The Art and Science of Fitness | How worried should you be about your flat feet and what to do about it?

Flat feet, even if present, do not necessarily lead to problems. Focus on taking a proactive role in improving foot health, rather than unneeded interventions

I often get patients coming to me with the diagnosis of flat feet. Now this could very well be self-diagnosis or told to them by someone with a medical degree. This ‘diagnosis’ is even more stressful for them when it is instead about their young children. It doesn’t help matters at all when they get to know from all kinds of sources, reliable or not, that flat feet can lead to knocked knees, which besides giving an awkward walk, can lead to lifelong ankle, knee, hip, back and neck pain.

Flat foot refers to inner (medial) arches being flattened and not being visible, as we stand(Representative Image- Pixabay)

First, it is important to understand what flat feet are. And even before that to know about our feet, whether flat or not. Our two feet have 52 bones, i.e. a quarter of the bones in a human body. In addition to that our feet have 66 joints and more than 200 muscles, tendons and ligaments. All of them team up to give us support, balance and mobility.

Flat foot refers to inner (medial) arches being flattened and not being visible, as we stand. When those of us with flat feet stand, the inner pads of our feet press into the ground. Typically, you can't see an inner arch in the foot, though sometimes the arch appears when you lift the foot or sit down.

Now to figure this out, I would like you, the reader, to take off your shoes and socks. The best thing would be to sit in front of the whole body-length mirror and look at your feet, especially both your big toes. Now focus on the inside margin of your feet starting from the big toes, till your heels. There is supposed to be an arch formation between your heels and big toes. When you stand, you’ll notice that the arch collapses a bit. If it collapses completely, you have a fallen arch or flat feet. Or is it?

Dr Jain, consultant foot and ankle surgeon at Delhi Foot, clarifies what an actual flat foot is. “Mostly we recognise flat feet as the collapse of the arch. We must be very cautious about a low arch person being identified with a flat foot because they may not have a flat foot, but rather a normal foot with an ill-developed arch. When we diagnose a flat foot, it is important to look at the heel. The part of the heel touching the ground, as seen from the back, goes outward compared to the rest of the foot. The foot rolls inwards as seen from the top and the arch completely collapses, as seen from the side, as if the roof of the foot has broken down. There will be a deformity seen on all these three views for it to be diagnosed as flat foot.” It's important to be aware if you have a low arch or a flat foot.

As John A Shedd said almost a century ago, “A ship in harbour is safe, but that is not what ships are built for.” The same holds true for feet. They aren’t meant only to lie, sit and stand. Our feet get us moving. And that’s where our inner (medial) arches play a role in getting us moving optimally. If our medial arches were to collapse a bit as we sit and stand, they would most probably collapse a bit more when we walk or run and almost all the body weight is on one leg at a time. The problem begins when those arches collapse excessively.

Again, let’s do this together as you read through this. While standing, this time on purpose, collapse your arches a bit more. You’ll notice both your knees rolling in and almost touching each other. This is what is referred to as knocked knees. From this standing position, I want you to take the support of something steady like a wall, railing or chair and stand on one leg. Now, again exaggerate that inner arch to collapse more than it actually does for you. Do a slight squat on the leg you are standing on, say about a quarter squat.

You’ll notice that the knee of the leg you are standing on will also fall in, followed by your hip rolling in. And obviously, your back will do the same too. Now switch legs. You’ll notice the same with the other leg too. If you were to imagine this: Ankle - knee - hip - back rolling with each step you take while walking or running, it’ll start making sense to you what would happen to your body when you walk an average of more than 4,000 steps that a majority of us end up taking in a day. With each step your arch collapses, your knees knock with each other, followed by your hips move each time like that of a model walking on the ramp. It’s a matter of time before you have pains all over, especially heel, shin, knee, hip and back, and are not able to perform all kinds of physical activities optimally.

As highlighted by Dr Gabriel Moisan, professor of human kinetics at the University of Quebec, in the British Journal of Sports Medicine editorial, titled ‘Flat feet: deformities or healthy anatomical variants’, this theory of high risk of sustaining musculoskeletal injury was postulated a long time ago, but it was William Phillip Orien, John Weed, and Merton Root, in their book ‘Normal and Abnormal Function of the Foot’, published in 1977, is said to have popularised the concept of ‘ideal feet’.

According to them, if the feet didn’t meet their criteria for normalcy, they were considered abnormal, less efficient and more prone to injuries. This was considered the turning point amongst healthcare professionals as medical educational curriculum globally started teaching the same. This led to a snowball effect to the extent that anyone associated with human movement was preaching the same, and do so till date.

Someone with flat feet and the resulting knocked knees is disqualified on medical grounds to join the police, military and paramilitary forces. This began during the Second World War when the military noticed that some recruits with flat feet had difficulty marching. Just to make it easier for themselves, if the recruiting officers found someone to have ‘flat feet’, they were disqualified from joining the forces, whether they had any other symptoms or not. In the US army, navy, air force and Marines, since the later part of the Vietnam war, for over half a century now, flat feet aren't a criterion for medical disqualification as long as there are no symptoms. But in India, whether it be the police, military or paramilitary forces, to date, flat foot is considered as an automatic disqualification.

