The Failings of Flip­‐Flops: Why Singaporeans Are More at Risk from Flat Feet

‘Flat feet’ or pes planus is a condition in which the arch of the foot is lower than usual. However, this can be a misleading term as flat feet can be divided into ‘rigid’ or ‘flexible’. Rigid flat foot is a rare condition in which the bones of the foot are fused together. On the other hand, flexible flat feet are much more common. This is where the joints of the foot move excessively and do not fully support the body’s weight when standing or walking. There are varying degrees of this condition and there are multiple factors which can contribute to it such as age, family history, medical conditions, previous injuries and weight gain (e.g. during pregnancy).

All infants are born with flat feet and it can be difficult to tell whether a child has flat feet because their arches may not fully develop until they're 10 years of age.

Flexible flat feet can occur in approximately 10-20% percent of the population. However, due to the increased ligament flexibility found in Asian populations, estimates suggest that flat feet may occur in as many as 1 in 5 Singaporeans.

Flat feet may put a strain on your muscles, ligaments and joints, which may cause tiredness or aching in your feet, legs, hips and back when you stand or walk for long durations.

Treatment is usually only required if the flat foot is causing pain in the foot or the lower limb. If there isn’t any pain, treatment is not indicated simply as a result of having a flat foot. However, in severe cases, treatment may be advisable in order to prevent any possible future problems.

Contrary to popular belief, having a flat foot does not necessarily increase the incidence of injury and it does not always cause problems. As a physiotherapist, I’ve seen many patients who have ‘flat feet’ but are pain free. But flat feet coupled with the a poor choice of footwear can be a big risk factor for pain, and in particular, a certain type of footwear… flip flops.

Flip Flops

The Problem with Flip Flops

Most Singaporeans own several pairs of flip-flops or slippers. They are hugely popular and are seen by many as the ideal choice of footwear in hot weather due to their comfort and convenience. However, such a choice of footwear might be a real health flop.

Aside from the obvious lack of protection (meaning you're more vulnerable to dropped objects, stubbed toes and infections), being dangerous to drive in, and making you walk slower, your favourite pair of flip-flops could be seriously damaging your feet.

Healthcare professionals will tell you that flip-flops are too flat, too thin and can lead to many foot problems. They should thus be avoided in for prolonged walking because they offer no arch support, heel cushioning or shock absorption. Furthermore, the thong that sits between your toes when wearing flip-flops can also be dangerous as it forces wearers to clench their toe muscles for grip to keep them from flying off. This can lead to repetitive stress on the foot and ankle, leading to overuse injuries or deformities such as hammer toes or claw toes.

This type of shoe can accelerate the problems associated with having a flat foot. The complete lack of arch support in flip-flops means those with flat feet who tend to over pronate already have nothing to limit from further excessive pronation, thus putting more strain on an already stressed arch.

Plantar Fasciitis

Among the most treated flip-flop induced injuries is plantar fasciitis, an inflammation of the tissue along the sole of the foot. It is most often sparked by all-day wear, with flat footed, overweight or sedentary wearers even more susceptible since their arches are already under strain. The feet are the foundation of your whole body and the base of your skeleton. Therefore it’s not surprising that wearing flip flops can have a domino effect, putting stress on your joints, which may result in ankle, knee hip or back aches.

Our bodies are designed to tell us when things aren’t working properly, typically in the form of pain. In the correct shoes you should be easily able to walk for a solid 2-3 hours without feeling discomfort. If your feet or any other part of your lower limbs hurts while walking or standing, there’s a good chance your footwear is playing a part. An easy test to try is to try walking in flip flops for an hour or so and then note how long it takes for any aches, pains or tiredness to set in. Try the same thing again in a sports shoe and take note of how you feel after an hour. Granted everyone will be affected differently, but chances are, walking in a sports shoe will be much more comfortable than flip flops.

We have already written a blog on things to look out for when choosing a shoe, so this can provide with some tips when shoe shopping. If you’re unsure then there’s always expert advice on hand to help pick the perfect shoe for you.

Hopefully I have convinced you how vital it is to wear supportive footwear. For those who ignore such advice and insist on continuing to wear flip-flips, slipping them on for short durations or by the pool should be ok, but moderation is key. Problems arise when flip-flops become your main choice of footwear.

