Conway McLean, DPM, Journal columnist

This is the story of two normal families, average folk, working people. And they had some similarities, these two families. They both gave birth to sons, and both had a family history of foot problems. As to what sort they were, this is typically unknown, only the vaguest of histories is usually passed down about problems such as these.

Our understanding of lower extremity biomechanics, how the foot works to support our bodies, has historically been extremely limited. An understanding of lower extremity anatomy has been easier to develop since physicians could dissect and examine cadavers. But the real time mechanical function of the foot, ankle, and lower leg, that is a more obscure topic entirely. The biomechanics of the human body is of such complexity as to frustrate the most accomplished engineer.

Returning to our average families, both sons were noted to have a flatter foot type. As infants, little had been made of this, but as both children became ambulatory, developing the motor skills required for this difficult task, both were noted to walk in a rather ungainly fashion, splayed feet, waddling like a duck. The pediatrician seen by, let’s call them Bill’s family, assured them this was perfectly normal and the child would grow out of it.

Bob’s family, the other party discussed, were told the same thing. Yet, they had a family friend whose son had pain from his flat feet, which was treated with prescription arch supports made for their son. These plastic shoe inserts were made from molds taken of his feet, with the doctor making a video of how Bob walked. X-rays were taken of their son’s feet when he was standing. The benefits to the boy’s gait were significant and impactful.

Bob’s father, upon receiving this friendly advice sought the care of a foot specialist who made the devices for their son. The youngster began using these around four years of age. Adjusting to the devices was difficult, but his parents insisted and he soon came to appreciate their benefits. With them, the boy was better able to compete with his peers at the playground. This helped him become more socially successful at kindergarten and onward.

Bill’s parents took the advice of their pediatrician and sought no other opinion. They were careful to purchase supportive stable shoe gear, seeking out designs intended for kids with flat feet. Still, they noticed their son had difficulty keeping up with his friends at daycare.

Over time, he came to complain of vague pain in his feet and legs after an active day or extended time at the playground. They naturally consulted the boy’s doctor who stated “it must be growing pains!”

Bob, on the other hand, wore his custom arch supports, his foot orthoses, in his shoes for nearly all activities. He became interested in youth sports and got involved in the local soccer program. This type of athletic pursuit encouraged in him a lean body mass and significant cardiovascular fitness.

Bill, on the other hand, shunned sports and even looked to avoid gym class. Early on, he turned to computers and their associated games since more physical activities made him feel bad, both physically and emotionally. Between the combination of a sedentary lifestyle and munching on sweets in front of the computer, Bill gradually crossed over into the “chubby” category. Obviously, a certain social stigma is associated with obesity and he did experience “fat shaming” more than once. By the time he was well into his teens, Bill was trending toward obesity and was also pre-diabetic.

The foot’s job? To carry our bodies around, moving us through space. But poor skeletal architecture, how all the bones are shaped and fit together, is pivotal to how everything lines up. In lower extremity biomechanics, function follows form. If the bones fit together in such a way that there is inadequate stability, various soft tissue structures are going to be stressed over time, as they try to keep things lined up and functioning.

When foot structure is sufficiently abnormal, reconstructive surgery is sometimes attempted to create a better foot structure. This is complex work with numerous opportunities for complications. Far more benign, tremendously less invasive, and nearly as complex is the design and fabrication of a prescription supportive device for the foot.

For a mild problem, a simple, off-the-shelf device may be sufficient, sometimes even the flimsy rubbery devices dispensed at the mall kiosk where you stand on the pressure plate. These provide minimal benefit but for some, enough. There are some good non-prescription supports on the market, but how to know, there are so many of them? And the claims made by some of these manufacturers are completely ridiculous.

The incidence of pediatric flatfoot is unknown. How to specifically define it and then to precisely identify when it is present? What angles are most important to making the diagnosis? Opinions vary from group to group on this topic, even how and when to treat. Although many physicians dismiss these concerns, those studying body mechanics agree there can be long term consequences to this foot type, including degeneration of knee cartilage, chronic low back pain, shin splints, and more.

There is frequently a problem in utilizing customized foot supports. The techniques required to prescribe them correctly, evaluating properly the patient’s foot mechanics, how far the joints are moving, the positioning of various structures when standing and walking, these skills are uncommon and challenging to come by. Many health care providers dispense foot orthotics but are not well acquainted with these concepts. Consequently, they are less successful in treating problems stemming from biomechanical issues. Many patients therefore conclude foot orthotics don’t work for them.

What of our protagonists, Bill and Bob? The family of the latter agreed, he had actually developed improved foot structure after years of use of his foot orthotics. He still used them as an adult, but did fine without if not excessively active. Bill, on the other hand, had a knee replacement at the age of 40. He exercised rarely and also developed diabetes and heart disease in his early 20’s. These changes are not conducive to a good quality of life.

Can we say that Bill’s un-treated flatfoot led to his heart disease? Scientifically speaking no, although certain deductions can be made and conclusions formed. Indeed, some smaller studies have demonstrated improved foot structure with early and consistent use of foot orthotics. At least when they are prescribed accurately, precisely, with an understanding of foot and leg biomechanics and how to improve it. Many people have less than optimal experiences with these medical devices. But, when everything works correctly, they can be, quite literally, life-changing. I’ve heard it too many times not to believe it.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean’s practice, Superior Foot and Ankle Centers, has offices in Marquette and Escanaba, and now the Keweenaw following the recent addition of an office in L’Anse. McLean has lectured internationally, and written dozens of articles on wound care, surgery, and diabetic foot medicine. He is board certified in surgery, wound care, and lower extremity biomechanics.