Flat foot pathomechanics and effect on gait

1. FLATFOOT GAIT DEVIATIONS
&
HOW TO FIX IT
UNDER SUPERVISION OF DR. SAMAH
PREPARED BY DALIA MOSTAFA IBRAHIM MAHMOUD

2. ADULT ACQUIRED FLATFOOT DEFORMITY STAGING
AND TREATMENT (SIMPLIFIED BLUMAN-MYERSON
CLASSIFICATION)

3. Foot Orthosis

4. 1) A FUNCTIONAL FOOT ORTHOSIS (FFO)
 MEDIAL HEEL SKIVE: A SMALL PORTION OF THE ORTHOSIS IS REMOVED ON THE
MEDIAL ASPECT OF THE PLANTAR HEEL. THIS CREATES A VARUS WEDGE WITHIN THE
HEEL CUP. THE FORCE APPLIED IS SHIFTED LATERALLY, RESULTING IN
SUPINATION/INVERSION AND IMPROVED PRONATION CONTROL.
 LATERAL HEEL SKIVE: A SMALL PORTION OF THE ORTHOSIS IS REMOVED ON THE
LATERAL ASPECT OF THE PLANTAR HEEL. THIS CREATES A VALGUS WEDGE WITHIN
THE HEEL CUP. THE FORCE APPLIED IS SHIFTED MEDIALLY, RESULTING IN
PRONATION/EVERSION

5. A TOTAL CONTACT INSOLE (TCI):
• IS A CUSTOM-DESIGNED FOOT ORTHOTIC WHICH AIMS TO REDISTRIBUTE A
PERSON’S WEIGHT EVENLY OVER THEIR FOOT. IT OFFERS SUPPORT THROUGH THE
SHAPE AND DENSITY OF MATERIALS. A TCI HAS BETTER SHOCK ABSORPTION DUE
TO THE MATERIALS USED IN THE DESIGN THAN AN FFO. USUALLY MADE FROM
ETHYL VINYLACETATE (EVA). WHILE THEY CAN BE BULKY, THEY ARE DESIGNED
TO SUPPORT, CORRECT AND ACCOMMODATE A FOOT WITH GOOD SHOCK
ABSORPTION.

8. 3)AN OFF THE SHELF (OTS) INSOLE
• IS GENERALLY IN A NEUTRAL POSITION WITH A STANDARD ARCH SUPPORT. THE INSOLE IS
MADE OF A MATERIAL, WHICH HAS DIFFERENT DENSITIES. IT IS LOW PROFILE AND HAS GOOD
SHOCK ABSORPTION. THESE INSOLES OFFER MINIMAL CORRECTION WITH NO
ACCOMMODATE ON OF DEFORMITY. BUT THEY ARE OFTEN A GOOD STARTING POINT.

9. POSTERIOR TIBIAL TENDON ORTHOTIC PRESCRIPTION
 PRESCRIPTION
 OFTEN THE MAIN ISSUE REVOLVES AROUND THE PART OF GAIT CYCLE THAT IS AFFECTED
 PES PLANUS REQUIRES ARCH SUPPORT
 SUBTALAR JOINT ROTATION REQUIRES WEDGING
 PROBLEMS HIGHER UP COMMONLY REQUIRE COMPENSATION
 PRINCIPLE OF ORTHOTIC DESIGN
 ALWAYS LOOK AT THE POSITION OF HEEL/FOREFOOT AND SUBTALAR JOINT ROTATION
 MEDIALLY ROTATED SUBTALAR JOINT:
 INCREASED PRONATION MOMENT/DECREASED SUPINATION MOMENT
 RE-BALANCE BY MOVING GROUND REACTION FORCES MEDIALLY, INCREASING SUPINATION MOMENT,
REDUCING MEDIAL ROTATION
 LATERALLY ROTATED SUBTALAR JOINT:
 INCREASED SUPINATION MOMENT, DECREASED PRONATION MOMENT
 RE-BALANCE BY MOVING GROUND REACTION FORCES CLOSER TO SUBTALAR JOINT, TO INCREASE
PRONATION MOMENT OF GROUND REACTION FORCES

10. EFFECTS OF FOOT ORTHOSES ON GAIT PATTERNS OF
FLAT FEET PATIENTS

11. THE REVIEW CONDUCTED BY DESMYTTERE ET AL. (2018)
HIGHLIGHTED THAT FOS INCLUDING A MEDIAL POSTING
REPRESENT THE MOST EFFECTIVE INTERVENTION TO REDUCE
REARFOOT EVERSION AND THEREFORE CONTROL EXCESSIVE
FOOT PRONATION IN FLATFEET.