How can PhysioActive help?

It’s important to recognise the problem as early as possible since its severity tends to worsen with time. Treatment would focus on specific aspects or parts of the foot that require modification or healing. This may be achieved in a number of ways.

Thanks for reading!

This post has been written by physiotherapist Liam Mc Ginley.

Plantar Fasciitis & Heel Pain Treatment: Questions Answered

Plantar fasciitis refers to an inflammation in the plantar fascia, which causes pain under your heel. Typical treatments include rest, good footwear, heel pads, painkillers, and exercises. In today’s blog, we answer five of the most commonly asked questions about plantar fasciitis.

What causes heel pain?

There are 2 main causes of heel pain. Plantar fasciitis is the most common, when pain is coming from the base of the foot, underneath the side of the heel, and it accounts for 15% of all adult foot problems. The plantar fascia is a fibrous connective tissue, running from the base of the heel and connecting to the base joint of each toe. The plantar fascia acts as a dynamic shock absorber for the foot and the entire leg when walking and running, acting like a gentle spring.

Plantar fasciitis can be caused by a number of factors, including poor footwear, weight gain, overpronation, biomechanical abnormalities, and specific muscle weakness and tightness, as well as work and lifestyle factors. The condition itself is created by repetitive and excessive stress through the plantar fascia, which creates micro-tears that are unable to heal at a rate that is faster than the damage is occurring. This causes degeneration and inflammation of the plantar fascia, causing pain in the base of the heel. The plantar fascia is like a rubber band – it will stretch out and contract during walking. However, if it becomes overworked, it will eventually tear and lead to pain.

Heel spurs are a common complication with plantar fasciitis. In response to the constant pressure being placed through onto the heel, the body replies by laying down extra bone tissue, in order to strengthen the structure. Not all heel spurs are painful, but they do indicate an underlying response by the body to poor biomechanics and stress reactions through the heel area. Heel spurs are indicative of plantar fascia problems, but they’re not a cause of pain – in fact, shaving the heel spur doesn’t always resolve any pain at all.

Achilles tendinopathy is the most common cause of pain at the back of the heel. In a similar process, degeneration and injury of the Achilles tendon is caused by excessive and repetitive stress. The main causes are similar to plantar fasciitis, including poor biomechanics, overpronation, poor footwear, weak calf and foot muscles, weight gain and changes in exercise or work habits.

Heel Diagram

Who is likely to have heel pain?

People who spend a lot of time standing up or who put excessive exertion on their feet are likely to have foot pain – for example, nurses, teachers, lab/factory workers, NS men, pregnant women, and salespeople, as well as those with a family history of medical conditions. However, what we see in Singapore is a lot of people with hypermobility. Genetically speaking, those of Asian ethnic backgrounds are generally predisposed to hypermobility, which is probably the biggest contributor.

An easy analogy to make is to try walking on a mattress. Then, try walking on the ground. There’s a big difference in the amount of effort required and energy expended. If you apply that to your feet, you can see why it’s easier to walk in a pair of sports shoes as opposed to a pair of flip flops. Unfortunately, in Singapore, everyone wears flip flops – poor footwear is abundant here. For most of the world, a few months in flip flops isn’t going to hurt your feet. However, in Singapore, people wear flip flops all year round, so you can imagine how that will affect their feet long term.

Clinically speaking, people who we see in the clinic with heel pain may have one or more of the following:

Walking and running assessments often pick up factors not only in the foot, but also in the knee and hip, that can ultimately lead to excessive stress and load through the heel.

Is there any way to prevent heel pain?

By the time patients feel pain in their heel, the injury and the degeneration have well and truly set in. Typically, most acute pain in the feet will resolve itself within 48 hours. However, if the pain is persistent then it can lead to a chronic injury that can last for weeks, months, and, in some cases, years. The difference between pain in the feet and pain elsewhere in the body is that it’s very difficult to rest our feet and let them recover.

Unfortunately, pain will not go away by itself unless the causes are addressed. We always find that the earlier we treat the condition, the quicker it resolves.

