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FLAT FEET

Flat feet (also called pes planus or fallen arches) is a postural deformity in which the arch of the foot collapses, with the entire sole of the foot coming into complete or near-complete contact with the ground. Some individuals (an estimated 20–30% of the general population) have an arch that simply never develops in one foot (unilaterally) or both feet (bilaterally).
 
There is a functional relationship between the structure of the arch of the foot and the biomechanics of the lower leg. The arch provides an elastic, springy connection between the forefoot and the hind foot. This association safeguards that a majority of the forces incurred during weight bearing of the foot can be dissipated before the force reaches the long bones of the leg and thigh.

In pes planus, the head of the talus bone is displaced medially and distal from the navicular. As a result, the spring ligament and the tendon of the tibialis posterior muscle are stretched, so much so that the individual with pes planus loses the function of the medial longitudinal arch (MLA). If the MLA is absent or nonfunctional in both the seated and standing positions, the individual has “rigid” flatfoot. If the MLA is present and functional while the individual is sitting or standing up on their toes, but this arch disappears when assuming a foot-flat stance, the individual has “supple” flatfoot. This latter condition can be correctable with well-fitting arch supports.

Three studies (see citations below in military section) of military recruits have shown no evidence of later increased injury, or foot problems, due to flat feet, in a population of people who reach military service age without prior foot problems. However, these studies cannot be used to judge possible future damage from this condition when diagnosed at younger ages. They also cannot be applied to persons whose flat feet are associated with foot symptoms, or certain symptoms in other parts of the body (such as the leg or back) possibly referable to the foot.

Flat feet in adults

Flat feet can also develop as an adult ("adult acquired flatfoot") due to injury, illness, unusual or prolonged stress to the foot, faulty biomechanics, or as part of the normal aging process. This is most common in women over 40 years of age. Known risk factors include obesity, hypertension and diabetes.Flat feet can also occur in pregnant women as a result of temporary changes, due to increased elastin (elasticity) during pregnancy. However, if developed by adulthood, flat feet generally remain flat permanently.

If a youth or adult appears flatfooted while standing in a full weight bearing position, but an arch appears when the person dorsiflexes (stands on heel or pulls the toes back with the rest of the foot flat on the floor), this condition is called flexible flatfoot. This is not a true collapsed arch, as the medial longitudinal arch is still present and the Windlass mechanism still operates; this presentation is actually due to excessive pronation of the foot (rolling inwards), although the term 'flat foot' is still applicable as it is a somewhat generic term. Muscular training of the feet, while generally helpful, will usually not result in increased arch height in adults, because the muscles in the human foot are so short that exercise will generally not make much difference, regardless of the variety or amount of exercise.[citation needed] However, as long as the foot is still growing, it may be possible that a lasting arch can be created.

Pathophysiology
Research has shown that tendon specimens from people who suffer from adult acquired flat feet show evidence of increased activity of proteolytic enzymes. These enzymes can break down the constituents of the involved tendons and cause the foot arch to fall. In the future, these enzymes may become targets for new drug therapies.

 
Diagnosis
Many medical professionals can diagnose a flat foot by examining the patient standing or just looking at them. On going up onto tip toe the deformity will correct when this is a flexible flat foot in a child with lax joints. Such correction is not seen in the adult with a rigid flat foot.

An easy and traditional home diagnosis is the "wet footprint" test, performed by wetting the feet in water and then standing on a smooth, level surface such as smooth concrete or thin cardboard or heavy paper. Usually, the more the sole of the foot that makes contact (leaves a footprint), the flatter the foot. In more extreme cases, known as a kinked flatfoot, the entire inner edge of the footprint may actually bulge outward, where in a normal to high arch this part of the sole of the foot does not make contact with the ground at all.


