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Do all flat feet need orthotics?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by footphysio, Jan 9, 2009.

  1. footphysio

    footphysio Member

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    I've had aquestion asked of me by a student recently that I wasn't sure how to explain. Perhaps some of you could help.

    He asked: Do all people with flat feet need orthotics? Will they eventually have lower extremity problems simply due to the fact they have flat feet? What about shock absorption - isn't this lost without an arch? Doesn't that lead to injury?

    My answers were "no", but I wasn't entirely sure how to back up my answer. I could use some help.

    Thanks in advance.
  2. Craig Payne

    Craig Payne Moderator

    Of course they don't.

    Only those who need orthotics are those whoose foot type (flat or otherwise) generate enough force to cause tissue damage.

    And don't forget that the evidence that flat feet/pronated feet actually cause anything is that they don't cause anything or if the do, they are only a very weak risk factor.
  3. Admin2

    Admin2 Administrator Staff Member

  4. Footphysio:

    Since you at least made the effort and took the care to use correct grammar and punctuation in your query, unlike many other individuals here on Podiatry Arena, I thought that I would take the time to answer your question. It would also be nice if I knew your real name and where you practice.

    If an optometry student asked one of his optometry professors, "Do all people without 20/20 vision require eyeglasses or contact lenses?", what should the professor's answer be to this very reasonable inquiry? Certainly the medical analogy of prescription eyeglasses to custom foot orthoses is not too distant from what your student is asking and warrants much more than the curt answer of "since not all flat feet have problems they don't all need orthoses".

    Even though the research literature has not shown that there is a significant correlation between flat feet and certain pathologies, that doesn't mean that in many individuals, their more pronated foot posture and flat arch height is not the cause of their pain and disability. I have treated literally thousands of patients with flatfoot deformity that was associated with painful symptoms in their plantar fascia, posterior tibial tendon/muscle, 1st MPJ, 2nd MPJ, and sinus tarsi that had their symptoms totally resolve just by the simple act of making their medial arch less flat (increasing the external rearfoot dorsiflexion moment) and the subtalar joint function less pronated (increasing the external subtalar joint supination moment) with a well-designed pair of custom foot orthoses. This has been a very consistent finding over my quarter-century of treating patients with this type of foot morphology.

    Since nearly all ethical podiatrists have no problem with treating the symptomatic flatfoot deformity with custom foot orthoses, the real question becomes then, should we treat the patient with an asymptomatic flatfoot deformity? My answer is.....it depends. Certainly, if a patient with a flatfoot deformity asks if foot orthoses have the potential to improve gait function and prevent potential problems in the future for them, I tell them that correctly-made foot orthoses do have the ability to perform these therapeutic goals for them and I highly recommend foot orthoses for them if they are concerned about developing pathology in the future. However, if I have a patient with a mild flatfoot deformity that is asymptomatic, and has insignificant associated gait pathology, then I tell them that they don't need custom foot orthoses and that they can simply buy an over-the-counter foot orthosis if they are concerned about their foot morphology and its potential sequelae.

    I have slept very well at night giving my patients these types of responses to their foot orthosis questions over the past 25 years.

    Hope this helps.
  5. Dananberg

    Dananberg Active Member


    Patients who are asymptomatic do not require orthotics; foot shape is not a reason to treat. However, the symptom questions to ask are not limited to the foot level. Subjects with mechanically dysfunctional feet can experience more proximal symptoms, ie, knees, lower extremity pain, chronic lower back pain, etc despite the fact that their feet do not hurt. The criteria for care should be dependent on assessing the entire body...and not just foot pain.

  6. bob

    bob Active Member

    How about asymptomatic kids with a flatfoot? Say their navicular is nearly touching the floor in static stance? Anyone out there giving children foot orthoses (or arthroeresis) based on this static clinical examination?
    What about kids that are less active than others as they are poor runners due to their flat feet? Anyone treating these with orthoses or arthroeresis?
  7. 56Furman

    56Furman Member

    I can not count the number of times that patients with flat feet (I hate this term) have come in for an unrelated office visit. Then when asked if they have any foot pain they answer NO, But, when asked specific questions about how long they can stand without foot pain, distances they can walk, calf cramping or wanting their feet massaged at night all of a sudden you discover the patient is symptomatic. That being said, and trying to stay on topic; if the patient's symptoms are mild I will have them initial try an OTC orthotic. More sigificant or they can not tolerate the contour of an OTC device I will make a CFO.

