462 | Flat Feet: Do They Cause Pain or Really Need “Fixing”? What the Latest Research Actually Says

[00:00:05] Welcome to the Optimal Body Podcast. I'm Dr. Jen. And I'm Dr. Dom. And we are doctors of physical therapy, bringing you the body tips and physical therapy pearls of wisdom to help you begin to understand your body, relieve your pains and restrictions, and answer your questions. Along with expert guests, our goal of the Optimal Body Podcast is really to help you discover what optimal means within your own body. Let's dive in.

[00:00:28] If you are suffering anything with your feet, or you just want to make sure that you're taking care of your feet so that you avoid plantar fasciitis, bunion pain, things that you might see happening in your parents or other people in your family, this is the time to get into Barefoot Mini Course. This is our famous foot and ankle course that is just two weeks. However, we added a brand new three weeks.

[00:00:52] So you had so much more information without paying extra. Right now, we are running a huge discount going through it as a community. So you have the accountability and support to go through and really learn. It's 10 minutes a day. It's not going to take much of your time. And I'm telling you, you're going to feel massive results. People have been able to say things like, I've been able to get rid of my plantar fasciitis twice now using your stretches and exercises while everyone I know has spent $1,200 on good feet store on orthotics.

[00:01:23] Or this one, Barefoot Mini Course saved my feet from bunion surgery. Thank you so much for all the knowledge you share. I mean, countless people have continued to report incredible results getting rid of plantar fasciitis, getting rid of pain from their bunions, and really healing their feet long term and having a resource for life that you can come back to. I am telling you, now is the time to get in. Just head to gen.health backslash barefoot.

[00:01:50] And as a podcast listener, use code optimal. You're going to get an extra discount on top of the already huge discount we have on the course going on. Flat feet is something that is asked about all the time. How do I fix my flat feet? Because I think they've been blamed on so much. And so we really want to go through, like, what does the latest research actually say when it pertains to flat feet? Do they need fixing? Do we have to wear orthotics? How long do we wear orthotics for?

[00:02:16] What are orthotics used? Like, when is appropriate to use orthotics versus not appropriate? And I think when you, you know, we need to realize that SS physical therapists are not against orthotics. Just because we talk about barefoot shoes all the time and barefoot living. Yeah. Physical therapists can actually prescribe orthotics, fit orthotics, and use orthotics within our practice. It's just how are we using them most effectively and who are they used for?

[00:02:43] I think it's a better understanding of what we need to be kind of talking about. It's like any tool. How are they used as a part of the plan? It's like when people think all physical therapists crap on chiropractic adjustments. Like, again, is it the one thing that we're relying on? Is it the one thing that we're getting? Are we only using orthotics? Send them out the door. That's it. Like, this will fix you. This will fix your flat feet. Right.

[00:03:08] And I think that initial message we want to start out with is like, not all flat feet are created equal. There are different types of flat feet. There is a flexible, asymptomatic flat foot. There's something that's more of a rigid flat foot. And this is where we tend to see more symptoms. And then there's a third type called it's like an adult acquired flat foot. Or it's somebody who may have had more of an arch in their foot. And then they started to develop a progressive flat foot later in life.

[00:03:38] And this is usually due to muscle weakening that causes the arch to drop. The better question is, are your feet painful? Are your feet symptomatic? And I like that there are a lot of physical therapists and just the medical profession in general. You're seeing more people just starting to treat more symptom based, which is what we should be doing. We should be treating what we're seeing in the person.

[00:04:03] Not have someone in our clinic who has no symptoms related to their foot or lower body and say, Oh, well, you have flat feet, so we need to fix that. But it's kind of like blaming a scapegoat. And unless there's really compelling evidence as to why that might be causing other issues, which is possible, I don't think it's always the first thing that we need to fix the flat foot. Right. And I think we've seen so many times again and again, that structure doesn't equal pain.

[00:04:32] This is something we harp on on our podcast. We have so much research now to back that up. It's like someone saying, I need to fix my anterior pelvic tilt. Are you getting pain? Why do you need to fix it? Well, no, but I've been told that I have it. Yeah. Okay. Anterior pelvic tilt is a great comparison because when you look at a hundred people, you know, a high percentage of them are going to be in anterior pelvic tilt. A lower percentage are going to be in posterior pelvic tilt.

