Flatfeet tend to be congenital. It is also commonly associated with a tight Achilles tendon. Its important to be evaluated at a young age the progression of a flatfoot in a child may be slowed down. It’s often assumed that all children’s feet look flat because they have fat in their arch, however it’s important to not make this assumption.  Its assumed arches  will develop and this is not always true. It's important to have your child's feet checked to ensure they don’t develop flatfeet.  If a flat foot is present a podiatrist may recommend custom made arch supports. These can be very useful to reduce the progression of the flatfoot deformity. In more severe cases surgical correction may be an appropriate decision to reduce the potential problems that can occur in the adult foot.

How do I know if I have a flatfoot?

The term pronation is often used to describe the motion that takes place when the foot flattens. It’s a complicated motion that involves three different planes of motion but to keep it simple understand that pronation means that the pronating foot will point outward away from the opposite foot and the arch will flatten so there is minimal to no arch. If you were to see the flatfoot impression in the sand there would be minimal foot arch noted. People with flatfeet are often referred to as having fallen arches. The opposite motion of pronation is supination. Another type of foot may pronate more in the back of the foot by the ankle and in this foot type some arch may be noted but the heel bone is rotating inward if you were to look at it from behind. This is less common but still is a flatfoot.

 These are the associated problems that can develop in adulthood that can cause foot pain with a flatfoot?

  • Achilles tendonitis
  • Posterior tibial tendonitis- the posterior tibial tendon is on the inside of the foot and ankle the supports the arch
  • Shin splints
  • Bunions
  • Hammertoes
  • Plantar fasciitis (heel pain) .

Plantar fasciitis

The basics – the plantar fascia is a strong fibrous band of tissue that originates in the ball of the foot and extends back to the bottom of the heel bone where it attaches. It’s not truly a tendon or ligament but connective tissue referred to as fascia. In children its flexible so as the foot bears weight the fascia is pulled but will stretch like a rubber band rather than pulling from where it attaches to the heel bone . As we get older it's thought to lose its elasticity and the chronic pulling from the heel bone will cause microtears where it attaches. Specifically this pulling is not an inflammatory process but rather a breakdown process of the fascia. A study by Harvey Lemont 1 showed with specimens of fascia removed  and analyzed when surgery was performed that only one out of fifty specimens showed inflammation . The term for this breakdown of the fascia is referred to as plantar fasciosis. 

Flatfoot heel pain- Are both related?

Yes it can be more common to have heel pain if you have a flexible flatfoot. Understanding that if your foot is overpronation, flattening this is going to cause more pulling of the fascia from the heel bone. , thus more microtears where it attaches. The flattening is putting added stress or pull on the fascia. In a foot with a more normal arch the bony structure would be supporting the arch rather than putting so much stress on the fascia.

How do I know if I have plantar fasciitis

Your pain will be on the bottom of the heel. It may also be slightly more towards the inside of the heel on the bottom rather than outside. It will often hurt most when you first get up and walk on it in the morning and you may also notice that it hurts more after sitting and then getting back up to walk.

What can you do?

In early stage icing and taking anti-inflammatories drugs may be helpful.. Modify your activities- reduce the activities that seemed to have started it. Do stretching exercises. In early stages this can help but do have limitation as the fascia for many of us just doesn’t want to stretch.

What your podiatrist may recommend?

Custom made inserts called orthotics. These will help support the foot in a very precise way as they are custom for your foot and reduce the pull of the fascia from the heel. This is what caused the problem. The success  rate of orthotics tends to be very high.

Cortisone injections- This is a conventional treatment option that has a high success rate for giving you relief however beware it’s usually temporary and a band aid or many.

Surgery- When surgery is done  an endoscope Is used to cut through a portion of the fascia allowing it to stretch. This will reduce the pull of the fascia from the heel bone and eliminate pain. We never remove the heel spur if it is present. The spur forms as a result of the fascia pulling on the heel but the spur itself is not painful.  This procedure allows you to walk immediately in a cam walker for 3 to4 weeks. The success rate is very high.

The three progressive options that will keep you out of the operating room.

Surgery for heel pain when other options fail however the odds of surgery have been greatly reduced by the following

  1. Regenerative medicine- Podiatrists currently use placenta cells or umbilical cord to help repair the damaged fascia. Remember it’s not inflamed but rather its plantar fasciitis as was mentioned earlier. The long-term success rate for this is much higher than for cortisone because it's not tissue that’s inflamed. This treatment is an injection given using ultrasound guidance so that the doctor can visualize precisely where the injection needs to go into the damaged fascia. Patients use a cam walker for one to two weeks and then return to wearing shoes. 
  2. Shock wave treatment- This treatment uses powerful sound waves that gently traumatize the fascia. This signals the body's reparative mechanisms to then help repair the tissue. Shockwave is similar to lithotripsy which is used to break up kidney stones. It usually requires three treatments over three weeks and there is no layup.
  3. Laser treatments- An MLS laser which also helps repair the fascia. It does this by stimulating the mitochondria in the fascial tissue. Each cell in our body has an area called the mitochondria that creates energy for the cell and helps it to repair.

You now have a clearer understanding of flatfeet and plantar fasciitis . It's important to have both evaluated, especially if your pain still persists after the recommendations this blog offers or if you’re a parent who’s considered about the children’s feet.

References

Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation. J Am Podiatr Med Assoc. 2003 May-Jun;93(3):234-7. doi: 10.7547/87507315-93-3-234. PMID: 12756315.