    I feel most patient with collapsed feet are or will be symptomatic at some level of activity and body weight.
  8. Asher

    Asher Well-Known Member

    So if someone comes in with no symptoms but some sort of bony change eg: bunions or 1st metatarsocuneiform joint exostoses, do you intervene? I would. Bony changes must come into the equation.

  9. footphysio

    footphysio Member

    Thanks for all the replies. It is obvious there are differing opinions. This is good to stimulate thought.
    Kevin, I introduced myself in the Introductions forum. My name is Joanne Weber. I am a physiotherapist from Canada.
  10. Joanne:

    Thanks for that.:drinks
  11. Graham

    Graham RIP

    Kevin wrote:

    Do they?

  12. Great question, this is something I've pondered upon too many times: how do we know that someone didn't get an injury / pathology they would otherwise have suffered were it not for an orthotic intervention?

    If we had good predictive models for all pathologies, we might be able to predict (within statistical limits) that subject x has a y % chance of pathology z, but the truth is we have few good models of this kind. If we had studies that demonstrated orthoses were capable of preventing pathology z, this would help enormously. But the reality is, we have studies showing the certain orthoses reduce the symptoms associated with certain pathologies, in certain individuals, some of the time. We have studies showing the kinematic and kinetic effects of certain foot orthoses in certain individuals. We have theories that provide potential causal mechanisms for said kinetic and kinematics in certain individuals. We even have studies that demonstrate an apparent reduction in the prevalence of certain pathologies in certain subject groups, at a certain time, in association with certain foot orthoses. But it is unlikely that we will ever be certain that subject x didn't succumb to pathology z due to our intervention. If someone could please look into a crystal ball and tell me precisely with a 100% accuracy, which patients were going to get which pathologies in the future and tell me how to prevent it.... boy, they'd be rich.

    Now "flat- foot deformity"... I've seen lots of people with feet as flat as pan-cakes, with no current problems. I have no-idea whether they'll have problems in the future. I guess a lot of it depends on what they do with their lives. If they spend the rest of they're lives sitting on a sofa, watching more TV, then they may have few problems; if they decide they want to run a marathon...... well that's another story. So the question becomes: what caused the pathology? Their foot biomechanics or running a marathon? Take two clones, put one of them in an "ideal shoe" and give them a sedentary life-style. Put the other in "rubbish shoes" and get them into triathlon- guess which one is going to get problems- no brainer- right?

    As I've been spouting since 1997: Pathology = function of: genotype + environment + (genotype x environment)

    Foot orthoses help us to manipulate the environmental component- but they don't give us total control over it.

    Question: take two clones- make one of them ambulate on a hard, flat, level surface and the other on a soft, uneven surface- which one gets injured- rhetoric.
    Last edited: Jan 14, 2009
  13. N.Knight

    N.Knight Active Member

    Thanks for the respones, as a student this has been helpful.

    Surley it depends on the type of flat foot as well? whether it is rigid or flexible. Would a rigid pes pancakas respond to orthotics?

    Mr Spooner witrh regards to the no brainer and along that train of thought, I saw a pt on placement who had some new orthotics perscribed to them, they went away and can back saying they worked wounders. However they worn them in the wrong shoe so the left in right and the right in the left, so is they a concept of mind over matter.

    As my lecturer said he gets called a "witch doctor" as alot of the work pods do is not evidence based with regards to inserts for shoes.

    Sorry for going off topic

  14. Cavus

    Cavus Member

    I've had many kids around the 7+ year age whose parents have noticed that they are quite 'flat footed' and that they can't run as fast or are not co ordinated.

    I've prescribed custom orthotics where cost allows and OTS otherwise. The changes have been interesting with improved foot function - and running etc! in a short period of time.