Orthotics serve as the cornerstone for treating heel pain. They’re most successfully applied when combined with specific manual treatment (massage and mobilisation), specific muscle stretches and strengthening exercises, and a correction of any biomechanical issues through the whole leg. If insoles/orthotics are required, they will give your heel bone an extra level of support and cushioning that they’re currently lacking. You could liken them to the shock absorber found in cars. They provide extra stability and cushioning from the forces that impact on your feet. You can function without them, but you’ll find that your gait (or ride) won’t be as comfortable as when you are using them.

At PhysioActive, we’re also having success with the use of shockwave therapy. This has been useful in treating long-term chronic heel pain, helping to break down scar tissue adhesions and to promote a healing response at the site of injury. Prevention is always a fascinating topic. Footwear and strengthening/stretching are very important, because the anatomical structure of the foot and ankle is impossible to change. The way that our joints and ligaments allow movement is generally fixed. What we can do, however, is to improve the strength and fitness of the muscles around the foot to support and unload pressure from the plantar fascia. This includes small muscles underneath the arch, as well as the calf.

For runners, the placement of the foot upon landing is very important. Our running assessment will pick up whether patients are landing on their heel first, which can lead to tremendous pressure. Not managed properly, it can result in heel pain and worse, a stress fracture. With exercises and different physiotherapy techniques, we aim to have patients landing on the whole foot.

Flat Feet Test

What about people with flat feet?

‘Flat feet’ is a somewhat misleading term – it can be divided into ‘rigid’ or ‘flexible’. Rigid flat feet are caused when the bones of the foot have fused together, and it’s quite a rare condition. On the other hand, flexible flat fleet are much more common. This is where the joints of the foot move excessively and do not fully support the body’s weight when standing or walking. There are varying degrees of this condition and there are multiple factors which can contribute to it:

As mentioned earlier, however, having flat feet or pes planus may not lead to pain, as I’ve seen many adults who have ‘flat feet’ but are also asymptomatic. The height of the arch in the foot doesn’t cause pain, as it’s more important to look at how the size of the arch changes when putting weight on it. This is a better indicator, as people with seemingly ‘normal’ feet often wonder why they have pain, because they have an arch in their feet which disappears when weight is put on it.

When assessing flat feet, I like to consider all of the above factors, as well as the angle of the knees, the ankles, the big toes and the mid and rear foot, before deciding whether the person really has pes planus or not. Depending on the severity, a treatment plan will then be devised. By the age of five, the arch of the foot should have fully developed in the majority of children. If it continues developing into adulthood, it can contribute to injuries not only in the foot and ankle, but also the knees, hips and lower back.

Some exercises, combined with stretching footwear and orthoses (insoles), will help the feet and the arch of the foot to develop naturally, so it’s important for children to be assessed early (if they complain of any lower limb pain, have poor coordination or the alignment of their limbs appears abnormal). For adults, the treatment is the same, but it’s harder to correct flat feet as the foot has usually fully developed by the age of eighteen. Pain is always the biggest indicator, but it needs to be remembered that although the feet themselves may not hurt, problems with the ankles, knees, hips and lower back can be caused by flat feet. So if you’re unsure, get them assessed as it can prevent the need for costly surgery later in life.

What's the correct way to walk or stand to prevent heel pain?

The best way to walk to avoid heel pain is to walk from heel to toe, something we learn from our very first steps as a child. But as easy as it seems, not everyone will do this knowingly. The heel should typically move towards the centre, followed by the foot rolling forward until the toes push off and the foot leaves the ground. We do this without thinking, but for some, the way that the foot functions during walking is a little different. This can be due to medical conditions (e.g. diabetes), injuries (e.g. chronic ankle sprains), weight gain (e.g. carrying children or shopping), footwear (e.g. safety boots or flip flops), muscle weakness, and the terrain (e.g. walking on a pavement versus a jungle trail).

If the foot moves incorrectly, joint tendons and ligaments will become overused, leading to pain and injury. A simple way to assess this yourself is to look at the way your feet are pointing whilst walking. In a normal gait, the feet are pointing straight ahead. If the feet are pointing in or out, it could be due to one of the previously mentioned factors. Of all the factors, footwear is the easiest one to modify.

Advice on preventing heel pain:

Problems with heel pain and seeking treatment?

Please get in touch with us today and book a physiotherapy session with the team.

Thoughts or questions?

