With rising numbers of lower leg injuries, and the growing number of amateur runners both recreationally, and semi-competitively in marathons and triathlons, we decided to enlighten those interested with an introduction to a few simple structures, deficiencies, and rehab tools use with both our professional and amateur athlete populations.
Flat Feet – Symptoms, Structures, and Management
Flat feet are a lowering or collapse of the medial longitudinal arch. Left untreated, this structural condition can lead to pronation at the ankle joint. Excessive pronation can cause pain and stress to several structures, including musculature and ligaments (Prentice, 2004). Today’s blog will outline the visual symptoms, associated structures, and a management plan for flat feet.
Figure 1 displays a posterior view of the left foot and ankle. On the right side, a collapse of the medial arch is shown indicating flat feet. On the left side, there is a sign of “too many toes” which is associated with mid-foot abduction. Also displayed in Figure 1, but not labeled, is an eversion of the calcaneus and a medial bulge of the talar head. With repeated pronation during weight-bearing activities (standing, walking, running), increased stress will be placed along the medial aspect of the ankle. As a result, Figure 2 shows swelling and edema posterior to the medial malleolus of the right foot. These are all visual symptoms of flat feet or ankle pronation.
A common tendon injury associated with flat feet is the tibialis posterior tendon (Yuill, 2010). The tibialis posterior originates at the adjacent margins of the tibia and fibula and runs posterior to the medial malleolus, then inserts at the navicular, medial cuneiform, and the 2nd-4th metatarsals (middle/inside of the foot). With flat feet and ankle pronation, strain is placed on the tendon (as shown in Figure 3) and stress occurs on the deltoid ligament of the medial ankle as displayed in Figure 4. Both the tibialis posterior and the deltoid ligaments serve to protect the ankle from excess eversion.
There are a variety of ways to manage pain and prevent injuries. On the path back to performance training or incorporated into performance training:
(1) The first step is to support the flattened arch through the use of orthotics.
(2) Next, we want incorporate a stretching program to ensure full range of motion in all planes.
(3) After an adequate level of range of motion has been established, a strength program can be added.
(4) Finally, proprioception and balance exercises will be trained to enhance neuromuscular control.
A primary aspect that we try to focus on is having the athlete train with a stable medial longitudinal arch. Although three distinct arches function to support the foot, the medial longitudinal arch has been found to be the arch of clinical significance in preventing injury due to flat feet (Franco, 1987).
One way to manage flat feet is by using orthotics. The main function of an orthotic is to provide a combination of neuromuscular reeducation and a change in body mechanics in an attempt to readjust the foot into a more ideal weight baring position (Franco, 1987). A proper fitting orthotic provides mechanical support to the flattened medial longitudinal arch and prevents further tendon lengthening or ligament stress. The muscles that are constantly being stressed and lengthened are then, finally relaxed and shortened.
While the orthotic passively creates an arch for the athlete and may help prevent overuse injuries, it is also important for the athlete to actively train and strengthen muscles that are underactive during over pronation. A program that incorporates the strengthening of the anterior and posterior tibialis is important because they help maintain a proper arch. Without the use of an orthotic, the athlete can work towards biomechanical betterment by practicing “bilateral short foot position.”
https://www.youtube.com/watch?v=oxU9uC5FHF4#t=7
Other exercises that should be incorporated into the athlete’s program to build strength in the ankle and lower leg include isometric exercises against all planes of motion. After that, the athlete can progress to concentric and eccentric movements using tubing or resistance bands and onward.
Kinesthetic awareness can be regained through multiple balance training exercises. One balance exercise that we may incorporate into the rehab training is a single leg RDL. While a main objective of this exercise is to strengthen the posterior chain, performing an RDL on one leg also forces the athlete to focus on balance, thus improving neuromuscular control at the ankle, lower leg, hip, and torso. Another way we improve balance is by having the athlete stand on a soft, unstable pad while throwing a ball for them to catch. When the athlete reacts to catch the ball, they must stabilize the foot and lower leg.
While these are general exercises for ankle and lower leg rehabilitation, athletes respond to treatment and exercises differently, so modifications should be made accordingly.
In the next blog post, we will talk about the effects of over pronation up the kinetic chain.
Howitt S, Jung S, Hammonds N. Conservative treatment of a tibialis posterior strain in a novice triathlete: a case report. Journal of the Canadian Chiropractic Association Mar2009, Vol. 53 Issue 1, p23 9p.
Yuill E, MacIntyre I. Posterior tibialis tendonopathy in an adolescent soccer player: a case report. Journal of the Canadian Chiropractic Association Dec2010, Vol. 54 Issue 4, p293 8p.
Kulig K, Reischl SF, Pomrantz AB, Burnfield JM, Mais-Requejo S, Thordarson DB, Smith RW. Nonsurgical Management of Posterior Tibial Tendon Dysfunction With Orthoses and Resistive Exercise: A Randomized Controlled Trial. Physical Therapy Jan2009, Vol. 89 Issue 1, p26 12p.
Mattacola, Carl & Dwyer, Maureen. Rehabilitation of the ankle after acute sprain or chronic instability. Journal of Athletic Training. 2002 Oct.; 37 (4); 413-429.
Prentice W. Rehabilitation Techniques for Sports Medicine and Athletic Training Fourth Edition 2004.
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