[00:05:00] And there's actually very few people that you see in actual pelvic neutral. Which, who's measuring that? Whatever the heck that is. Same thing with feet. We have a pretty high percentage of people that have flat feet. We have a decent amount of people that might have more of a cavus, pes cavus, or a high arched foot. Again, like what is normal? What is the normal amount of arch so that you can be classified in this normal foot arch range?

[00:05:29] I don't know. Again, we need to be more focused on function and symptoms than what does it look like. Exactly. And understanding that even if a structure doesn't change, like we can still change your pain and how you're functioning. So that's what we're going to be focusing on. We'll give you some exercises along the way as well to kind of help redefine this conversation and what it really means.

[00:05:55] At the end of the day, we cannot say that you have flat feet and this is the cause of pain. And if someone has told you that, it's actually very outdated. Because again, structure doesn't automatically equal pain. And so we have to be looking at the function of how someone is moving. Even if you have a low arch, you can have no pain. So why can someone who doesn't have an arch or was born without the arch,

[00:06:21] like this is how their foot has congenitally always been and they don't have pain, then why would someone who doesn't have an arch automatically have pain? We cannot say that. So I think we just have to get that out of the way, first of all. So the better question is, well, how are we fixing the function of your foot rather than how are we rebuilding an arch? Because we may not change the structure. It could change. For some people, you can start to see an arch lift again.

[00:06:49] You can start to see this, you know, look different. But for others, it may not look different, but we can still, you know, observe. Are we reducing pain? Are we improving function? Are we, is it worsening? Is it stiff? Like, is it limiting our activity or are we improving in activity? And that's really what we want to measure. So I mentioned earlier that there's three different primary types of flat foot, flexible flat foot, which the arch flattens while standing,

[00:07:17] but appears to offload when you're on your tiptoe. And this is one that we'll talk about as we don't tend to see as many symptomatic people in this range. And it's one that if you do have symptoms, but are classified as more of the flexible flat foot, you're more likely to see pretty quick improvements using conservative measures, rigid flat foot where the arch stays flat and the foot is stiff, regardless of whether you're

[00:07:44] putting load on it or offloading it. And then that adult acquired flat foot that I mentioned earlier, which has more to do with, it's also known as progressive collapsing foot deformity, but I'm not a huge fan of that phrase because it sounds very foreboding where the arch starts to collapse later in life, usually developing from ties to posterior table tendon dysfunction and ligament failure. Which I know Dr. Emily, we've had her on the podcast.

[00:08:14] She's the owner and founder of Neboso. So she has talked about this a lot as well in terms of, you know, once we do get that tissue or that ligament, especially to get so lax to the point that there's no structure to it, it's, we're not going to fix that arch. Meaning we're not going to make a significant change to how it looks. Now, can we still help with conservative measures and strengthening exercises? We believe yes.

[00:08:41] Like why would you ever stop trying to make, you know, strength improvements? Even if there's changes to the tendon and ligament, there's still opportunities of other support around the foot. So just wanted to point that out that yes, that could sound scary as we get older in age and things change, especially if you do have a diagnosis like EDS and increased laxity of your ligaments, you've gone through pregnancy, you've gone through different hormonal stages of your life.

[00:09:08] Like this can all have a really big impact of your foot, which is why it is imperative that we work on the function and the strength of the foot overall, no matter what the structure looks like. Now, this is where, you know, we're going to go back to, well, does flat foot cause pain? And it's just needs to be overstated that we cannot just look at the foot and say, okay, this is why you're having pain.

[00:09:37] We cannot just look at it and say, this is... We should avoid blanket statements. Yes, exactly. When it comes to all flat foot and say, oh, flat foot, no, that doesn't cause your pain or yes, you have flat foot, that's going to cause pain or that's going to be an issue. When we're looking at the literature, we do see that some studies suggest mild flat feet. So you're not having a ton of symptoms. Possibly we're talking about being a little bit more flexible here in the flat feet.

[00:10:04] They're not clearly associated with disability or worse quality of life in adults. However, there are some studies that is linking like moderate to severe pes planus. So that's moderate to severe flat foot. Maybe we're talking more of that rigid foot, that foot that can't really be changed or fixed at this point. Being associated with higher rates of front of the knee pain, anterior knee pain, intermittent low back pain. And in older adults may be linked to frequent knee pain and medial tibiofemoral cartilage damage.