    One case in particular after a couple of years of OTS orthotics this kid is now at English Championship level running, yet he was last before. For my part I'm going to keep on prescribing, taking the videos and watching the improvement.
    Winchester England
  15. If one takes a modelling approach to the question of whether a foot with a low medial longitudinal arch (MLA) may have an increased risk of developing certain pathologies, then the answer seems clear that foot orthoses do have the potential to prevent these pathologies. Using mechanical modelling, subtalar joint rotational equilibrium and preferred movement pathway theory, here are the following conditions that may occur with a lower MLA during weightbearing activities that may, eventually, lead to future pathology:

    1. Increased tensile forces within the central component of the plantar aponeurosis.
    2. Increased tensile forces within the plantar ligaments of the MLA.
    3. Increased contractile activity from the posterior tibial muscle.
    4. Increased tensile force within the posterior tibial tendon.
    5. Increased functional hallux limitus.
    6. Increased medial deviation of the subtalar joint axis.
    7. Increased dorsal 1st metatarsophalangeal joint compression forces.
    8. Increased dorsiflexion bending moments in the metatarsal shafts.
    9. Increased dorsal midfoot interosseous compression forces.
    10. Decreased resupination of subtalar joint during late midstance.
  16. Itchyfeet

    Itchyfeet Member

    If it ain't broke don't fix it. Surely if a patient is asymptomatic then leave well alone. If he/she cannot feel the benefit of an orthotic they may think that the clinician is just trying to make more money from them. I would prefer to go down the route of patient education, to explain possible problems they could have in the future, what that would mean, and that orthotic provision is a way of giving a degree of control etc etc.

    As we age body parts drop, sag, lose strength and elasticity, and it becomes more difficult to compensate or self-correct, so symptoms are likely to increase. It would be good to get the patient using orthotics before they reach that point but most would put those changes down to ageing and which can't be helped, that's where we need to step in.

    If I went to the dentist and he were to say I think you need a filling in this tooth as you might get a cavity in the future, I would be suspicious of his motivation. But if he were to say - I'm going to keep and eye on that tooth and if you get xyz symptoms let me know and we'll discuss the options, I'd have more confidence and trust.
  17. What would you think of a dentist that x-rayed your teeth, found a cavity and told you need a filling, even though you are not having any problems or pain otherwise? Would you have confidence and trust in them, or would you rather have them tell you not to worry about it since it doesn't hurt yet and that you shouldn't come back and see him/her until you are having a tooth ache? What kind of doctor would you prefer to see?
  18. What does this mean and how is it determined?
  19. I think this is an interesting example. Doesn't this come down to predictive evidence as I discussed earlier? Does the dentist "know" with good quality scientific evidence to back-up their claims that the cavity is pathologic in its own right and/ or will definitely lead to pain/ pathology in the future? The comparative: does the podiatrist "know" with good quality scientific evidence to back-up their claims that the flat-foot is pathologic in its own right and/ or will definitely lead to pain/ pathology in the future?

    I'm not a dentist and I'm not familiar with dental literature, so I can't answer the first part, but what does the good quality published podiatric research tell us?
  20. It would be nice if we had any good quality published podiatric research to inform us. However, is podiatry so different from other health specialties that recommend treatment, such as filling a cavity in the dental profession, for asymptomatic pathologies? Until we see "good quality published podiatric research" that says yes or no to orthoses for asymptomatic flat feet, then I suppose we will just have to use our best professional judgement, as most of us always have, to determine what treatments would be best for the patient. We must remember that just because the research hasn't been done yet, doesn't mean that having flatfeet doesn't increase the risk of many pathologies for the flatfooted individual as they age or perform more weightbearing activities.
  21. Absolutely. I just wondered if there was any research which demonstrated that it was, or was not an increased risk factor? My PhD suggested that arch index (or at least the one I used- there are several indices) was a reasonably strong predictor of hallux valgus. Any others we could list here, Kevin?

    Confounding this discussion is the definition and multiple methods of measuring "flat-foot". When is a foot: "flat"? Take two patients: we measure the height from the floor to their navicular tuberosity in weightbearing; we find them to be identically "low". We might conclude that both subjects had "flat-feet". But if on weight-bearing x-ray we noted one patient's sinus tarsi were occluded (positive Kirby's signs) and the other patients were not, which one should we predict has the greater risk of sinus tarsi syndrome? Moreover, take two subjects: one as above with occluded sinus tarsi, the other with a "high-arch" and a history of chronic inversion sprains of the ankle. Which one has the greater risk of developing sinus tarsi syndrome?