Treatment
Most flexible flat feet are asymptomatic, and do not cause pain. In these cases, there is usually no cause for concern, and the condition may be considered a normal human variant. Flat feet were formerly a physical-health reason for service-rejection in many militaries. However, three military studies on asymptomatic adults (see section below), suggest that persons with asymptomatic flat feet are at least as tolerant of foot stress as the population with various grades of arch. Asymptomatic flat feet are no longer a service disqualification in the U.S. military.

In a study performed to analyze the activation of the tibialis posterior muscle in adults with pes planus, it was noted that the tendon of this muscle may be dysfunctional and lead to disabling weightbearing symptoms associated with acquired flat foot deformity. The results of the study indicated that while barefoot, subjects activated additional lower-leg muscles to complete an exercise that resisted foot adduction. However, when the same subjects performed the exercise while wearing arch supporting orthotics and shoes, the tibialis posterior was selectively activated. Such discoveries suggest that the use of shoes with properly fitting, arch-supporting orthics will enhance selective activation of the tibialis posterior muscle thus, acting as an adequate treatment for the undesirable symptoms of pes planus.

Rigid flatfoot, a condition where the sole of the foot is rigidly flat even when a person is not standing, often indicates a significant problem in the bones of the affected feet, and can cause pain in about a quarter of those affected.Other flatfoot-related conditions, such as various forms of tarsal coalition (two or more bones in the midfoot or hindfoot abnormally joined) or an accessory navicular (extra bone on the inner side of the foot) should be treated promptly, usually by the very early teen years, before a child's bone structure firms up permanently as a young adult. Both tarsal coalition and an accessory navicular can be confirmed by x-ray. Rheumatoid Arthritis can destroy tendons in the foot (or both feet) which can cause this condition, and untreated can result in deformity and early onset of Osteoarthritis of the joint.[citation needed] Such a condition can cause severe pain and considerably reduced ability to walk, even with orthoses. Ankle fusion is usually recommended.

Treatment of flat feet may also be appropriate if there is associated foot or lower leg pain, or if the condition affects the knees or the lower back. Treatment may include using Orthoses such as an arch support, foot gymnastics or other exercises as recommended by a podiatrist/orthotist or physical therapist. In cases of severe flat feet, orthoses should be used through a gradual process to lessen discomfort. Over several weeks, slightly more material is added to the orthosis to raise the arch. These small changes allow the foot structure to adjust gradually, as well as giving the patient time to acclimatise to the sensation of wearing orthoses. Once prescribed, orthoses are generally worn for the rest of the patient's life. In some cases, surgery can provide lasting relief, and even create an arch where none existed before; it should be considered a last resort, as it is usually very time consuming and costly.


Running
It is generally accepted by professionals that a person with flat feet tends to overpronate in his or her running form.[9] However, persons with flat feet may also have a neutral or underpronating gait. Pronation is a natural form of shock absorption during running and walking, when the ankle rolls inward and the weight distribution in the foot shifts medially. Overpronation is excessive pronation; it disrupts the alignment of the leg and may result in injuries due to over-stressing of the knee and leg. With normal, or neutral, running shoes, a person who overpronates in his or her running form may be more susceptible to shin splints, back problems, and tendonitis in the knee.[dubious – discuss] Running in shoes with extra medial support or using special shoe inserts, orthoses, may help correct one's running form by reducing pronation and may reduce risk of injury.

Military studies
Studies analyzing the correlation between flat feet and physical injury in soldiers have been inconclusive, but none suggests that flat feet are an impediment, at least in soldiers who reached the age of military recruitment without prior foot problems. Instead, in this population, there is a suggestion of more injury in high arched feet. A 2005 study of Royal Australian Air Force recruits that tracked the recruits over the course of their basic training found that neither flat feet nor high arched feet had any impact on physical functioning, injury rates or foot health. If anything, there was a tendency for those with flat feet to have fewer injuries. Another study of 295 Israel Defense Forces recruits found that those with high arches suffered almost four times as many stress fractures as those with the lowest arches.A later study of 449 U.S. Navy special warfare trainees found no significant difference in the incidence of stress fractures among sailors and Marines with different arch heights.
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