foot ankle complex includes bone, muscle and ligament which support the medial
longitudinal arch which gives shape, strength and stability to the joint. Flat feet are determined by the collapse or over - flattening of the medial longitudinal arch of the foot. Most previous studies have concluded the indications of flatfoot to be related to the collapse of the medial longitudinal arch caused by abnormal bone structure in the foot or the relaxation of muscle ligaments.
Joint ligament relaxation was also a critical factor in the occurrence of flatfoot in children, adolescents or adults. The occurrence of flat feet was shown to be affected by internal factors (age, sex, nutritional status, genetics, race, and development differences) and other external factors (shoe shape, environmental conditions, and physical activities).
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| Flat feet's shoes shape (Ref: https://sgbonedoctor.com/) |
I think of creep's phenomenal deformity biomechanics. It is visco - elastic properties of foot soft tissue, especially ligament that creates a deformation in the soft tissues (muscles, tendon, and ligaments). It is the non-recoverable strain energy that results in the permanent deformation or resting length change of the feet tissues.
Flat feet was divided into two types: congenital and acquired. A rigid flat feet or congenital flat feet is characterized by a stiff, collapsed arch in both weight-bearing and non-weight-bearing positions. The acquired flat feet was mainly affected by external factors, such as physical activity level, shoe-wearing habits, and living area.
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| Flexible flat feet when full weight and heel off (Ref: https://orthoinfo.aaos.org/) |
The flexible flat feet or acquired flat feet is characterized by a normal - appearing arch when the foot is not bearing weight but by a flattened arch when weight - bearing. Flexible flat feet are the most common type of flat foot.
Most of my patients have flexible flat feet that have different complaints. I have seen 2 most common flat feet characters while standing in the clinic, including small arch and full flat. All flat feet were evaluated carefully by me to get specific mechanics of impairment that consists of internal and external factors. This information will be designed to be customized therapeutic exercise and accessory support for each single case.
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| Mild flat feet or flat feet first degree (the second from the left) (Ref: https://www.runningshoesguru.com/) |
Basic 12 therapeutic strengthening exercises to treat flat feet.
Each exercise needs 10 - 15 reps with 3 sets for 3 - 5 days a week.
Exercise #1: Achilles tendon stretching: You can follow stretching on previous topic that is https://yimphysionearme.blogspot.com/2022/07/physiotherapy-with-9-options-to-stretch.html The stretching leading to 30 sec hold and was repeated 5 times each session. I would like to recommend to who have pain, should follow stretching exercise #1. Whereas, patients who do not have pain, should follow exercise #3 or exercise #8, or exercise #9.
Exercise #2: Toe extension exercises: You are in a sitting or standing position and lift the big toe away from the floor with hold 5 seconds in each rep. You can apply some resistance by a very light elastic band if you want. You can be in a long sitting and tight the band away from your toes.
Exercise #3: Toe flexion exercise: You are in a sitting or standing position and bend the big toe away from the shin with hold 5 seconds in each rep. You can apply some resistance by a very light elastic band if you want. You can be in a long sitting and hold the band away by your hands.
Exercise #4: Toe abduction exercises: You are in a sitting or standing position and shall be instructed to stabilize the ball of the foot on the ground while lifting and spreading out the toes, with hold 5 seconds in each rep. Or you can be long sitting if you want.
Exercise #5: Ankle Dorsiflexion: You are in a sitting position or standing position and bend the foot away from the floor with hold 5 seconds in each rep. You can apply some resistance by a light elastic band if you want.
Exercise #6: Ankle Inversion with plantar flexion: You are in the long sitting position on a mat with back supported and bend the foot away from the floor with hold 5 seconds in each rep. You can apply some resistance by a light elastic band if you want. Or you can be long sitting if you want.
Exercise #7: Foot abduction: Sit on a chair with feet touching the floor. One end of the exercise band is fixed around the feet, and the other end of the band is held by the other foot to maintain resistance. Bending needs to hold 5 seconds in each rep. You can do active bending if the exercise band is too heavy for you. Or you can be long sitting if you want.
Exercise #8: Short foot exercises: Place the foot flat on the ground, and draw the metatarsals inwards creating an arch with progression which holds 5 seconds in each rep.
Exercise #9: Heel raises with ball: You are in a standing position near a wall or stable furniture, with ball placed between the malleolus of left and right side, then raise the heel up - down slowly.
Exercise #10: Heel raises waking: You are in a standing position performing heel raises. Then walk forward with the heel raise (without shoes).
Exercise #11: Towel curls: You are in a sitting or standing position and bend your toes to pick and slide towels into you.
Exercise #12: Objects curls: You are in a sitting or standing position and bend your toes to pick objects and put them in the box.
Although foot exercise may be able to improve foot arch posture permanently, stronger soft tissue may increase pain or injury threshold. I have always encouraged foot exercise in patients with flat feet. Not only therapeutic exercise, but also control risk factors may be an essential component to help to treat flat feet.
The distinct limitation of this study design is that no separate the external and internal factors affecting flatfoot, which is likely to be a significant confounder, as more external and internal factors progressions increase the risk of flatfoot development.
