Our First Steps – Flat Feet

I often hear people tell me that they have the “flattest feet” or their feet are “flat as a board”. In truth, the only people that truly have normal “flatfeet” are infants.

Flatfoot may be defined as an absence of the arch upon standing or walking. It is often associated with excessive inward “rolling” of the foot known as pronation. It is well accepted that children under the age of 7-10 years normally do not possess a significant arch or one that resembles the average adult foot. James Losito, D.P.M., Professor of Biomechanics at Barry University and a team physician for the Miami Heat, University of Miami and Barry University Intercollegiate Athletic Programs and Medical Director for Pro-Tech Sports Medicine, has had lots of experience with care of common pediatric pathologies. ” It is for this reason, that pain and function be emphasized rather than the cosmetic appearance of the foot when determining if a child’s foot is abnormally flat,” says Dr. Losito.

Dr. Losito states that a history of fatigue, cramping, pain, excessive shoewear or “sloppy” gait are the most reliable indicators that an abnormality is present. Several different causes of flatfoot exist including, ligamentous laxity, tightness of the Achilles tendon (equinus), muscular weakness or spasticity, and pigeon-toed gait. In the adult, excessive pronation (flattening of the arch) may produce many problems including tendinitis, fascitis, shin splints and stress fractures. Therefore, treatment of a symptomatic pediatric flatfoot should not be ignored. In some cases, treatment such as muscular strengthening or stretching is the key to improving the flatfoot condition. However, in many instances a functional orthotic device may be used in conjunction with exercises or used alone.

For example, children who walk pigeon-toed (intoed) or slew-foot (out-toed) suffer from severe pronation (flattening of the arch) as compensation during gait. A functional foot orthosis helps prevent the excessive pronation, which can lead to a structural flatfoot. In those children who trip, stumble or are clumsy, the orthotic can be fabricated to reduce the degree and severity of the abnormal gait pattern.

Children who suffer from equinus, defined as a tight Achilles tendon almost always suffer from excessive pronation and a flatfoot. This requires rigorous stretching exercises or surgery to eliminate the abnormal force creating the flatfoot. Functional foot orthosis are useful in eliminating any residual pronation and supporting the foot if any permanent structural changes have occurred.

Shoes and functional foot orthosis are not necessary for normal development of the child’s foot. However, when the aforementioned symptoms are present, functional foot orthotic devices are a proven and successful option that families can benefit from to help correct and prevent future problems.

Heel Pain? Arch Pain?

Heel spurs are one of more common problems faced by Podiatric Physicians.  A heel spur is a point of excess bone growth on the bottom of the heel.  Heel spurs are visible by x-rays.  The spur formation usually starts at the heel bone and extends towards the toes.

An even more common problem that is faced by Podiatric Physicians is Plantar Fasciitis.  This common heel problem is caused by a partial tearing of the plantar fascia (a dense fibrous connective tissue that connects the heel to the toes) usually at the attachment of the fascia to the heel bone.  This partial tear can result in a heel spur, fasciitis, or both.

The most frequent cause of heel pain is an abnormal motion of the foot called pronation.  Normally while walking your foot will strike the ground on the heel, then roll forward toward your toes and inward to the arch.  Your arch should only dip slightly during this motion.  If your heel is rotating outwards too much and your arch is lowering too much then you have excessive pronation.  The excess pronation leads to the arch of your foot stretching excessively.  It is this extra stretch in the arch that causes the partial tearing of the plantar fascia and the possibility of spur formation.

Other factors that may contribute to plantar fasciitis and heel spurs include a sudden increase in daily activity, increase in weight, or a change in shoes.  Dramatic increases in training intensity or duration may cause plantar fasciitis.  Shoes that are too flexible in the middle of the arch or shoes that do not bend in the correct location will also increase the amount of tension on the plantar fascia, as will an increase in weight.  And it is this increase in tension that leads to the partial tearing of the plantar fascia.

Plantar fasciitis is usually controlled with conservative treatments.  About 90% or more of the patients with plantar fasciitis will be controlled with conservative treatments.  Conservative treatments consist of: strapping of the feet, combined with a physical therapy program, and anti-inflammatory.  One of the main things a patient can do is stretching of the calf muscles and icing to the painful areas on the heels.  If the patient improves with the temporary strapping, then the patient would most likely also benefit from an arch support.  There are many types of arch supports on the market today.  The best arch support is a custom made orthotic which will control the excessive pronation and also support the arch taking the tension off the plantar fascia.The orthotics can then worn in a variety of shoes.

If the patients continue to have pain a physician could choose to do injection therapy, which consist of injecting a small amount of cortisone into the painful area trying to decrease the amount of inflammation present.  The patient could receive several injections while still performing the conservative treatment also over a period of several weeks or months.

If the pain still continues for a time period of 6 months or more, despite treatment, the patient may be choose to have a new treatment which uses shock waves.  This new treatment is called, Extracorporeal Shock Wave Therapy (ESWT).   This innovative, non-surgical treatment involves the delivery of sound energy or shock waves to affected areas of the body triggering the body’s own natural repair mechanisms and stimulating healing.  ESWT can be done in the office (low energy) and without the need for anesthetic.

ESWT is a safe and effective treatment option for many kinds of chronic pain associated with tendonitis.  The recovery period is shorter than traditional invasive surgery and the procedure eliminates many of the risks associated with traditional surgery.   Insurance may cover these treatments; however, it would be best to check with your specialist.

For the remaining small percentage of patients who fail to be relieved of the pain, the patient may choose to have surgical correction.  Surgical corrections consist of releasing the part of the plantar fascia from the attachment to the heel bone.  This is done to stop the pull of the fascia on the heel bone, thus stopping the pain.  The physician may also choose to remove the heel spur at this time also. Following surgical correction it will require the patient to be immobilized for a period of time.  The patient will then have the need for rehabilitation later.

In summary heel pain, heel spurs, and plantar fasciitis are common problems that are faced by many patients.  It is a problem that can be controlled and managed without surgery for the majority of the patients suffering from heel pain.