Do shoes cause flat foot in children?

There have been a number of previous studies in children in African countries that have shown a high correlation between flat foot and the wearing of shoes. This often gets touted as the shoes caused the flat foot and is used by those with an agenda to promote barefoot. However, that is not what those studies showed. All they showed was a correlation. Correlation does not mean causation

The studies could be interpreted several ways:
1. The wearing of the shoes did indeed cause the higher incidence of flat foot
2. Those with a prior flat foot wear shoes more often as the feet feel better wearing them
3. Those that wear shoes more often walk on harder surfaces and it is the harder surface that is responsible for the higher incidence of the flat foot, and not the shoes
4. Etc

Those with an agenda, clearly like to push option one as to what they think the studies have shown. Those without an agenda are open to all the options as an explanation of the results of those studies.

Now we have a new study on a population of children in Nigeria that has taken the analysis of these types of studies to a new level (see discussion: Flatfoot not related to footwear in Nigeria study) in which they used a more sophisticated analysis and controlled for some other variables. They concluded that the footwear was not a factor in the development of flat foot.

Don’t get me wrong, I have no doubt that footwear can and does cause a lot of problems, its just that the studies referred to above cannot be used to imply that wearing shoes in children cause flat feet.

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Growing Pains in Children

Just have been having to deal with the issue of growing pains in the children. Growing pains in children have a very specific definition – its unexplained pain usually at the back of the knee and upper calf muscles that occurs at night. The cause is thought to be fatigue and sleep related, so is probably a biochemical problem. The real problem with the term growing pains is that any leg pain can often be written off as being a “growing pain” and they will grow out of it. There are several potentially serious (and not common) that cause pain in the leg. This means that every leg pain in the child is not growing pains and must be checked out. I only raise this as a child I know was repeatedly dismissed as having growing pains and it turned out to be an osteosarcoma. If the pain occurs in the day time or in the bone and is not relieved by gentle massage, then its not growing pains.

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Manipulation for Cuboid Syndrome

Cuboid syndrome is an interesting condition with many different understanding about what exactly it is; what causes it; and how to treat it. Everyone seems to have an opinion on cuboid syndrome. Is it a subluxed cuboid? Or is it just a strain of the ligaments about the joints the cuboid is involved in. Opinions are also divided on the value of cuboid manipulation. For some it’s the only treatment, for other cuboid manipulation is dangerous if not done properly.

Personally, I actually have no idea exactly what cuboid syndrome is. It does seem to respond to strapping foot orthotics and gentle manipulation. The manipulation does seem to work some times, but not at other times.

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Is Forefoot Varus Posting Bad?

Forefoot varus is rare, yet some researchers always seem to manage to recruit enough subject for their research that have what they claim is forefoot varus. I suspect that they are not forefoot varus, but the much more common forefoot supinatus and they got confused. The reason that this is a problem is that they are totally different beasts. One is osseous and causes rearfoot pronation and cannot be reduced. The other is soft tissues and is the result of rearfoot pronation and can be reduced. Yet they look the same. They will both respond very different to foot orthoses … kinda think that the distinction between the two would be important in research projects don’t you? Also forefoot varus will respond very differently to rigid compared to flexible/semi-rigid foot orthotics.

To be clear, forefoot varus is a forefoot that is inverted when the subtalar joint is in its neutral position and the midtarsal joint is maximally pronated. As the forefoot is inverted, the rearfoot has to pronate to bring the medial side of the foot to the ground. To treat forefoot varies, you are supposed to use a medial forefoot post to bring the ground up to the foot, so the foot does not need to pronate the rearfoot to bring the medial side of the forefoot down to the ground. Right?

Consider the very rigid plastic orthotic with a forefoot varus post, when the foot is placed on top of it the forefoot varus post will invert the rearfoot (or stop it pronating/everting) through its effects on the rearfoot via the rigid plate of the orthotic.