[00:10:33] So just kind of cartilage damage at the knee joint. However, we need to understand that all of these pain issues, knee pain, low back pain, there are so many other components to this. Again, it's associations. So they're saying they're associated, they're correlated. We still can't say, oh, knee pain or you have a bunch of cartilage damage in your knee. It's because of your flat feet. But we can say that working on strength or function at the foot could help other areas

[00:11:03] of the belly. Yeah, it gives us a good idea of where we might be able to work to support through the knee or through the low back to support that whole kinetic chain. So then really, do we need to fix the arch? I think the answer that we are coming to is not necessarily. Especially the structure. And the frustrating physical therapy, physical therapist answer is always, well, it depends.

[00:11:28] And so in many cases, especially in those cases with the flexible flat foot, we don't need to fix the arch or restore the arch, even if you're having symptoms. As we are going to point out, there's current evidence that shows people who have flexible flat foot can improve pain, function, balance, and load tolerance measures through exercise alone, even when the structural change is limited.

[00:11:56] So no, we don't need to fix how the arch looks. I think if we're talking about fixing the arch from an angle or a lens of muscular support and our ability to control range through that foot's flexibility, then yeah, I think we should work on that. I don't necessarily believe it will change the appearance of the arch in everybody. So a 2024 network meta-analysis of randomized control trials found different exercise strategies

[00:12:26] had improved outcomes. And their strongest rankings for some variety of these exercises included posterior tibial strengthening. So your posterior tip is a muscle that runs on the inside of your calf or inside of the ankle. And then down kind of wraps around that bone on the inside of your ankle and down into your foot. So this is literally a muscle that is supporting the inside arch of your foot.

[00:12:51] And what we do see with acquired older adult, you know, flattening of the foot is that sometimes this muscle is, we're either getting a tendinopathy. So we're getting changes in that tendon. We're getting weakening in that tendon. And we don't want to get to the point where we can't use that tendon and that muscle at all. So strengthening this part of the foot, think of it like putting the foot in.

[00:13:16] So anything that we're creating resistance and working that foot like to move in toward the body or toward the other foot, that's going to be strengthening. Same with any kind of like short foot exercise. So when I'm trying to contract the arch, that's directly related to some strengthening that we can do for that posterior tip. The next one on the list was hip focused neuromuscular training, which I love because that has seemingly nothing to do with the foot.

[00:13:46] You know, you're having, you're working on flat foot or symptomatic flat foot and you're working on the hip, which for us makes a lot of sense because our hip and our balance between our foot and our hip, you know, they have so much to do with each other. So if you have more control through the hip, you're generally better controlled on one leg. Neuromuscular training tells me that to some degree, they're probably doing single leg type exercises.

[00:14:12] And some of our favorite things to tell people to work on if they're working on foot issues is single leg hip drills, which I would categorize under this hip neuromuscular training. And it is a really cool thing to do. If you just stand and look in the mirror, no shoes, and you squeeze your glutes, just squeezing and kind of almost tucking under in your hips, you're going to notice your feet change. So we can see a direct correlation.

[00:14:39] If I strengthen my glutes, I'm going to have a change at the bottom of my foot, which is honestly a really cool thing. And then obviously combined intrinsic foot muscle strengthening and glute strengthening. So this is where we're talking intrinsic foot muscles just means the deep muscles within the foot. So if I even just think about leaning in toward my toes and almost like my heel is barely going to lift off the ground and I'm pushing pressure into the front, into my toes, and then I kind

[00:15:08] of do like a hip hinge deadlift type movement, I should be able to feel the bottom of my foot light up and my glute because now I'm going to feel this connection from my foot into my glute. And that's one way just to get this quick activation of both the foot and the hip. So I love that they're talking about that together. Yeah. And there's another one where it's like, great, we're doing some foot stuff, but also incorporating the hip.

[00:15:32] The last one on the list was orthoses plus stretching plus eccentric tibialis posterior work for foot function. Again, the posterior tib like you talked about, that really helps with the control of the arch and we see the appearance of orthoses. But again, it's not a standalone. It's something that is a part of this plan that includes stretching and some strengthening work.

