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.

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