Factors such as age, gender, foot length, familial history, practicing the usage of footwear early in infanthood, body mass index (BMI), comorbid illness, associated with pain, fatigue in women, and urban residence were reported to be associated with flat feet. Flat feet are also seen secondary to ligamentous laxity, neuromuscular disorders, hereditary conditions (osteogenesis imperfecta, Down syndrome, and Marfan syndrome), collagen disorders (Ehlers‑Danlos syndrome). Biomechanical causes (ankle equinus, valgus deformities, accessory navicular bone) are potential to develop flexible flat feet may relate to secondary injuries like ankle sprains, plantar fasciitis also deformities include hallux valgus . It is often difficult to identify the exact reason for flat feet in every individual because of the existence of various factors associated with developing it.
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| One of Marfan syndrome clinical (Ref: https://www.istockphoto.com/th) |
Adolescents who are not fully developed should avoid taking part in overloaded labor (such as burden-bearing) and sports (such as weight lifting). They could engage in high leg lifting, jumping activities (such as rope skipping, long jump, high jump, vertical take-off, etc.), and climbing activities (such as climbing ladders, using balance beams, rope climbing, pole climbing, etc.) to fully exercise the muscles and ligaments of the arch of the foot.
According to one theory, failure of muscles supporting the arch leads to flat foot; according to the second theory, weakness of passive ligamentous support around the arch leads to flat foot; and according to the third theory, failure of both muscles and ligaments leads to flat foot. Many studies demonstrate weakness of intrinsic foot muscles and extrinsic foot muscles that the posterior tibialis tendon is the main dynamic stabilizer of the arch with lesser contributions from the peroneus longus, flexor digitorum longus, and flexor hallucis longus.
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| Long tendon from posterior shin muscles (Ref: https://www.howtorelief.com/) |
Tightness or any changes in Achilles tendon is associated with dysfunction of tarsal alignment that leads to dorsolateral displacement of the navicular bone causing chronic stress on posterior tibialis tendon eventually, leading to microtrauma and degeneration in the later stages.
Intrinsic foot muscles are contained in the foot bone. To strengthen such as short foot and toe abduction exercises, help to prevent pronation related injuries and integrity of the medial longitudinal arch. This helps in reducing navicular drop scores and plantar arch index scores. They help to maintain not only longitudinal arch, but also transverse arch.
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| Intrinsic foot muscles and tendon of extrinsic muscles anatomy (Ref: https://quizlet.com/) |
Although intrinsic muscle helps in maintaining arch, the tibialis posterior plays an essential role in maintaining the medial longitudinal arch during dynamic weight‑bearing and balance activities. For these reasons, strengthening of the tibialis posterior muscle is more preferred in individuals with flat feet than the intrinsic muscles. However, I will provide an exercise program for all of them if necessary.
The function of the posterior tibialis tendon is essential to maintain the gait pattern without any abnormal deviations. During gait cycle, the posterior tibialis tendon function is critical during the push‑off phase. Posterior tibialis contracts to invert the foot and maintains the transverse tarsal joints in a closed pack position. Weakness of posterior tibialis tendon leads to failure of stability in the transverse tarsal joints during the push‑off phase. The unopposed peroneal muscles abduct the forefoot due to weakness of the posterior tibialis tendon.
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| Muscle activities during walking that tibialis posterior works in stance phase (Ref: https://www.researchgate.net/figure/Representation-of-muscle-activity-during-a-gait-cycle-The-grey-color-indicates-periods_fig5_297048967) |
Long‑term goal of any flat foot rehabilitation program aims at strengthening the posterior tibialis muscle. Strengthening program begins with isometric and progresses to isotonic exercises. Concentric and eccentric types of exercises were routinely implemented in strengthening programs.
Orthoses and taping were always suggested to diminish the demand of the posterior tibialis tendon during the stance phase of gait cycle. In the clinic, I have made rigid taping to stabilize and support the foot arch in patients with pain. To tape is a very good way to help these patients, but patients may feel annoyed and dirty from the adhesive. Moreover, it is not convenient for patients who are lazy to tape and unskilled to tape.
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| Low - dye tape technique to stabilize foot arch (Ref: https://clinmedjournals.org/) |
For this reason, I suggest they get insoles or stable shoes to support the foot arch. Running shoes are the easiest to suggest which is motion control running shoes. However, patients with mild flat feet may comply to select a stability running shoe which is lighter than motion control.
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| Insoles for flat feet |
For children, the correct choice of footwear is especially important because their growth and development are characterized by the evolutionary dynamics of the locomotor system and by the physical activity to which the lower body is subjected. However, this choice is often influenced by aesthetic, economic, or marketing issues, rather than by considerations of health. To raise awareness of the importance of these questions, and to enable parents and others to reach suitable decisions, research is needed to highlight the direct influence of the shoe on the movement of the foot and on its functionality. The design of children’s shoes should be based on the barefoot model, prioritizing impact absorption and load distribution, in the understanding that overly rigid and/or tight-fitting footwear can provoke injuries or deformities.
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| Kids shoes |
I do not involve people who do not have pain or poor quality of life from flat feet especially in the athlete population. Because some athletes are accustomed to sports specific skill with flat feet. Their performance may be dropped if their flat feet are changed that make worse than better.
Reference:
https://www.ijhsr.org/IJHSR_Vol.12_Issue.1_Jan2022/IJHSR015.pdf
https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.74B4.1624509
https://www.drkinast.com/wp-content/uploads/2006-pinney-Current-concept-AFFD.pdf
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