What if having flat feet isn't a bad thing?
That's what a group of podiatrists in Canada and Britain assert in a recent editorial in the British Journal of Sports Medicine. The authors, all clinicians or researchers, say it's time to move beyond the idea of flat feet as a deformity, and that low arches, which up to a third of individuals have, should be considered a healthy anatomical variant.
"Every day that I'm in the clinic, I see patients worried about their feet, their flat feet," says Gabriel Moisan, the editorial's lead author. Invariably, such patients have been told by someone that having flat feet is a problem, he adds.
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Yes, flat feet - the medical term for the condition is "pes planus" - can be associated with problems, but it's not a certainty. What's more important is focusing on pain and getting that treated, rather than worrying about the way feet or arches look, Moisan and others say.
"You might have a low arch, but a lot of people do, and a lot of people with low arches don't have anything wrong with them," says Patrick McKeon, an associate professor and athletic training clinical education coordinator at Ithaca College in New York who did not contribute to the essay. So how could that be a deformity, how could that be a deviation from what's normal, especially if many people have it, he asks.
"We are splitting hairs calling it normal or abnormal," says John Kiel, an associate professor of emergency and sports medicine at the University of South Florida's Morsani College of Medicine and the co-author of a paper on pes planus. Kiel and his co-authors note that flat feet are common among children, but most children develop a "normal arch" by age 10.
Your foot’s base and spring
The arch of the foot - the medial longitudinal arch - is a tough, elastic network of ligaments, tendons and connective tissue that run on the inside between the front and back of the foot.
A base of support for the body, the arch both acts as a shock absorber, dissipating the forces of bearing weight, and a spring, storing and releasing energy during walking and running.
Rather than considering flat feet as part of the bell curve of normal variation, the medical and footwear fields for decades have rushed to treat flat feet with supportive shoes, orthotic inserts and surgery, even in the absence of pain or other problems.
But there's little to suggest that treating flat feet helps anything.
"If there was a causal link between flat feet and injury, most people with flat feet would get an injury," Moisan says. "And that's just not the way that it is." Moisan highlights several more important factors to consider, variables such as volume of exercise, the surface you're walking or running on and past injuries.
Several meta-analyses have failed to find a link between many biomechanical factors, including foot shape, and running injury.
One of them, a 2022 review of 30 studies and 3,404 runners, included over 100 discrete biomechanical and musculoskeletal risk factors. The researchers concluded that the available research did not generally support biomechanical or musculoskeletal measures as risk factors for running injuries in non-elite runners.
Part of treatment has involved shoe choice, especially for walkers and runners. That paradigm prescribes a supportive shoe, stability or motion control, for those with flat feet. High-arched individuals, because their feet are presumed to be more rigid, are directed toward a more cushioned shoe. But there's also little evidence to suggest that this approach, matching foot shape with shoe type, makes any difference.
Military running shoe study
Research on members of the military illustrates the point. Because injuries often occur during basic training, injury prevention is a significant area of research for military medicine.
In a pooled analysis of three studies involving about 7,200 Air Force, Army and Marine recruits, the reviewers determined that selecting running shoes based on arch height had little influence on injury risk in military basic training.
Shoes matter, just not as much as we think they do, says Jay Dicharry, a physical therapist and author of "Running Rewired: Reinvent Your Run for Stability, Strength, and Speed."
"As somebody who does validation and innovation work with footwear for a bunch of different brands, footwear does make a difference," he says. "But a shoe is not going to fix your problems. A shoe might make a difference between an ouch and kind of getting by, but that's not going to fix things."
Rather than relying on passive measures such as shoes and orthotics to prevent injury, experts like McKeon urge a more active approach to foot care. Much like core stability for the spine, McKeon says the foot core, using the intrinsic muscles of the foot, can play an important role in injury prevention.
Dicharry agrees: "We train the core, hips and knees to improve athleticism. The feet are no different."
"That's really the way that we started to look at the foot core," McKeon says, "that if we can get a person to learn how to activate their intrinsic foot muscles better, there's a couple things that can take place."
First, they become better immediate stabilizers of the joints of the foot, he says. Second, the foot becomes a sensor of sorts, a connection between body and surface. "By learning how to turn on the foot muscles, we're getting better sensors for how the foot changes with movement," he says.
For runners and walkers, McKeon recommends starting with what he calls your "neutral foot," which you can locate by lifting your arch up and down while seated and then standing, and rocking the foot side to side - and finding the midpoint between the two extremes.
When it comes time to go to the shoe store and pick a shoe, Moisan has two rules. "The first rule I have is if you're not injured, don't change your shoe type." Resist the pull of new colors or trendy brands if it means changing from something that is working.
His second rule is that the shoe should fit well - it should be comfortable and light. "It seems very simple to say, but a lot of people are wearing shoes that are not wide enough, or too short," Moisan says.
Ultimately, Moisan says, the message is simple: "Don't be worried about the appearance of your foot."
For clinicians, his take is similar. "Try to remove the emphasis on the foot itself and put the emphasis on the problem."