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Shoe Buying Guide - Ensuring A Healthy Fit

In a previous blog post, we discussed the different types of running shoes and how to select the best one for you. But what about our day to day shoes; for work or play? Again there is a bewildering myriad of shoes available, but what should we look for when buying a pair of shoes. Choosing the right shoe can often mean the difference between comfort and painful injury.

As a podiatrist people seek my advice on dealing with foot injuries. One of the first things I ask my patients is 'what shoes do they typically wear?'

A well-made shoe will perform several functions:

Due to this, a mountain climbing boot is going to be vastly different to a woman's stiletto shoe. Yet all shoes incorporate these design factors to varying degrees. Bearing this in mind, buying a shoe in Singapore however takes a little more time and effort. Due to the hot humid climate, lightweight shoes are often preferred to more supportive (heavier) shoes. While comfortable and breezy, lightweight shoes often don't provide enough support for our daily routine. And to complicate matters even further, the workplace often dictates what sort of shoe is acceptable as opposed to what you can wear after hours.

Our bodies are designed to tell us when things aren't working properly, typically in the form of pain. In the right pair of shoes you should be easily able to walk for a solid 2-3 hours without feeling discomfort. If your feet, or any other part of your lower limbs hurt while walking or standing, there's a good chance your shoe is playing a part. An easy experiment to try is to try walking in a flip flop for an hour or so and note how long it takes for any aches, pains or fatigue sets in. Try the same thing again in a sports shoe and take note of how you feel after an hour. Granted everyone will be affected differently, but chances are, walking in a sports shoe will be much more comfortable than flip flops.

This is because a sports shoe incorporates a higher degree of design features I mentioned earlier compared to flip flops (but fear not, there are supportive flip flops out there; more on that later).

So for ease of understanding, here are my top tips to help guide you when buying shoes:

Top Tips For Buying New Shoes

1. Listen to your body

It seems fairly simple, but we often ignore what’s staring us directly in the face (or feet). If you've been pain free but are now getting pain with your new shoes, there's a good chance the shoes are the cause. Most of us like buying new shoes, and even if we didn't, shoe designs change from season to season. What seem like minor cosmetic differences can affect how your feet feel at the end of the day. Change in to your old shoes. Still getting pain? If not, your new shoes aren't good as you thought they were.

2. Change your shoes regularly

You've had these great shoes for a few years and you've had no problems. Now all of a sudden your feet are starting to ache. What gives? Unfortunately, modern shoes are made from materials that deteriorate over time and use. This translates into decreased support of the foot, which can lead to overuse injuries. Most modern shoes will typically last between 1 to 2 years, depending on daily use. Even if they're used sparingly, Singapore’s climate can cause materials to spoil sooner than you think.

3. Size matters

Your feet grow with age. As does our weight. Increased weight along with general wear and tear will cause our feet to grow not only in length, but width. Get your feet measured correctly at a reputable shoe shop. UK, US and European sizing is all different. Even then it’s not uncommon to find that a size 42 from one company is a size 44 from another. So if you're finding your shoes no longer fit, it may be that sizing is wrong, or more likely, your foot has grown.

4. Support

Most shoes have some form of cushioning. But a lot of shoes don't have support. A good level of support makes it easier for your feet to function properly. Think of it this way. Try walking on wet sand at the beach. It feels nice and soft initially, but soon enough your leg muscles will start to become tired. Now try walking on the dry sand and notice how much easier it is. When your feet are unstable, your muscles require more effort to get the feet off the ground. A shoe (or flip flop) doesn't have to be rock solid to provide a good level of support. If the shoe bends slightly at the toe, feels firm when twisted and has a strong heel support then your shoe be good enough for your needs. If you can bend or twist the shoe with minimal effort, then it’s likely your shoe is going to cause problems for your feet. Your shoes don't have to be heavy to provide support. There are lightweight shoes that have a good level of support. Just bend and twist them to see for yourself.