12. REGARDING JOINT MOMENTS, MEDIALLY POSTED
FOS WERE SHOWN TO :
• DECREASE THE ANKLE INVERSION MOMENT
• ALLEVIATE LOWER-LIMB DISORDERS RELATED TO FLATFEET (PENG ET AL., 2020; TELFER ET AL., 2013).
• MOREOVER, WHEN INCREMENTALLY CHANGING A REARFOOT POSTING LEVEL (2 ), A DOSE-RESPONSE
◦
EFFECT AT THE REARFOOT AND KNEE JOINT HAS BEEN REPORTED.
• HAD SIGNIFICANT EFFECTS ON FRONTAL PLANE FOOT KINEMATICS. INDEED, REARFOOT EVERSION WAS
SIGNIFICANTLY DECREASED, ESPECIALLY AT EARLY STANCE AND MIDSTANCE (>2 ).
◦
• THE POSTING INDUCED A REDUCTION IN REARFOOT ADDUCTION, ANOTHER VARIABLE CONTRIBUTING TO
FLATTEN THE ARCH (LEVINGER ET AL., 2010).

13. • AS FLATFEET MAY LEAD TO PATELLOFEMORAL PAIN SYNDROME, DUE TO AN EXCESSIVE
TIBIAL AND FEMORAL INTERNAL ROTATION AND LATERAL PATELLAR DISPLACEMENT, FOS
WITH POSTING COULD REPRESENT A BENEFICIAL INTERVENTION TO IMPROVE PAIN AND
PHYSICAL FUNCTION BY BRINGING THE KNEE ABDUCTION MOMENT TOWARD NORMAL
VALUES (JOHNSTON AND GROSS, 2004).
The applied use of foot orthoses on PFPS as suggested clinically and in literature is the use of
single leg squat or double leg squat.
 If reproduced pain in the patellofemoral area then the clinician asks the patient to repeat the test
wearing a foot orthosis.
 If this reduces pain, this patient might benefit from a foot orthosis.
Another test that was developed to identify patients with Patellofemoral Pain who are likely
to benefit from foot orthoses by
 Measuring the width of the patient's foot from a non-weight bearing position then compares it to
standing mid-foot width
If there was a great increase in midfoot width, then foot orthoses might help

14. Desmyttere et al., 2021 highlighted that The addition of anti-pronator
components on FOs seems more suitable than modifying FO stiffness to alter gait
patterns in individuals with flatfeet. Indeed, postings can induce significant
biomechanical changes in the frontal plane, such as a reduction in rearfoot
eversion angle and ankle inversion moment, as well as an increase in knee
abduction moment, highlighting its beneficial effect on the control of excessive
foot pronation.

15. STRENGTHENING EXERCISES
• IN NORMAL GAIT, IT IS SAID THAT THE MUSCLE ACTIVITY OF THE GLUTEUS MUSCLE GROUP,
THE QUADRICEPS, AND THE TIBIALIS ANTERIOR INCREASES DURING HEEL-STRIKE AND THAT
THE MUSCLE ACTIVITY OF THE CALF MUSCLE AND THE INTRINSIC FOOT MUSCLES INCREASES
DURING TOE-OFF .
•
WEAKENING OF THE GLUTEUS MAXIMUS IS A CAUSE OF FOOT DEFORMITIES THAT INDUCES
THE HIP JOINT TO INTERNALLY ROTATE AND THE FOOT TO PRONATE

16. • THE MLA IS CONTROLLED WITH THE ASSISTANCE OF BONE STRUCTURES, LIGAMENTS, AND
THE EXTRINSIC AND INTRINSIC MUSCLES OF THE FOOT . AMONG THESE MUSCLES, THE
ABDUCTOR HALLUCIS (ABDH) HAS BEEN REPORTED TO CONTROL EXCESSIVE FOOT
PRONATION . THE ABDH HAS ALSO BEEN REPORTED TO BE IMPORTANT FOR STABILIZATION
OF THE MLA AND INDISPENSABLE FOR TOE-OFF DURING GAIT .
• ALTHOUGH THERE ARE MANY EXERCISES FOR STRENGTHENING THE ABDH, THE TOE-
SPREAD (TS) EXERCISE HAS BEEN SHOWN TO ACHIEVE HIGHER LEVELS OF ABDH MUSCLE
ACTIVITY IN WHEN COMPARED TO THE SHORT-FOOT EXERCISE

17. Goo et.al.25 suggested that strengthening the gluteus maximus while also
performing exercises to correct the pronated foot is an effective method for
achieving normal gait.