[00:15:57] So again, you don't have to have a pretty perfect arch to have a very functional foot. So let's talk a little bit more about orthotics and when this is useful, right? When do they make sense? So orthotics can be useful for someone who has pain with standing, walking during their activity or their sport that they're trying to do, symptoms related to a flexible flat foot, adult acquired flat foot, or that posterior tibial tendon dysfunction.

[00:16:27] So that means again, that muscle that's running on the inside of that ankle down into the arch of the foot. And then a short term need to reduce tissue stress while strengthening and building that tolerance in the foot and kind of working on whatever symptom that you're having or whatever pain or diagnosis. So that's the main reason I personally like to utilize and rely on orthotics. It is, it helps to reduce that tissue stress.

[00:16:57] So if I can take down some of those pain levels while I'm getting you to work on the strength and the exercises that you need to be doing, it is going to help with all of those things that we listed. That also is reflected in the research. There's a systematic review on orthotics that for flexible flat feet concluded the evidence was too heterogeneous, meaning the evidence was just too different or all over the place to say that orthoses are universally effective.

[00:17:23] The meta-analysis did suggest they may reduce pain in adults for those that are symptomatic, which that's what we see with orthotics. It helps to offload. It helps to reduce the ground reaction force pressures. There was a 2023 Cochran review in children that did not support routine use of expensive custom orthoses for healthy, flexible flat feet. We've kind of been repeating that.

[00:17:47] If you have an asymptomatic flat foot, there's no reason to use an orthotic to try and fix that. And in symptomatic flexible flat feet, combining exercise with orthotics may be more useful than orthotics alone. That was found in a 2023 randomized control trial, which found benefit of the combination of short foot exercise plus orthotics to treat symptoms in flexible flat foot.

[00:18:16] And I just want to mention children real fast since that was kind of mentioned in one of the studies. Children are known to have flat feet until around age six because you are literally still developing the bones and the muscles of the foot. So you haven't even built the structure of the foot, which is why it is so even more important in children to allow them to have shoes that are wide, flexible, move with their foot so that

[00:18:45] they can actually use and build that support that is needed. Or allow them to be barefoot. As much as possible. I mean, we're just, we're kind of doing that with our kids lately. Like our one-year-old just loves to open the door and run outside. And so if we know that we're just going to be hanging out at the house, we'll take their socks off and just let them go in and out barefoot. It's so much better for their feet than putting it in any sort of shoes and not just flat foot.

[00:19:11] Like our kids' legs, feet, every hips are developing. And there are many cases where people can have flat feet until ages seven to 10, until they start to develop some sort of visible arch. It's the same thing with toe, you know, in-toeing or kids who walk with toes inward. Like that resolves at different stages for different kids depending on their development.

[00:19:36] So again, another reason that we shouldn't immediately see flat feet in our five-year-old and be like, oh, we need to do something about this. Just allow them, their foot to naturally do what it's supposed to. So now, and speaking of what it's naturally supposed to do, when are orthotics not necessary? Because it's not just like, oh, you have flat foot, you need orthotics. Well, not necessarily, again.

[00:20:03] So it's generally not necessary for asymptomatic flexible flat feet. So meaning your arch can change if you put it into like a tiptoe position. You now see an arch, right? So if we have that flexibility of the foot, and especially when you're not in pain and we don't need to offload anything or reduce stress or strain, not necessary to automatically get an orthotic in children.

[00:20:33] And in people functioning well who only have a foot shape difference. So again, we are looking more for using that orthotic under a symptomatic condition along with other treatment protocols. And then the last thing I think, and you see this a lot, is people start to develop that dependence or they feel like they can never be barefoot. They can't walk around their house barefoot. They can't go to the beach and be barefoot.

