Conditions of the Foot
by Dr. Mark H. Tompkins

Flat Feet

"Flat feet", or Pes Planus (PP) is a relatively misunderstood term in the general public, and amongst certain members of the medical community.

To understand more about PP, it is important to have some working knowledge regarding normal foot structure(s). There are three basic normal foot structures which exist in the human foot:

1) Rectus Foot Type-this is a normal foot structure with an 'average' arch, and has an 'average' calcaneal inclination angle.

2) Cavus Foot Type-this is a normal foot structure with a 'high' arch, and has a higher than average calcaneal inclination angle.

3) Planus Foot Type-this is a normal foot structure with a 'low' arch, and has a lower than average calcaneal inclination angle.

The normal (or average) calcaneal inclination angle is between 18-22 degrees. For information, and graphics, regarding the calcaneal inclination angle, and other related radiographic angles of the human foot, click here.

One of these three basic foot structures are inherited at the time of birth. There are varying degrees within each individual foot type; however, the important thing to recognize is ALL three of these foot structures are normal .

{There are fewer foot problems associated with individuals who have a rectus (average arch height) foot type vs. a cavus (higher arch height) or a planus (lower arch height) foot type.}

There are two variations within the PP foot structure that are important to recognize - flexible and rigid. These terms relate to the amount of motion which occurs within the joints of the foot. Obviously, the flexible PP foot type undergoes significantly more motion than the rigid type.

The amount and degree of this motion (or lack of) is a major factor in determining if a particular foot type should be evaluated, and possibly treated, by a foot specialist.

It is important to point-out that the majority of individuals with PP have little to no foot problems, or complaints throughout their lives. These individuals have, what is referred to as, Asymptomatic PP. Individuals who demonstrate problems or complaints at anytime throughout their lives have what is referred to as, Symptomatic PP (SPP). Usually, patients who have a SPP foot type, demonstrate extreme degrees of flexibility or rigidity. This is not always the case, but is a good rule of thumb.

The most common complaint(s), or symptom(s) associated with SPP are arch and/or heel pain. This pain may begin in adolescence, or not occur until adulthood.

The most important factors which influence when symptoms may occur include body structure (height and weight); foot size in relation to body structure; individual growth patterns; level and degree of physical activity; and individual shoe considerations.

Other potential symptoms associated with SPP include forefoot pain; ankle pain; lower leg/knee/hip and/or back pain. Again, the extent of symptoms associated with SPP is dependent upon a number of factors. Predominantly, the severity of flexibility or rigidity, body structure considerations, and environmental factors such as degree/type of activity, and shoe preferences.

The level and degree of evaluation and/or treatment necessary in patients with PP, is (in my professional opinion) entirely dependent upon the presence of symptoms and complaints of the individual patient(s).

Symptoms and complaints in the adult patient population are easy to recognize, and patients will seek medical treatment themselves. However, adolescent patients possess a much more difficult presenting-symptom and complaint scenario. Many, in fact most, children do not complain of pain or problems, unless their symptoms are relatively severe in nature.

For this reason, it can be very difficult, and challenging, (for parents and doctors alike) to determine what, if any evaluation and/or treatment is necessary.

Other than subjective pain, the most common symptom(s) to look for in adolescents with PP is unusual, or abnormal shoe wear; kids who take their shoes-off consistently; and, relative inactivity of the child compared to their peers. It is important to mention that most toddlers and small children have some degree of PP (flat feet) which they will out-grow with age.

The important issue is determining which patients with PP need to be evaluated and treated by a foot specialist. The majority of family practice physicians, and pediatricians, typically inform parents that their child will eventually 'grow out' of the condition, and tend not to refer the patient for further evaluation and/or treatment.

The hallmark of treatment for SPP is supportive in nature. Support can come from something as simple as shoe modification, to OTC inserts for shoes, to expensive biomechanical functional orthotic (BFO) devices.  Additional treatments include (but are not limited to) anti-inflammatory medications (oral and/or injectible); varying methods and levels of immobilization; physical therapy; and stretching.

Severe, resistant cases of SPP can also be treated with a variety of surgical procedures. However, it should be emphasized that only a very small percentage of patients with SPP need any type of surgical intervention for appropriate treatment.

Surgical procedures for the correction of mildly-severe, resistant cases of SPP include specialized implants inserted into the rear-foot. These procedures are referred to as subtalar joint (rear-foot) arthroeresis and limit/reduce the amount of motion which occurs during ambulation. Various types of soft tissue and tendon procedures are used in more moderately-severe, resistant cases of SPP.

More-complicated, resistant cases of SPP are corrected utilizing different osseous (bone) procedures. These procedures actually change (correct) the architecture of the foot to improve function. The most-complicated, resistant cases of SPP are corrected with a combination of both soft tissue/tendon procedures and osseous procedures.

In conclusion, the most important factors in determining whether a particular patient with flat feet (Pes Planus) needs to be evaluated (and possibly treated), are 1) severity of the deformity; 2) limitations that occur; and most importantly, 3) presence of symptomatic signs and/or patient complaints.

A certain degree of PP (flat feet) is relatively common (and normal) in infants and adolescents; and the majority of patients will either 'grow-out' of the condition, or will never demonstrate problematic signs or symptoms.

If there is a strong family history of SPP, and/or the patient demonstrates (or complains of) symptomatic signs, then they should be evaluated by a foot specialist with training/expertise in the field of biomechanics.



Athletes Foot

Bio-Mechanical Pain


Calluses & Corns

Diabetic Foot

Flat Feet

Hallux Limitus/Rigidus

Hammer Toes

Heel Pain/Heel Spur

Ingrown Nails


Morton's Neuroma



Plantar Fasciitis

Plantar Warts

Running Injuries

Sclerosing Injection Treatments


Severs Disease

Shin Splints

Sweaty Feet/Odor

Toenail Fungus





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Dr. Mark Tompkins | 4402 Vance Jackson, Suite #146 | Phone: 210-341-2202

Copyright © 2001-2009 Dr. Mark H. Tompkins.  All rights reserved.