    One more thought, is the 18-month-old child with "flat-feet" at risk?
  22. I didn't even want to talk about the problem with the term "flat-foot". "Flat-foot" is one of those clinical parameters that is ill-defined. Your points, Simon, are good and I agree with you. However, I think that this sort of topic deserves good discussion since "flat-foot" is commonly encountered in practice and the clinician should be exposed to the different viewpoints on how to approach this situation with the patient.
  23. Cavus

    Cavus Member

    Simon apologies but I'll have to get back to you later. We've had a bereavement in the family and I'm off to Scotland for the funeral
  24. drsarbes

    drsarbes Well-Known Member

    Do all patients with FLAT FEET need orthotics?

    It depends.

    1. No insurance and no money - orthotics not needed.
    2. Good insurance but high deductible - orthotics MAY be indicated.
    3. Full insurance coverage - ABSOLUTELY! They can't survive another step without them.


  25. Steve The Footman

    Steve The Footman Active Member

    While I am sure there are many people with flat feet without symptoms I also think it is an increased risk factor for pathology related to biomechanics. Devices such as the Foot Posture Index have found some relationship between arch height and increased risk factors for injury.

    There are a few things that I think need to be considered clinically when suggesting orthotic therapy for flat feet.
    1. Most patients see us with a problem so you must suspect the flat feet as a contributing cause and look for a logical mechanism of action to cause their current pathology. If there is no logical link then it may not be necessary to prescribe orthotics.
    2. Has the arch collapsed down to be flat or has it always been flat? The foot which is collapsed is much more likely to be related to the pathology. IA collapsed MLA can be a sign of post Tib Dysfunction and obviously will need aggressive correction ASAP. If someone just has a flat foot and their family have flat feet then it is less likely to be an issue. Asians and Pacific Islanders have a higher prevalence of flat feet. I have not seen any research showing they have increased pathology because of it.
    3. Is the arch rigid or flexible? A flexible flat foot should be able to have greater correction then a rigid flat foot. I have seen too many orthotics that are nothing more than a teeter-totter/see-saw because the podiatrist thought they had a very flat foot so they needed a very high arch. If the foot is rigid then it will not conform around a high arch.
    4. Do you prescribe for a child? Excess fat deposits in very small children usually result in a pseudo-flatfoot. The bony structure is unlikely to reflect the soft tissue in most cases. I remember Craig Payne's pediactric clinical notes included a study that showed that long term outcomes were not much different in children with flat feet who were treated with orthotics compared to those who were not.
    5. The level of variation across individuals is vast. There will always be exceptions. Do you do an intervention just because it will work for most people? We need to take the time and make the effort to establish the causal link between the pathology and flat feet. I do not think there is enough evidence to show that all flat feet are pathological.

    Do all flat feet need orthotics? The answer is NO. But the qualified answer is most times YES.
  26. drsarbes

    drsarbes Well-Known Member

    Hi Steve M.

    "Do all flat feet need orthotics? The answer is NO. But the qualified answer is most times YES."

    You don't have a LAW degree by any chance do you?

    I guess I'll have to agree with you. No (and YES)


  27. I'm with surgeon Steve, what does this mean "footman" Steve?:confused:
  28. Steve The Footman

    Steve The Footman Active Member

    Does sound like a bit of waffle doesn't it?

    I meant to say that all flat feet do not need orthotics but that more flat feet need orthotics than those with an average arch height. Even that is a bit spurious because you could say the same thing about high arched feet. Perhaps feet that lie outside the norm have a greater chance of needing orthotics - but that could be self evident. It can also be misleading. What is better is if every patient is approached with an open mind with the goal of identifying the contributing factors to their pathology and not jumping on the obvious structural abnormalities.
  29. drsarbes

    drsarbes Well-Known Member

    "Does sound like a bit of waffle doesn't it?

    I meant to say that all flat feet do not need orthotics but that more flat feet need orthotics than those with an average arch height. Even that is a bit spurious because you could say the same thing about high arched feet. Perhaps feet that lie outside the norm have a greater chance of needing orthotics - but that could be self evident. It can also be misleading. What is better is if every patient is approached with an open mind with the goal of identifying the contributing factors to their pathology and not jumping on the obvious structural abnormalities."