[00:20:59] They have to have some sort of supportive shoe with their orthotic in it. And it comes almost more from the fear than it does from the symptoms, which are very intertwined by that point. If you're starting to develop this fear-based dependency on, I can't be barefoot, so I have to have my slippers that I put my orthotics in to walk around the house. Those are cases where we need to start trying to find a different solution to help people

[00:21:26] feel comfortable being barefoot to some extent. And I understand if you have really hard surfaces within your home, like you have hardwood floors or tile. We have tile in our home. And so it is a hard surface or cold surface. And sometimes you don't always want to be barefoot on that. What I do, actually Vivo Barefoot has some barefoot slippers. So surprise, surprise, I wear those a lot because they're wide and super flexible, but also just

[00:21:56] bigger socks, bigger cushiony socks that have a ton of toe space. Those are always good. And actually, Neboso Technology has some toe spacer socks that have the stimulation underneath it. It feels pretty crazy when you're first starting to step on it, but especially those who are in shoes all the time, we're missing that stimulation of the foot. And even if you walk on hard surfaces a lot, you're missing that stimulation.

[00:22:22] So getting your feet in those, even if you're going to wear your home shoes, like it at least is a step in the right direction to starting to spread those toes a bit and get that stimulation and that feedback back to the foot because it's so incredibly necessary. And we even have studies that show. So there was a 2021 study that reported a 57% increase in foot strength after six months of daily activity in minimal footwear.

[00:22:49] So these are like barefoot shoes, that really flexible bottom. And what that showed is that without even doing extra exercise or strengthening exercises, your foot is naturally building its own strength within six months, almost 60%, which again is one of the main reasons we talk about going barefoot, no matter what kind of foot structure. Dom and I both have very different foot structures.

[00:23:13] I would fall more into the flat foot camp and he is a high arch person and we both wear barefoot shoes. Yes. And again, because we look more at the function and symptomology rather than the structure of the foot and there's benefit to be had from whatever type of foot you have. For me, it has gone a long way to help with the flexibility of my foot and growing strength through that flexibility.

[00:23:38] I've inherently had this super rigid arch, which has probably resulted in some deconditioning of my foot muscles as well. So allowing the barefoot style and barefoot living to make my foot a little more flexible and gain strength through that flexibility has been huge for me. There was another 2019 trial that found minimalist shoe walking was as effective as foot strengthening exercises for increasing foot muscle size and strength.

[00:24:07] So again, rather than doing a bunch of exercises for your foot strength, just walking around in barefoot shoes was comparable. This does not mean, however, that everyone should go buy barefoot shoes and do everything in them. You know, there is a progressive strategy based on where you're starting. If your goal is to be doing everything in barefoot shoes, which is not everyone's goal, there's a progressive way to get there.

[00:24:33] If your goal is to be able to walk around your house barefoot, again, depending on where you're starting, there's a progressive way to get there too. So taking it step by step and systematically is going to be the best approach for everyone. And we do have a deeper episode on transitioning into a barefoot shoe. If that's like your goal that you want to be wearing more barefoot shoes, we do have a whole podcast episode on that. Now, when we go back to like, okay, what are the top exercises that we should be doing to help

[00:25:02] with my flat feet then? This is where we go into building that foot strength first. Like let's look at the direct, what's going on on the foot. And we kind of mentioned some of them. So this is going to be like the short foot exercise or the short arc exercise where I'm thinking of drawing the ball of my big toe to my heel. And with keeping my toes relaxed and straight, can I contract the bottom of my foot, hold it for a few seconds and then let it lengthen and go.

[00:25:31] And having that ability to contract and relax at the bottom of the foot is something that's so, so good along with toe control. So this is being able to spread my toes, move just my big toe, move my other toes, wave my toes. Like all of this kind of toe yoga can also help to strengthen the intrinsic foot muscles, those deep foot muscles, because those muscles connect to the sides of those toes. So if I can spread and move and engage those toes, then I can better engage and support the

[00:26:00] bottom of my foot. Other exercises that people work on are like toe crunches, towel crunches. I also like to say, if you're going to crunch the towel, make sure that you can push the towel. So different types of foot strengthening exercises. And then just said that a couple of times now, and I haven't ever done that myself or I mean, I don't do toe crunches or recommend people do toe crunches much anymore, but it's a great idea. Yeah.

