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What if flat feet were normal? Debunking an injury myth

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What if flat feet were normal?  Debunking an injury myth

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For decades, if not centuries, researchers, medical professionals, and the general population have believed that people with flat feet are more prone to developing a variety of problems.

In particular, it was believed that having flat feet makes people more susceptible to future pain and other musculoskeletal problems (such as muscles, tendons and/or ligaments).

Flat feet were seen as a kind of time bomb.

However, at one recent editing published in the British Journal of Sports Medicine, my research team challenges this myth. We show that the theory that having flat feet inevitably leads to pain or other musculoskeletal problems is unfounded.

As a researcher in podiatry at the Université du Québec à Trois-Rivières (UQTR), I will explain here the main conclusions of our research.

Where does this theory come from?

The idea that flat feet are a problem goes back centuries.

It was revived in the second half of the 20th century by American podiatrists Merton L. Root, William P. Orien, and John H. Weedwho popularized the concept of ‘ideal’ or ‘normal’ feet.

These physician-researchers were the first to suggest that if the feet did not meet specific criteria of normality (e.g., a well-defined plantar arch, a straight heel in line with the shin bone), they would be abnormal, less efficient, and more prone to injury . injury resulting from multiple biomechanical compensations, such as increased arc flattening during walking.

This theory became central to health professional education programs. Although today this theory is gradually disappearing as modern curricula are updated, the theory was taught around the world for almost fifty years even though the scientific basis was weak. In fact, science has never validated the theory: it has remained at the hypothesis stage.

Nevertheless, many health professionals over the years have continued to support the theory that flat feet pose a major risk for developing musculoskeletal disorders.

As a result, this idea is still firmly entrenched in the beliefs of the general public.

Do flat feet cause musculoskeletal injuries?

Contrary to the theory of Worrot and colleaguesMeta-analyses, the highest level of scientific evidence, have shown no increased risk of developing the vast majority of musculoskeletal injuries in people with flat feet.

This meta-analyses identified only weak associations between having flat feet and the risk of developing medial tibial stress syndrome (pain in the shin bone), patellofemoral syndrome (pain around the kneecap) and non-specific overuse injuries of the lower extremities.

That is it.

Furthermore, a systematic review and a meta-analysis concluded that runners with flat feet are no more at risk of injury than runners with normal feet.

These analyzes question the idea that people with flat feet are at significant risk of developing musculoskeletal disorders.

However, despite these findings, there are several sources such as gray literatureProfessional websites, forums, and other media often suggest that people with flat feet are at greater risk for injury or even need treatment, even if they have no symptoms.

Unfortunately, this often leads to people having to undergo unnecessary interventions, such as the use of orthopedic shoes or custom-made foot orthoses for asymptomatic flat feet. It also leads to major concerns among patients about the appearance of their feet.

To set the record straight

Asymptomatic flat feet generally do not require intervention from healthcare professionals. Based on current scientific knowledge, it is ineffective and counterproductive to assess whether someone has flat feet to determine the risk of injury.

Although it is possible for a person with flat feet to develop a musculoskeletal injury, this does not necessarily mean that flat feet caused the injury.

It is entirely possible for two variables to be present at the same time without any causal relationship existing. There is an important difference between a causal relationship and a correlation. A cause-and-effect relationship means that a change in one variable (the cause) leads to a change in another variable (the effect). When two variables are correlated, changes in one variable may be related to changes in the other, but this does not mean that one causes the other.

To illustrate the concept, let’s take the following example: we give 500 children aged six to twelve the same math test. By conducting correlation tests, we see a trend: the larger the children’s feet, the higher their final grade on the exam.

This begs the question: does foot size really affect math skills? Of course not!

Another variable not taken into account, age, plays an important role in this correlation. Since feet get bigger as we age, there is a strong but false correlation!

The same principle applies to flat feet. If a musculoskeletal injury occurs in a person with flat feet, current research indicates that flat feet are not necessarily the cause and that other factors should be investigated.

The connection is one of correlation, not of cause and effect.

Reducing overdiagnosis in healthcare

Reducing overdiagnosis in healthcare has become crucial. This phenomenon, defined as the diagnosis of a condition that provides no net benefit to the individual, poses a global burden with potential adverse consequences for the patient. physically, psychologically and financially welfare.

In financial terms, it is easy to understand that prescribing custom foot orthoses, which cost hundreds of dollars, to prevent the musculoskeletal injuries associated with asymptomatic flat feet has a significant negative impact. This is especially true because the presence of flat feet only slightly increases the risk of developing these injuries.

To solve this problem, healthcare professionals must help reduce the overdiagnosis of flat feet by more clearly distinguishing for their patients between harmless anatomical variants and potentially worrisome conditions.

Because overdiagnosis often leads to overtreatment, avoiding unnecessary treatments will help alleviate patients’ concerns about their flat feet.

Finally, we must give up the outdated, still widespread idea that flat feet is a problem that exposes individuals to a high risk of musculoskeletal injuries. It is time to change our perspective and approach to the meaning of flat feet and recognize their natural diversity in the context of overall foot health.

Above all, it’s time to consider asymptomatic flat feet for what they are: just an anatomical variant!

More information:
Gabriel Moisan et al, Flat feet: deformities or healthy anatomical variants?, British Journal of Sports Medicine (2023). DOI: 10.1136/bjsports-2023-107183

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