Canadian professor, researcher, and podiatrist, Gabriel Moisan recently posted a paper titled, “Flat Feet: deformities or healthy anatomical variants?” (Moisan 2023), where he discussed the often debated topic of flat feet.
If you know us here at Made 2 Move, you know we were probably already leaning on the side of “healthy anatomical variants” before even reading the article. We also then went down a rabbit hold on all things flat feet. When did the obsession with flat feet start? Are different shoes or inserts helpful if your feet are flat? Do your flat feet need fixing? Let’s jump in.
But First, a Few Fun Facts about Flat Feet
“The foot has 26 bones, 10 major extrinsic tendons, more than 30 joints, and numerous intrinsic myotendinous units and ligaments arranged together to form three arches [yes THREE arches!]” (Flores et al. 2019).
Flat feet are also referred to as “pes planus,” where as a high arch is referred to as “pes cavus.”
One of the biggest supporters of the arch is the posterior tibial tendon, which actually originates outside of the foot. The posterior tibial tendon runs right alongside your medial malleolous (the inside ankle bone). It is referred to as extrinsic because the muscle belly is outside of the foot, right behind your calves, while the tendon runs into the foot and contributes to the force absorption and springiness inherent to the foot’s arch.
Most infants have no arches! This is due to “ligamentous laxity and lack of neuromuscular control” (Raj et al. 2023). Instead, babies have a fat pad to protect the arch until age 5 or 6 when their arch develops.
History of Flat Feet
The concept and pathologization of flat feet is not new. Galen, a Greek physician after Hippocrates, described flat fleet as early as 129-216 AD . He identified pes planus as a deviation from “normal” anatomy, labelling flat footed humans “λειοποδες” (liopothes), which translates to “people with smooth feet”(Biz et al. 2023).
In 1884, surgeons were performing surgeries for flat feet, consisting of removing parts of the medial foot bones and replacing it with an ivory block. Plaster casts were then applied and removed anywhere from 4 days- 4 weeks with bed rest orders for the next 2-3 months. (Biz et al. 2023). Bed rest for 2-3 months? No thanks!
Insoles and high support running shoes aren’t a new concept either. Doctors in the early 20th century prescribed boots comprised of an elevated medial sole, steel arch supports, and other supportive materials ranging from firm cork pads to cushy caoutchou (AKA natural rubber) pads (Biz et al. 2023)
Jumping forward to WWI, soldiers were turned away from duty if they had flat feet. This could have been for a variety of reasons: the historical pathologization of pes planus, the advent of orthopedic surgery specialization, or the army attempting to optimize and standardize footwear to reduce injuries. Regardless of the reasons, 10% of perfectly healthy soldiers were turned away during WWI for their flat feet, labelled “deformed and unfit,” and given stretches and exercises to “fix” their flat feet (Linker 2007).
In 1977, authors (Root et al. 1977) popularized the concept “ideal feet,” stating that if feet didn’t fulfill these 6 criteria, they were abnormal and a cause for concern. (You can get his book for just $750 on Amazon!). The concern if your feet didn’t fulfill the 6 criteria? Increased risk for injury and overall inefficiency because of biomechanical pitfalls, and this applied even in the absence of pain or symptoms.
Dr. Moisan noted in a recent podcast that the obsession with flat feet is yet another attempt of humans trying to give a simple answer (“it’s because your feet are flat”) to a complex problem such as knee or foot pain.
When should we be concerned about flat feet?
There are times when foot morphology should be addressed and may be the cause or result of some other pathology. These times include:
After traumatic injury
Significant side to side differences
If it is the result of a dysfunction elsewhere…
Moisan notes, “an acquired flat foot is pathognomonic of advanced stages of posterior tibial tendon dysfunction” (Moisan 2023).
But overarchingly, the concept of flat feet being abnormal has been overdone and leads to anxiety, overprescription of foot orthotics, and overcomplication of care. Authors came up with a better solution, one that we hone into with every patient at Made 2 Move.
“We need to consider a comprehensive range of factors, inclusive of the kinetic chain, contributing to musculoskeletal disorders. To improve our understanding of individual requirements and susceptibilities, it is essential to prioritise the evaluation of tissue capacity and load in both clinical and research settings, as well as other psychological and social considerations” (Moisan 2023)
In our own words?
Dialing into individual load capacity, pain tolerance, and tissue strength and integrity.
Helping you manage overall load, volume, intensity, and recovery.
Doing these things has been far more effective in our experience than worrying over whether your arch is “normal” or not.
Why should we not worry so much about flat feet?
When compiling the research for this 2023 article on flat feet, Moisan and authors found a few reviews that pointed to a WEAK correlation between flat feet and shin splints, patellofemoral pain syndrome (knee pain), and non-specific lower limb overuse injuries. Therefore, the notion that individuals with flat feet are inherently more susceptible to injury may not be as significant as once believed.
Patients often come see us with a self-diagnosis or one from their doctor and want to know if we can “fix it” (flat feet being one of them). This is all too common and relates to Moisan’s point that, “reducing overdiagnosis in healthcare has become a crucial priority. Overdiagnosis can be defined as the diagnosis of a condition that does not provide a net benefit to the individual” (Moisan 2023). Will it change our course of treatment or provide you with a postive outcome? If not, let’s leave the labels alone for now and focus on more important, controllable factors such as modification of movements and load optimization.
An article in the Washington Post this year noted, “Rather than considering flat feet as part of the bell curve of normal variation, the medical and footwear fields for decades have rushed to treat flat feet with supportive shoes, orthotic inserts and surgery, even in the absence of pain or other problems” (McMahan 2023).
We’re here to flip this script. We agree…“FLAT FEET SHOULD BE CONSIDERED AS HEALTHY ANATOMICAL VARIANTS...a natural diversity in the context of overall foot health” (Moisan 2023).
Interested in working with a PT who won’t pathologize normalize or overdiagnose but who will instead work to get to the root cause of your pain? Reach out to firstname.lastname@example.org today to set up an initial evaluation!