5. Listen to your body

Even if you've followed the steps I’ve mentioned, the temptation is still there to squeeze your feet into a pair of shoes that may be a little bit small. That pair of Italian loafers you saw on sale. Or those tiny heels that look amazing. Tempting as it is, your shoes don't change size. Your feet do. Would you buy a jacket that was too small in the hope that it would expand so that one day it was finally comfortable? Most likely not, but there is still the common belief that your shoes will expand in time with enough wear and tear. In my experience this never happens. So instead you're left with a shoe that gives you numbness and blisters. Your shoes by their very design are meant to be comfortable. So as tempting as it is, go for comfort. If it feels tight, go for a half size bigger. Still too tight? Try a more conservative design. Rounded toe box, less of a high heel are a good place to start when finding a comfortable shoe. Too tight and there's a high chance of lasting injuries.

On a final note, no two feet are the same, so picking a shoe out isn't so straight forward as it seems. What works for your friend's feet isn't always going to work for you. But if the shoe feels comfortable, fits well and looks good, then go for it. If you're unsure then there's always expert advice on hand to help pick the perfect shoe for you.

Concerned about finding the right fit?

Please get in touch with us today and book a footwear assessment with our podiatry specialists.

Thanks for reading!

This post has been written by PhysioActive Podiatrist Greig Price B.Sc.

Thoughts or questions?

Leave a comment below, say hello on Twitter (@physioactivesg) or visit us on Facebook (

Running Shoe Buying Guide

Picking the right shoe is key to ensuring comfort, performance, and remaining injury free when you run. However, in today’s society where we are faced with rows upon rows of shoes displaying the latest technology, colours, special features and new fads, this can be an overwhelming task.Running Shoes

There’s no single 'best shoe' as everyone has different needs that must be met. Your biomechanics, weight, the surfaces you run on, and the shape of your feet means that one person's ideal shoe can be terrible for another. It is not uncommon for people to have several types of running shoe to suit all of their adventurous needs. In general, a pair of running shoes should last between 400 to 500 miles of running. Take a look at your shoes and check if the midsoles and outsoles are compressed or worn down- If they are, it may be time for a new pair.

There are several different categories of shoe available today, so to clear this up below is a round up of the different types you will see on those shelves.

Types Of Running Shoe

Motion-Control Shoes

They are good for over pronators, those with flat arches and are also a good choice for heavier runners. This category is the most supportive and controlling, and is designed to slow down excessive pronation. They tend to have a harder midsole on the inside of the shoe and a tough rubber outsole material. Due to this extra or denser material on the sole, they are generally heavier and slightly less flexible.

Stability Shoes

Stability shoes usually have reasonable cushioning with some midsole features (for example dual-density midsoles) to improve stability. They are often made with a semi-curved shape and suit most runners, especially neutral pronators. They are suitable for average builds and runners with normal arches.

Cushioned Shoes

Cushioned shoes are ideal for supinators, who wear the outside of their shoes, and for runners with high arches. These have a softer midsole and less support to encourage some pronation.

Racing/Minimalist Shoes

Minimalist ShoesThese shoes tend to be light, flexible, have little motion-control, stability or cushioning. The heel to toe drop tends to be smaller than the shoes above (<6mm) and they will wear quickly due to light thin rubber sole and thin midsole. They suit the lighter or more efficient runners who looking to do get a good run time. There is a risk of injury if you transition to these shoes too quickly.

Off-Road or Trail Shoes

These are very durable and have deep grooves in the soles to enhance grip. They tend to be a little heavy due to the soles and are ideal for off road running/ rocky trails.

How Do I Choose My Running Shoe?

So now you know what the different type of shoes are out there, you need to ask yourself some key questions before you hit the shops to make your choice as pain free, easy and accurate as you can:

1. What type of running will I be doing? E.g. Leisure, racing, triathlons, trails?

The type of running is important to determine the type of shoe to look at, as the shoes will provide different soles, weight, and support. For example, an everyday running shoe tends to have more support and a slightly thicker sole, compared to a racing shoe which tends to be lighter, and have a thinner sole, verses a trail shoe which tends to have larger treads and better grip.

2. What type of terrain will I be running on? E.g. Roads, trails, rocky terrain?

Again this will help determine the type of shoe necessary to ensure the support and soles are adequate for your needs. Trying to run on hard, rocky trails in racing shoes will cause damage and wear not only to your shoes, but to your body too, so adequate shoes are important for injury prevention.

3. What type of foot support do I need? E.g. Neutral, over pronation or supination?

Foot SupportShoe Wear Patterns

This depends upon your foot type and biomechanics, which can be determined by your podiatrist, physiotherapist or sports doctor. If you have an old, worn pair of running shoes, check the bottom of them to see the patterns of wear, as this can often provide a clue into your foot mechanics.