Dr Moisan pointed out that several recent studies found a weak causal link between flat feet and injuries leading to pain in shins, knees, and other overuse injuries in the legs. Studies have also shown that flat feet are not a risk factor for running-related injuries, yet we are all trying to fix them. Anecdotally, you’ll find a lot of such videos of Olympic-level runners with flat feet doing very well in their events and even winning gold medals.

Dr Abhishek Jain points out that flat feet can happen during adolescence, adulthood and late adulthood, i.e. after 40 years of age. Whether it is your own feet or your children’s that you are worried about, please relax, it isn’t at all as gloomy as I have made it out to be. There is a lot more you need to know, and there is a lot you can do.

When it comes to baby’s feet, most do have flat feet as they are still developing. But as parents tend to do, they get worried when they discover that their children have flat feet and seem to walk a little differently from other kids. By the time they get to their teenage years, the arches start to develop, and more so if children lead a physically active life, leading to better posture and movement.

In any case, it matters if there are any symptoms or not, and you are able to carry on your regular and sporting activities without any hindrance. As in most medical conditions, even back pain, something I deal with day in and day out, a significant proportion of people have abnormal findings on their MRIs, but throughout life, don’t experience even one serious episode of back pain.

There is a whole industry that uses scare tactics to get you to buy things (insoles/orthotics, motion control/stability shoes) and to get interventions (surgeries) that aren’t actually needed even when you have no symptoms and you are able to do all your physical activities without any hindrance. Orthotics and stability shoes can play a temporary role in providing the support, balance and proper mobility that your feet lack. But we shouldn’t permanently become dependent on them.

Whether low arch or flat foot, it’s effectively a weakness of the musculoskeletal system. Remember that our skeleton is held together and helped by muscles, ligaments and tendons during movement. In quite a high number of cases, the medial arch starts to improve once we know how to run better and exercise some muscles that are weaker than they should be. As for improving your walking and running form, simply start by shortening your stride length. This will help you to avoid landing on the heel, which will prevent your feet from collapsing with each step. As a result, your knees will not knock and your hips will stop rolling in, preventing injuries and improving your performance.

There are two muscles that play an important role in helping the medial arch to be higher. Abductor hallucis, is a muscle in the sole of the foot attached from the heel to the big toe and gluteus maximus, the other muscle a bit further north, commonly known as the buttocks.

Here are a few exercises to get the muscles working to improve the medial arch of the feet. For each of them, start with 5-10 repetitions. 2-3 sets are enough.

• Foot/ Abductor Hallucis - Toe Curls: Stand without socks and shoes. Curl your toes up, shortening your feet, such that your medial arch raises. One easy way to go about it is to stand on a towel, a sheet of paper or a handkerchief and then curl it up with your toes. Hold it for 2-3 seconds and then let go, coming to your stationary position.
• Foot/ Abductor Hallucis - Spreading Toes: Sit down and spread your toes apart such that the space between them increases. In the beginning, you might not be able to do much but as you keep practicing, you’ll start to separate your toes out well. Hold it for 2-3 seconds and then come to a stationary position.
• Buttock / Gluteus Maximus - Coin Hold: Stand up tall and imagine there is a coin in between your buttocks and you are supposed to hold it together. This visualisation will help activate the butt muscles unlike what you’ve done before. Hold that imaginary coin for 2-3 seconds and then come to a stationary position.
• Buttock / Gluteus Maximus - Leg raise: Lie down on your tummy. Bend one leg at the knee such that your lower leg is vertical to the ground. Now slowly vertically raise the thigh off the ground by about 2-3 cm, hold it there for 2-3 seconds and slowly bring it down.

These exercises done for 4-6 weeks tend to help with a low arch and flat foot. Once you’ve done so, your medial arches will naturally get better and you’ll not be dependent on orthotics and stability shoes.

It is important to know that some will have symptoms along with their flat feet and should not be ignored, but it is important to try what is being suggested above before getting some serious interventions done. On asking a senior army officer who has been involved in the selection and training of army cadets why we still have flat feet as medical disqualification, he gave me the most satisfying response I’ve heard so far. “We already have way too many people applying. It helps us reduce those numbers. Yes, we could have worked on those with flat feet and improved them, but we already have so much work to do with them. We would rather focus on what we are good at.”

As for the individuals keen to apply for police, military and paramilitary forces, or those leading a physically active lifestyle, please do these exercises and get on with life. Orthotics and stability shoes only make a temporary change, if at all, whereas the running form and exercises suggested above will make a permanent change. Take a proactive role in improving yourself, rather than becoming dependent on others, or else they'll take you for a ride.

Keep miling and smiling.

Dr Rajat Chauhan (drrajatchauhan.com) is the author of The Pain Handbook: A non-surgical way to managing back, neck and knee pain; MoveMint Medicine: Your Journey to Peak Health and La Ultra: cOuch to 5, 11 & 22 kms in 100 days

He writes a weekly column, exclusively for HT Premium readers, that breaks down the science of movement and exercise.

The views expressed are personal