Health matters

Many complications of a flatfoot deformity

Conway McLean, DPM, Journal columnist

Humanity comes in all shapes and sizes. Some people are tall and some short, some thin and some wide. The same variation holds true for our skeletal structure, which may manifest in a wider foot or a slimmer foot. What about a longer one versus a shorter foot. And what about the height of your arch?

It is difficult to quantify specifically what constitutes a flatfoot. Multiple different terminologies exist, numerous measurements cited. Because of human variation, there are going to be some people whose arch is lower than the average, but the joints are well aligned, and things function well. Many people have a lower arch, but don’t have problems because of proper joint congruency and appropriate biomechanics. By way of an example, Walter Payton, a famous football player, had flat feet and he functioned quite well.

Still, there are no specific formulas universally recognized for making the diagnosis of a flatfoot deformity. The technical term for a flattened foot type is pes planus. Naturally, there are multiple variations on the theme. Is the arch collapsed straight down? Or is it twisted in such a way that the foot has rolled inward? Unfortunately the intricacies of the condition, in all its permutations, is rarely studied by the non-specialist. Many people are told casually by a healthcare provider that they have a flatfoot, a quick glance the only analysis, obviously not a precise evaluation.

The consequences of pes planus, a.k.a. a flatfoot deformity, are numerous and varied, often affecting structures not obvious to those unfamiliar with the subject. For example, when the foot collapses excessively, it causes the lower leg to turn inward, changing the alignment of the pelvis with the spine. The effect is to place greater strain on the musculature of the back, leading to chronic low back syndrome. Those so afflicted often find tremendous relief by reducing this “rolling down” effect with some type of supportive device placed under the foot (usually inside a shoe). Predictively, a well-prescribed custom device will achieve the best results.

Because of the recurrent abnormal alignment, knee problems are also a common complication of a congenital flatter foot type. The cartilage lining the knee joint is chronically stressed when the arch doesn’t line up correctly. The altered line of force, best summarized as the kinetic chain, places more compressive force on the inner half. Alternatively, this same foot type can overwork the muscles in front of the shin causing shin splints, often a particularly painful problem.

Naturally, a variety of complaints can develop with the foot when someone is born with a flatfoot. Likely the most common is chronic or recurrent heel or arch pain. This pain is typically the result of plantar fasciitis, an incredibly common problem resulting from excessive tension or physical stress to one’s arch ligament. This structure runs from the heel, all along the arch, and into the ball of the foot. The fascia is tensed when someone has a lowered arch, but because it’s not elastic, it becomes inflamed when physically stressed. This is a condition which varies greatly person to person with some experiencing only a mild ache when more active, while others have debilitating pain with any weight-bearing.

A lifetime with a (too) lowered arch alters the alignment of the tendons that run out to the toes. A balance in these tendons must be maintained for our toes to stay straight, but many with this foot type develop bent toes over time because of their foot deformity. These deformed toes may lead to pressure to the top or the tips of the toes and eventually, callusing and pain.

Unfortunately (especially for those with this foot type), this list is just the tip of the iceberg. A host of everyday problems are the result of functional abnormalities of the myriad structures involved in weight bearing. A bunion deformity is much more likely to develop, as is Achilles tendinitis. Perhaps the most predictable effect is shortening of the Achilles, the largest in the body, and this in itself has numerous complications to the musculoskeletal system. Pain from the top of the foot is another commonly experienced symptom in those with pes planus.

Numerous approaches are utilized for therapy. From simply changing shoe gear, stretching and strengthening programs, to reconstructive surgery, all manner of treatments are attempted. To the detriment of many sufferers, most of the time nothing is done. Even though flat feet could keep someone out of the army, most healthcare providers know little about the effects of this deformity and the changes to the kinetic chain. These are the forces experienced by the musculoskeletal system when weight bearing. Having the foot planted on the ground alters motion of every joint, every ligament, that is involved in gait and stance.

One of the more common consequences of the flatter foot type is the performance of many knee replacement procedures, secondary to walking with a collapsed arch. Experts believe most of these operations could have been prevented if, years earlier, these individuals had utilized prescription foot supports (e.g. foot orthotics) which help to maintain a more efficient, less deviated position of the many joints, bones, tendons, and ligaments, which function inappropriately in the presence of a flatfoot deformity.

Clearly, there can be significant consequences to the flat foot type. Although many Americans have no real problems living with a lower arch, who can predict the occurrence of these many complications? Familial history provides only tendencies. A physician trained in the nuances of lower extremity mechanics is a good place to start.

With a thorough and multi-faceted evaluation, many of these painful conditions can be prevented. As a nation, we will all benefit by focusing on this approach: any malady will cause less pain, less damage, if it is treated prior to causing symptoms. Preventative medicine is an effective approach to healthcare which has not been adequately developed.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.


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