    Oh, OK.
    SIMON? All yours.

  30. efuller

    efuller MVP

    I can say that in my clinical experience flat feet tend to (but, do not always have) medially deviated STJ axes. Perhaps, we should change the question to: Do feet that have severely medially deviated STJ axes deserve orthotics. Wouldn't this be a better predictor of stress on tissues than arch height? And, those feet with medially deviated STJ axes should get orthotics that have medial heel skives, not just generically prescribed devices.


  31. joejared

    joejared Active Member

  32. To add to Eric's idea, if the medial longitudinal arch height is so low that it firmly is planted on the ground, then a very stable tripod (heel, talar head, forefoot) effect is created. Dr. John Weed called this foot a "fully compensated rearfoot valgus foot". This type of foot will have greatly altered loads within the joints and within the plantar medial arch muscles and ligaments, compared to normal. This "fully compensated rearfoot valgus foot" is very similar to the weightbearing structure of the foot of apes.

    Last edited: Jan 28, 2009
  33. Yeah, but no, but yeah, but... shut up
  34. jacko39

    jacko39 Welcome New Poster

    Im in agreement. I believe that if the patient is not experiencing any pain (feet, back, knees etc) then personally I dont prescribe orthotics just for flat feet.
  35. Chirotech

    Chirotech Member

    Hi Footphysio,

    Well its a Yes & No. Not all flat feet person have complain or problems on their feet.

    Neither it will create a pathology in their old age.

    Some can be very well compensated in terms of their posture and their gait cycle.

    There is so many factors to look/check before a customer would be a good candidate for an orthotic even though structurally they have flat feet or no arch at all and either with or without complain.

    It also depends on the activity their doing, foot wear types s/he is wearing and lifestyle.

    One rule is everybody is different and it should be assessed accordingly. And if ain't broken don't fix it....

  36. Very sage. The question, I think, is what constitutes "broke"?

    First off, I'd refer everyone back to Simons point. What, exactly, are flat feet? Its kind of a broad church. So the question in essence is "are there any presentations of flat feet which DON'T warrant treatment".

    A few points. Firstly I think one must consider the negatives of treating as well as the positives

    Here are some I lifted from a presentation on Treating Asymptomatic Paediatric Hypermobile Flatfoot I'm working on.

    The biggest ones for me there are numbers 3 and 4. I think that real harm can be done by interpreting a normal anatomical variation as a pathology, especially in children. I've known more than one child suffer in a very real way from the nocebo effect (the dark side of the placebo effect) imparted by well meaning parents and probably well meaning clinicians. I have absolutley no evidence, but anecdotally, I see many a chronic pain syndrome case start this way. Kids are impressionable (so are adults but kids more so). Tell em they have pain, they'll have pain. Tell em they can't run, they won't run.

    That said, in 12 studies (3 RCTs) on paediatric flat foot I found no cases where the orthoses had a significant negative effect on things like gait efficiency, pain, and Quality of life. 7 had some kind of positive effect and several had "positive" effects on function. So from a purely mechanical viewpoint, I can't see any harm.

    So I would suggest that in each case one must balance the potential negatives against the potential positives, both of which will vary on a case by case basis. Do all flat feet need orthoses? Clearly not. Assessing which do and which don't is the trick.
  37. dougpotter

    dougpotter Active Member

    Not a good reflection for the profession.:confused:
  38. Deborah Ferguson

    Deborah Ferguson Active Member

    Hi All
    Does anyone know if there have been any studies carried out to assess the long term benefits or otherwise of foot orthoses in preventing or reducing the progression of deformities such as HAV.
    I have looked through some of the databases ( Pud Med etc.) and can't find any long term studies.
    Thanks in advance
  39. Craig Payne

    Craig Payne Moderator

    Apart from Tim Kilmartins paediatric one and the Budiman-Mak rheumatoid arthritis one, there are none.

    There was this RCT in JAMA, but it did not really provide any useful info: Surgery vs Orthosis vs Watchful Waiting for Hallux Valgus

    There was some discussion here:
    Treatment of Hallux Valgus with orthoses

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