[00:26:26] And one that we also just talked about, you know, where it's just starting to balance on a single leg, like literally just standing on a single leg is going to help to activate those intrinsic foot muscles. Get understand, are my toes lifting up? Can they, can they stay on the floor? Like that alone is going to help to start to connect you into your foot. All right. The next kind of category is muscles as exercises that are going to help with that posterior

[00:26:52] tibialis muscle that we've been talking about, which helps control the arch, um, heel raises, especially progressing to single leg heel raises. I would say progressing beyond that to doing single leg heel raises where you're on your heels hanging off a step. So you're going down and up. That's like a deficit heel raise. The most important thing about starting with heel raises is that you're not allowing your ankles or your heels to go outward.

[00:27:20] When you raise on your toes, you want to keep them together and in line with your feet. Great way to do that is by squeezing a ball between those heels, um, resisted inversion and plantar flexion. So that's kind of like pointing your toes away from you and inward away and inward. That's going to be something that activates that posterior tibialis, um, eccentric and concentric posterior tibial strengthening, which is doing these exercises that we're talking about.

[00:27:48] But if you want to focus on the eccentric portion, again, you'll be using a band, pressing that toe down and in, and then slowly allowing it come back towards where the band is pulling from. And then of course, we don't want to just stop at the foot, which is kind of what we mentioned. So we want to be strengthening those glutes. We want to be strengthening those hips, um, and, and working on that limb control, especially in a single leg balance.

[00:28:14] So kind of mentioned already single leg balance and how that's working that, that foot, but it's also working the hip. And so many people lose that balance when it comes, and then they start doing single leg exercises, like a Bulgarian split squat or a single leg deadlift. And they're like, Oh my gosh, I can't, I have zero control. I can't do this. We're losing that ability to connect from that foot to the hip and that core complex really. So working on all of these are so incredibly important for overall body. Like this is where it all begins to connect.

[00:28:44] And it's not just about a flat foot anymore, but it's honestly about how we're connecting to our entire body because that's going to support our knees, our hips, our low back, especially as we age. Yeah. The 2024 meta analysis that we mentioned, um, talks about having integrated lower limb approaches. So approaches that include hip and foot exercises or approaching the lower, the leg as a whole, um, tend to be the most effective and then modifying load. It's not just anatomy.

[00:29:14] So temporarily reducing proactive or provocative volume. So if you're a runner and you find that your symptoms increase when you run, there may be a need to adjust our running volume to change what we're doing, to look at our footwear. Um, there's a lot of ways to adjust load. So it's no, not saying like you need to stop running altogether, but there's a way to be a little more thoughtful about how much load we're putting, especially if that's the motion that is increasing our symptoms.

[00:29:44] Choose shoes based on comfort and tolerance. Use orthotics if they make activity more tolerable. Again, we're using orthotics based on symptoms, not just based on the look. And we're using it to modify the load on that foot that we can do other strengthening and rehab exercises a little more effectively. Yeah. I know so many people who are just like, well, I was told to get orthotics and that's it. Right? Like, and now I wear that for the rest of my life.

[00:30:11] And it's like, so there's no training that's being done into the foot. You know, there's no hope. And then there's immediately complete dependency. Right. Exactly. So we're treating orthotics more as a crutch rather than a tool, which I think, you know, there are minimal cases where orthotics may need to be in your life forever. You know, we may need certain instances where that is the case.

[00:30:38] But in other, in so many other cases, the goal should be to get away from the dependence on the orthotics and back into the, the independence of your foot and the function of your foot, especially when we're talking long-term care. Like we're, I, this is a course that I'm taking and it's ingrained in me now, but we're all older people in training. No matter how old you are right now, you're an older person in training.

[00:31:07] So what are we doing now to set ourselves up for how we want to feel and function later on? And that's so incredibly important. And if we're losing that function of the foot, if we have no contact to how, how it's simulated, how it's working, how it's moving, it's going to affect everything later on in life. And so please do what you can now to help. Thanks for tuning in for another podcast.

[00:31:32] And if you are somebody who has flat feet or has foot pain or is dealing with bunions, plantar fasciitis, we are actually relaunching our barefoot mini course and adding a third week to the barefoot mini course, where this is going to go into more depth, talking about the hip and the pelvic floor and the interplay of those structures with how they all work together with the foot to move us through our day and to do so effectively.

[00:31:58] And with minimal pain, uh, there's a huge discount on this course that is only live until Wednesday. So go get in now. It's Jen dot health backslash barefoot as our podcast audience. You can get another special discount on that using code optimal at checkout. We'll see you next time.