PT on the Net Research

Flat Feet


Question:

Is it possible to help alleviate and/or correct flat feet? I just assessed a client with this problem. He is 73 years old, 6 feet tall and weighs 200 pounds. He is in good condition for his age. He plays golf three times a week and complains about having knee and low back pain when he is done playing. What type of exercises/stretches can I implement to help him with his flat feet condition?

Answer:

In order to help alleviate the client’s pain, an entire kinetic chain assessment is necessary. Flat feet are one of the compensation patterns that the client is showing, but it is essentially just a small segmental compensation among other compensations not listed above. Since the body works as a kinetic chain, each individual joint affects every other joint in the body. Given this, the client’s flat feet can be followed up the kinetic chain to the knees and lower back, where pain is being experienced.

First, we must address the “flat feet.” This compensation is defined as Pronation Distortion and is indicative of tight peroneals, soleus/gastroc complex, IT band, hamstrings, adductor complex and psoas.

The first group of muscles to be discussed is the peroneals. The peroneus longus originates on the lateral, superior portion of the fibula and inserts at the base of the 1st metatarsal and medial cuneiform. Its concentric function is acceleration of eversion of the ankle. Eccentrically, it controls deceleration of inversion of the subtalar joint during propulsion. The peroneus brevis originates at the distal 2/3 of the lateral fibula and inserts on the tuberosity of the 5th metatarsal. Concentrically, the peroneus brevis everts and plantar flexes the ankle. The eccentric function is to decelerate inversion of the subtalar joint during propulsion. This is important because when the peroneal complex is tight, the ankle will evert, abduct and dorsiflex more (pronate), creating a “flat foot” condition. The soleus becomes hyperactive as well. The soleus originates at the head of the fibula and medial border of the tibia. It inserts into the calcaneus by way of the achilles tendon. The function of the soleus is to concentrically accelerate plantar flexion and accelerate subtalar joint supination. Eccentrically, the soleus decelerates subtalar joint pronation and internal rotation of the lower leg at heel strike. When the soleus is tight, it limits dorsiflexion forcing the foot to externally rotate during movement. A tight soleus will contribute to a weak posterior and anterior tibialis. The anterior tibialis originates on the lateral condyle and the body of the tibia and inserts at the first metatarsal and first cuneiform. The posterior tibialis originates at the posterior shaft of the tibia and fibula and inserts into the navicular, cuneiform, cuboid and bases of the second and fourth metatarsals. Both of these muscles work concentrically to invert the ankle and to eccentrically decelerate eversion at heel strike. Separately, the posterior tibialis plantar flexes the ankle, while the anterior tibialis dorsiflexes the ankle. When these muscles are weak, they cannot decelerate eversion properly, allowing the ankle to pronate more. Tightness of the bicep femoris affects the position of the lower leg as well. Due to the attachment of the bicep femoris on the proximal tib-fib joint, tightness of this lateral hamstring pulls the fibula laterally increasing lower leg external rotation. If the tibia stays fixed in an externally rotated position, the knee is affected by increasing internal rotation of the femur when the knee flexes and extends.

By increasing femoral internal rotation, the external rotators (glute medius and glute maximus) become lengthened and weak. The external rotators function to decelerate femoral internal rotation. If the external rotators are weak, the tensor fascia latae, IT band and adductor complex become hyperactive and thus increase femoral internal rotation and frontal plane adduction. Continuing up the chain, weak glutes can be a result of a tight psoas as well. The psoas originates at the transverse processes and bodies of the lumbar vertebrae and insert into the lesser trochanter of the femur. A tight psoas will reciprocally inhibit the glutes and increase lumbar extension, leading to lower back pain. When this occurs, the synergists, the hamstrings and the erector spinae, are activated to extend the hips. Although the hamstrings can perform the job of hip extension, they are not as strong, nor as efficient as the glutes and therefore, this altered force-couple will lead to an eventual breakdown or strain of the hamstrings. This leads to tightness of the erector spinae, increasing stress on the lumbar spine. An increase in lumbar extension places the lats into a shortened position. The lats originate from the thoracolumbar fascia and insert into the anterior portion of the humerus. If the lats are short/tight, they will restrict shoulder flexion, pulling the lumbar spine further into extension, while protracting the shoulder girdle. Increasing lumber extension decreases the ability of the core muscles to work properly. The intrinsic stabilizers (transverse abdominus, multifidi, pelvic floor muscles) work to stabilize the spine and control movement of the extremities. Without proper activation, the prime movers will not be recruited properly due to the altered force couple of the core.