Some people need extra support if they have distinct biomechanical abnormalities with their foot type to reduce the risk of injury, or for extra protection when returning to sport from an injury. You need to determine whether you have a neutral, high or low arch, a wide or narrow forefoot or any additional support or protection your foot needs.

4. What is the heel to toe drop?

The drop of a shoe represents the difference between the height of the heel and the height of the toe. This is one element that can affect how your foot strikes the ground when you land and also load the tissue around the foot and ankle to different degrees. A low or medium heel-to-toe drop (zero to 8mm) promotes a forefoot or mid-foot strike and tends to increase the loading on the calf, achilles and plantar fascia, while a higher drop shoe (10–12mm) can promote more of a heel striking pattern.

Heel To Toe Drop

One thing to note is the heel drop size and degree of cushioning are independent of each other. It is possible to find ultra-cushioned shoes that still have a zero or low heel-to-toe drop, for example.

5. Do I currently or have I previously had a significant injury, if so was this through running?

It is essential to determine the cause of your initial injury (technique/ overuse/ poor foot wear etc.) and to correct this first with the help of your physiotherapist. Within the first 6 weeks of your injury, it is unwise to change footwear to run in, unless this was the cause of your injury. Secondly, if you have been experiencing foot/ ankle/ achilles or calf issues, it is recommended that you use more supportive shoes and refrain from using minimalist shoes until you have recovered.

6. Do the shoes fit and feel comfortable?

• Firstly, you need to be trying the shoes on in the same socks you will be wearing during your runs to ensure an accurate fit.

• Take the shoes for a test drive- get on a treadmill if there is one in the shop and try them out. Alternatively try jogging up and down the hall way to ensure they feel comfortable.

• The best time to shop for shoes is in the latter half of the day, when your feet tend to be at their biggest.

• Check for adequate room at the toe box by pressing your thumb into the shoe just above your longest toe. Your thumb should fit between the end of your toe and the top of the shoe.

• Check for adequate room at the widest part of your foot. The shoe shouldn't be tight, but your foot shouldn't slide around either and the outer part of the foot should not be hanging over the edge of the sole. The heel of your foot should fit snugly against the back of the shoe without sliding up or down as you walk or run.

• The upper (part of shoe that wraps around and over the top of the foot) should fit snugly and securely without irritating or pressing too tightly on any area of the foot.

• Lastly, they feel comfortable!

Now that you have taken the time to kit out your feet appropriately, it’s important to know how well you actually run in them. More often than not, we find in the clinic that it is the way that people run in their shoes and their running technique they adopt that has one of the biggest impacts on how they land and injury risk.

If you feel that your running technique may be at fault, get in touch to book a Biomechanical Video Running Analysis with our in-house running specialist at the clinic.

Enjoy your run!

Thanks for reading!

This post has been written by PhysioActive physiotherapist Jenny Johnson B.Sc (Hons) - Physiotherapist, Sports Therapist, Pilates Instructor, Dry Needling

Thoughts or questions?

Leave a comment below, say hello on Twitter (@physioactivesg) or visit us on Facebook (

PhysioActive Featured In Body and Soul Webisode

We’re pleased to announce that we have been featured in a webisode of ‘Body And Soul’, presented by Daniel Martin from 938 Live. The webisode is on the topic of foot care and stars our very own physiotherapist, Joel Bates (left) and podiatrist, Greig Price (right).


Filmed at our CBD (Raffles Place) clinic, Daniel Martin and his production team joined us for an exciting afternoon on 26th November 2014.

Joel uses the opportunity to highlight the two most common foot problems, before demonstrating a range of exercises including calf stretches, eccentric heel drops and toe curls.

Following on from Joel’s debut, podiatrist Greig discusses the importance of foot support, cushioning insoles and a correct walking technique, as well as discussing the drawbacks of wearing tight fitting shoes.

Click here to view the Webisode on

Behind the scenes:

Body And Soul - Behind The Scenes

What did you learn?

Let us know with a comment or tweet (@physioactivesg)!

If you have a podiatry issue that you’d like to address, please get in touch to book an appointment.