Consider the less than totally rigid foot orthotic with a forefoot varus post. How will that affect the rearfoot pronation? The only way it can affect the rearfoot pronation is by dorsiflexing the first ray to end range of motion, then invert the midfoot joints to end range of motion, then it has a shot at affecting the subtalar joint. As the orthotic shell is not totally rigid, the forefoot varus post has to affect the rearfoot “through the foot”. Whereas if the shell was rigid, the forefoot varus posts work directly on the rearfoot by tilting the orthotic shell. It cannot do this with a less than rigid orthotic when the person is standing on it.

Is the use of forefoot varus posts potentially injurious?

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Vibram FiveFingers

Vibram Five Fingers as an alternative footwear to ‘barefoot’ have been getting a lot of attention, especially from the barefoot/minimalist running community. The anecdotal evidence is accumulating that barefoot running is increasing the injury rate in runners. I have seen predictions and posts that say something like because of ‘barefoot running’ that podiatrists must be ‘shaking in their boots’ at the thought of barefoot running due to all the business they will lose. Well, where are the people that made those claims now? The opposite has happened. Barefoot running is turning into an economic stimulus package for anyone who treats and rehabilitates running injuries. If you do not believe me, just ask them. Here is a typical comment:

"I do not see many runners in my clinic, but lately over half the ones I have seen are barefoot or minimalist runners. Given that my impression is that barefoot runers make up less than 0.01% of runners, and if 50% of the runners I see with an injury are barefoot, then should not alarm bells be going off?" source

and these types of comments:
“We’ve seen a fair amount of injuries from barefoot running already, or from just running in the Vibrams,” says Nathan Koch, PT, Director of Rehabilitation at Endurance Rehab in Phoenix, AZ. Vibrams are the barely-there “foot gloves” that have become popular among barefoot running devotees.Steve Pribut, a Washington, DC podiatrist and one of America’s most respected running injury specialists, says he has experienced a recent influx of barefoot runners at his office as well. And, asked by email whether he could confirm a barefoot running injury trend in his clinical experience, Lewis Maharam, a.k.a “Running Doc,” replied with two words: “Oh, yeah!” source

There is no doubt that some are getting less injuries after taking up barefoot running and there is no doubt that there are some that are getting more injuries.

There is even a rumour going around about a class action law suit against Vibram Five Fingers because of all the injuries that are occurring, but it may be just a rumour as I have seen nothing concrete on this. Certainly some running speciality shops have been asking customers to sign disclaimers to waive legal responsibility when the buy the Vibram Five Fingers.

There was even an insight into the sort of people who buy Vibram Five Fingers - they are being reported as being annoying people by the San Francisco Weekly!

See:
Why are barefoot runners getting so many injuries?
The Barefoot Running Injury Epidemic
Vibram FiveFingers Cause Metatarsal Stress Fractures?

While barefoot running or the Vibram Five fingers is certainly turning out to be not all they are touted as being, there is nothing wrong with barefoot running drills as part of balanced running program. Just don’t believe all the hype and propaganda that is being sold.

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The Foot Posture Index

Measurements taken of the foot as part of a biomechanical assessment have been shown to be notoriously unreliable and not that repeatable. When the initial studies started to come out showing that, I wanted to disagree with them as “I” was reliable. That was until I became a participant in these studies and realised just how unreliable I was.

When it comes to determining the posture or alignment of the foot (for whatever reason you might want to do that!) what do you measure. The Calcaneal angle? The arch height? The transverse plane position of the midfoot? Whichever one you choose, you may end up with a ‘normal’ or ‘abnormal conclusion.

For the above to problems, Tony Redmond developed the Foot Posture Index. The index is based on observations and is based on a number of observations. The FPI has been shown to be reliable.

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Foot Orthotics for Golf

What do you do with a golfer and the need for foot orthotics? Golf involves a lot of walking, so they need a reasonably firm or rigid pair of foot orthotics to control the foot during that activity (assuming that foot orthotics are indicated). The crucial part of the golf game is the swing. The swing stance involves a reasonable amount of inversion and eversion of teh foot to be done efficiently. How much does a rigid orthotic with a rearfoot post interfere with that motion and affect that efficient golf swing? Foot orthotics for golf are going to have to be a compromise. It is surprising how often this issue comes up on some golfing forums for discussion.

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