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Monday, November 1, 2010

Are You Truly Flat Footed or Do You Have Adult Acquired Flat Foot?

I would like to make one thing clear.  Having pes planus, also known by a more common term as being “flat footed”, does not increase the risk of acquiring plantar fasciitis.  It is however a common misconception.  Many times when in the clinic working, I will hear seasoned physical therapists, trainers, coaches, and runners saying they need an orthotic for their flat feet so that they don’t become afflicted with plantar fasciitis. 
It is a fact that people who are truly flat footed were born this way.  Pes planus is a genetic trait.  Either you are flat footed or you are not.  Pes planus should not be confused with acquired pes planus oradult acquired pes planus.  It is a fact that if one is born with pes planus, they should count themselves as lucky especially if they plan to participate in high impact endurance sports.  Since the plantar fascia associated with pes planus is already elongated genetically and lets the arch of the foot fall to the ground, then there is going to be much less stored energy in the plantar fascia during heel lift and toe off phases of the gait cycle.  The incidence of plantar fasciitis among those people that have a true pes planus is very low! 
This then begs the question of whether or not the person with pes planus would not be as efficient a runner as someone with a higher more rigid arch?  Again, the answer is yes, the person with pes planus can be just as efficient running.  The body does what we are told to do.  We respond to conditioning and training.  While attending a running seminar in Las Vegas, NV, we were studying the gait cycle during walking and then during running.  While taking notes of the subjects in standing, it was noticed that true pes planus was present on two of the male subjects.  When observed during a fast gait and running, the pes planus was not observable.  The subjects had been trained to adjust their walking and running mechanics so that a more efficient stride was used. 
So, in summary, being flat footed rarely is the single contributing factor to acquiring plantar fasciitis.  Also, being flat-footed does not make you a less efficient runner.  However, if you do not adjust your foot mechanics from heel strike through toe off, the potential for being a less efficient or slower runner is present.
Acquired Flat Foot
Acquired flat foot can be a combination of break down in the arch of the foot or a break down and subsequent changes in the ankle joint.  But be careful, acquired flat foot is not just limited solely to soft tissue, musculoskeletal imbalances, and joint breakdown.  There are other factors that can cause acquired flat foot.  These factors include prior injuries, predisposition to osteoporosis, nutritional deficiencies, as well as systemic disease, and genetics.
A very common place for acquired flat foot is in a joint in the ankle called the “subtler joint”.  This joint is just below the area that the tibia (our shin bone) meets the calcaneus (our heel bone).  If the muscles connected to the tendons that cross over the subtalar joint become too weak, then the inside of our ankle will drop causing an appearance of being flat footed.  When the inside ankle drops, this also causes the arch of the foot to drop closer to the ground.  Again, this is the flat foot that the majority of laypersons literature is referring to.  It’s very important to know that acquired flat foot can be corrected.  You were not born with this!  There is a catch though.  If this is left unattended, then the joint could suffer irreversible damage.
Prior to writing this, I performed a rather extensive literature review and found that plantar fasciitis is much more common in the population with acquired flat foot.  In fact, these studies confirmed my findings over the past three years in the clinic when working with people that suffered from plantar fasciitis.  The most common age group with acquired flat foot is between the ages of 40 to 55 years of age.  As far as gender, plantar fasciitis prefers men and women equally.  Children and adolescents rarely present with plantar fasciitis!  These findings coincide with my clinic findings.
So Why Not Use an Orthotic to Maintain Arch Height?
I only prescribe orthotics when working with the most chronic and stubborn cases of plantar fasciitis.  I will only use them for specified lengths of time as well as intermittently.  Initially, the orthotic can facilitate improved mechanics of the foot.  Orthotics doesn’t ever support a foot during running or walking.  Instead, orthotics put pressure on specific areas of the foot causing the wearer to adjust their gait so that the discomfort from the pressure lessens.  Orthotics acts as a contact cue to the foot so the movement of the leg/foot performs a desired movement.  Basically, the orthotic is retraining you.  The reason I don’t like long-term orthotics are that if worn too long, the compensation in gait can cause weakness in specific leg/foot muscles (especially in the foot).  An imbalance in muscle strength can occur.  That being said, if you want to go back to not wearing orthotics or orthotics go bad for some reason, then you would have to do so slowly.  Otherwise, you run the risk of re-acquiring plantar fasciitis because the intrinsic muscle of the foot is significantly weakened.  This is especially true if you wear a full-length or three quarter length rigid foot orthotic.  Beware!  Orthotics is not necessarily your friend in this situation!  It’s extremely important to improve the strength of the foot intrinsic muscles!
So, What to do Next?
The most conventional method so far to treat plantar fasciitis is to rest.  Rest so that you don’t inflame the tissue any more than it is already.  If rest doesn’t do it, then get an injection.  If the injection doesn’t do it then see a physical therapist.  If physical therapy doesn’t resolve it, then try an orthotic and continue with conservative treatment from a physical therapist. 
Whew! What a tedious process!  All of the above are the traditional methods for resolving plantar fasciitis.  Stretching, strengthening, icing, self administered massage, and reducing your activities to just about nothing has and for the most part remains the standard for treatment for plantar fasciitis.  Much of this leaves a person questioning whether or not if this plantar fasciitis is going to go away. 


Happy Bipeding!

Brad Senska, PT, DPT, BS, ASTYM.

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