Caught Flat-Footed
Pes Planus Rx and PT
Monday September 28, 2009
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If a patient isn’t genetically predisposed to flatfeet, the dysfunction can occur from improper training techniques, obesity, diabetes mellitus-induced Charcot arthropathy, rheumatoid arthritis, leg length discrepancies, improper footwear, or some other, unknown cause. Other contributing factors include dysfunction in the static stabilizers of the medial longitudinal arch, particularly of the spring ligament complex (calcaneonavicular ligaments) and the talocalcaneal interosseous ligament.
Calf muscle tightness often is a big issue for patients with flatfoot. When the calf is tight, the foot may compensate by falling into pronation to allow the body to pass over the foot during ambulation. “The bottom line is that if there is tightness in the calf and it restricts that motion, the foot has to distort. It does that by pronating and that puts a lot of stress on the tibialis posterior tendon,” he says.
A cascade of events might occur in symptomatic adults with flatfoot, starting with swelling and pain around the medial malleolus and progressing to tibialis posterior tendon degradation, Paulseth says. In time, the tendon can rupture, causing the arch to significantly descend and forcing the body to rely on static restraints — primarily, the plantar fascia and the spring ligaments. The eventual collapse of the arch creates an inward rotation of the lower extremity, which can affect the knees, hips, and lumbar spine.
“The appearance of flatfeet can be a positional problem at the hip. For example, if you have weak external hip rotators, your femur and tibia may rotate internally, giving you the appearance of a flat foot,” says Richard H. Haglen, MSPT, CSCS, director of physical therapy at A Physical Therapist, Inc., Delray Beach, Fla. “So, as PTs, we should be evaluating the whole person from an alignment perspective before we can determine if there really is a flatfoot issue,” he says.
Whether the pronation is a cause for concern or should even be treated is another matter. Treatment for adult flatfoot is generally based on symptoms, and an important consideration is whether the patient has always been flat-footed, or if the flatfoot gradually occurred in one or both feet over time.
When a patient exhibits more pronation on one side than the other, PTs should take notice. “That’s a warning sign ... it can be a progression for what may become acquired-adult flatfoot dysfunction or deformity,” Paulseth says. “Often, [patients] start to feel certain kinds of pain around the foot and ankle on that involved side.”
Kim Williams, PT, staff pediatric PT, Blank Children’s Hospital, Des Moines, Iowa, says that flatfoot can be treated in childhood to prevent foot, ankle, knee, hip, and back problems later. “Children are much easier to treat because they’re still growing and their tissues are more malleable than adult tissue. It’s easier to change their foot and improve their alignment and keep it,” Williams says.
But even with children, a PT has to rely on experience when making the decision of whether to treat flatfoot, according to Williams. Children who are 1 or 2 years old, for example, often developmentally have flat feet before their arches develop, so treatment is not indicated, she says.
“We’ve found that a lot of those kids probably didn’t spend a lot of time on their tummies, so we do a lot of prone activities [such as] wheelbarrow walking or playing while they’re laying on their tummies in a plank or push-up position where they have to shift their weight,” Williams says.
She might also use stretching and serial casting before, possibly, putting the child in orthotics.
“The goal is to manage their orthopedic alignment and foot alignment ... as they’re growing, so that when they are full grown they haven’t developed some of those asymmetries and ... poor postural alignment,” Williams says.
In adults, one of the mainstays of therapy for problem flatfoot includes calf stretching to ensure the restoration of normal ankle dorsiflexion, Paulseth says. Manual therapy techniques also can help restore normal ankle and midfoot motion.
He often will supplement with low- or high-Dye taping to restrict excessive pronation at the subtalar joint and control maximum eversion of the rearfoot, especially early in treatment. When taping helps, Paulseth might then make a customized shoe insert for the patient with flatfoot. Another option is motion-control shoes. However, Paulseth insists these more permanent measures are not required for all patients with flatfeet.
“A lot of therapists in foot and ankle now are really looking at arch height indexes, trying to determine the true height of the arch. Maintaining [arch height] it is an important issue for normal lower extremity biomechanical function,” Paulseth says.
“We want to at least avoid velocity of pronation — the speed at which the foot flattens which creates the problems in the lower extremities — more than the fact that they actually pronate.”
Lisette Hilton is a freelance writer. To comment, e-mail pteditor@gannetthg.com