Based on all the compensations that could be occurring within the kinetic chain, a comprehensive approach should be taken to correct his muscle imbalances. First, addressing his pronation, use self -myofascial release to roll out any fascial knots, or adhesions, that he might have. These knots occur as a result of the body’s cumulative injury cycle and act as a protective mechanism to prevent further injury to damaged tissue. These adhesions can affect muscle length by restricting the tissue from full elongation. Use a bio-foam roll and roll out the muscles listed below, holding each adhesion (indicated by a painful “bruise” feeling) for 20 seconds. Continue by statically stretching tight muscles and holding each stretch for a period of 20-30 seconds each. Static stretching allows the tissue to elongate so that there is more extensibility during movement. Remember that a muscle has elastic properties, and according to Davis’ Law, a muscle will mold itself along the lines of stress. Therefore, in order to truly affect the muscle length, a stretch has to be held for at least 20 seconds, and this has to be done everyday at least twice a day.

After addressing the tight musculature, strengthening weak muscles is crucial. Again, referring to the chart and program below, strict form and tempo are important. Your client’s nervous system will have to relearn how to recruit the proper muscles at the right time, in the right plane of motion. In the beginning, slowing your client down and teaching stabilization first will be of prime importance. Without building a foundation of strengthening the body’s intrinsic stabilizers (transverse abdominus, multifidi, pelvic floor muscles), the prime movers will not be recruited properly. This again results in compensations and eventually breakdown of different muscles within the kinetic chain.

By taking a comprehensive approach, you will be able to address your client’s pain as well as compensations. Flat feet are just a result of various actions occurring within the entire kinetic chain. By systematically stretching and strengthening various muscles throughout, the client will attain neuromuscular efficiency and functional flexibility to continue his recreational activities

Please look over the enclosed chart and program template. Refer to the PTN Exercise & Flexibility Library  for exercise descriptions and demonstrations.

Compensations, Muscle Imbalance and Corrective Strategies

Abnormal Movement
Tight Muscles
Weak Muscles
Corrective Strategy
Foot and Ankle Complex
Feet Flatten Gastrocnemius, Peroneals Gluteus Medius, Anterior Tibialis, Posterior Tribialis Foam Roll + Static/Active Stretch: Peroneals & Gastrocnemius;
Core Stabilization:
Tube Walking, Ball Bridges
Single-leg balance progression:
Single-leg balance reach, Single-leg Squat
Feet Externally Rotate Soleus, Biceps Femoris, Piriformis Gluteus Medius, Foam Roll + Static/Active Stretch: Soleus, Biceps Femoris, Piriformis
Single-leg balance progression:
Single-leg balance reach, Single-leg Squat
Core Stabilization:
Tube Walking, Ball Bridges
Knees
Knees Adduct Adductors, Iliotibial Band Gluteus Medius, Gluteus Maximus Foam Roll + Static/Active Stretch: Adductors & Iliotibial Band;
Core Stabilization:
Tube Walking, Ball Bridges
Single-leg balance progression:
Single-leg balance reach, Single-leg Squat
Lumbo-Pelvic-Hip Complex
Increased Lumbar Extension Iliopsoas, Rectus Femoris Erector Spinae, Latissimus Dorsi Gluteus Maximus/Medius, Lumbo-Pelvic-Hip Complex Stabilization Mechanism Foam Roll + Static/Active Stretch: Iliopsoas, Rectus Femoris, Erector Spinae, Latissimus Dorsi;
Core Stabilization:
Tube Walking, Ball Bridges, Ball Crunches
Single-leg balance progression:
Single-leg balance reach, Single-leg Squat
Shoulder Complex
Arms Fall Forward (when overhead) or Lumbar Spine Hyperextends Latissimus dorsi, Pectoralis Major Middle/Lower Trapezius Foam Roll + Static/Active Stretch: Latissimus dorsi, Pectoralis Major;
Core Stabilization:
Ball Prone Cobra, Ball Scaption, Ball PNF
Single-leg balance progression:
Single-leg Windmill

*SL= Single leg MP= Multi-plane

OPT Template: IST- Pronation Distortion

Flexibility
SMR
Static
Corrective
  • Peroneals
  • Gastroc/Soleus
  • IT Band
  • Adductors
  • Piriformis
  • Bicep Femoris
  • Lats
  • Gastroc/Soleus
  • Psoas
  • Adductors
  • Piriformis
  • Lats
Exercise
Sets
Reps
Intensity
Tempo
Rest Period
Core/Balance
Prone Iso-abs 2 12 60-70% 4-2-2 Circuit
Ball bridge 2 12 60-70% 4-2-2
SL Windmill 2 12 60-70% 4-2-2
Reactive
MP hop w/ stabilization 2 4 each plane 60-70% 4-2-2 45 sec.
Strength
Chest: Seated Ball 2 Arm Press 1 15 60-70% 4-2-2 30 sec.
Back: Ball Cobra 2 20 60-70% 4-2-2 30 sec
Shoulders: SL Scaption 2 20 60-70% 4-2-2 30 sec
Legs: SL Squat 2 20 60-70% 4-2-2 30 sec