When Cathedrals Crumble

Living with Flat Feet

“You ready?” my roommate asked me, pulling her coat on hurriedly.

“I’m … I’m not sure I’m going to come, actually.”

“Come on! How many times in your life will you get the chance to hear Seth Meyers speak?” she said, with a hand on the doorknob.

“I don’t know if it’s worth it. It’s far, and my feet are flat, and they hurt, and it’s not like it’s the Dalai Lama, or Beyoncé …” I rambled, knowing full well how lame I sounded.

She rolled her eyes at me. “It’s only a 15-minute walk and you already bought a ticket, but suit yourself.” And, shrugging, she walked out the door.

I know most people would roll their eyes at this excuse too, but people underestimate the importance of the foot’s arch. (If you are feeling the urge to roll your eyes yourself, you may take a moment to do so at this time.)

The foot has a very specific structure consisting of the ball of the foot and the heel, in between which is an intricate set of small bones that fit together in an arch.  This principle was fundamental to the architecture of gothic cathedrals.. In a cathedral’s arch, bricks are laid in a semi-circular array that comes to a central point at the top, called a keystone; by balancing opposing forces, the keystone directs the weight of the heavy roof down into the sturdy columns underneath, allowing the structure to stand. So too with the human foot—the bones are held together by springy material made of cartilage, tendons, and ligaments to make an arch, which distributes body weight throughout the foot and absorbs shock, thus supporting the weight of your body as you walk, run, jump, and stand.

The arch itself is supported by a series of tendons and ligaments. In a normal foot, a string of tissue called the posterior tibial tendon suspends the arch from the calf muscle like a chandelier, holding the arch in place and leaving the muscle and tendons underneath free and strong (see middle and back figures, right). In the foot of a person with flat feet, also called “fallen arches”, a damaged or defective posterior tibial tendon cannot properly support these bones, which crush the muscles and tendons below, disabling the function of the arch. The keystone falls down, leaving only a few bones instead of the whole arch to support the body’s weight. This, along with the accompanying tissue damage and inflammation, often leads to chronic pain. It can turn a mere 15-minute walk to see Seth Meyers into a daunting, painful task.

“Oh, I have flat feet too, but I just wear an orthotic that my doctor gave me and it works fine,” a friend once told me; this is the most common response I get from other people who have flat feet. It worked for them, so I simply must not have found the right shoe. This fallacy comes from the lack of a distinction between two variations on flat-footedness: flexible and rigid. My friend has flexible flat feet, the most common type. Flexible flat feet are distinguished by the foot’s ability to “reconstitute a nice arch when standing on tip toe” or while the foot is off the ground, and often causes no pain at all. When it does cause pain, orthotics or other forms of “arch supports … are used to help alleviate symptoms,” although they “do not correct or reverse the deformity.” Rigid flat feet, on the other hand, do not change shape, and are associated with a much more serious abnormality. For rigid flat feet, with which I was born, a hard orthotic only increases the pressure on the immovable, fallen bones, often intensifying pain rather than relieving it.

Studies have shown that “no specific types of shoes, arch supports, or braces … will lead to the development of an arch.” Why, then, do doctors continue to recommend orthotics and supportive shoes? It is true that it can help maintain an existing arch for flexible flat feet and alleviate pain. Yet doctors rarely consider the distinction between flexible and rigid flat feet until years of prescribing failed arch support treatments have gone by. I have spent the last 12 years of foot pain trying to convince my doctors and parents that the orthotic made for me by this or that doctor, or the hard one my mom bought me from the Walking Company, or the soft one with the raised heel, or the lace-up ankle braces, were actually making the pain set in faster and more intensely. Most of the time I am prescribed or recommended an orthotic without even getting an X-ray to see what my foot bones actually look like. One reason for this, I have been told, is that the doctors do not have much information about what type of surgery is appropriate, and that the new “fad” surgeries are risky at best. Another culprit, of course, is money. Orthotics and supportive footwear constitute a giant, multi-billion dollar industry in North America. Therefore, both doctors and manufacturers benefit financially from recommending orthotics, making providers even less likely to look into alternative treatment options.

The military has recently started to recognize these differences, despite the jokes surrounding the infamous “flat feet” exemption. Flexible flat feet no longer disqualify recruits from military service, since studies have shown no difference in pain or risk of injury between flexible flat feet and normal feet. Rigid flat feet, however, are still prohibitive—and speaking from experience, rightly so.

During my one week of Israeli army boot camp, I had to stand at attention for an hour-and-a-half straight; embarrassingly enough, I didn’t even make it halfway through! The first 10 minutes were pain free, but then I started to feel a vague sensation right where my arch is supposed to be, just medial to center, as if someone were pressing into the bottom of my foot a little too hard for comfort. By minute 15, a steady dull ache had set in, and by the 25-minute mark it felt as if a pair of porcupines were jumping underneath the earth, and each time they reached the top of their jump their hard needles poked through the ground and dug into the sole of each foot. I started to squirm in my spot, knowing I wasn’t allowed to move from the “at-attention” position, well aware that this was a losing battle. By minute 40, I finally caved and rolled onto the outsides of my feet, desperate for relief. I was then faced with the task of explaining to the army commander, in Hebrew, about my flat feet and how I couldn’t do what any able-bodied young person is expected to do—stay on their feet for more than 20 minutes without feeling like they’d be happier to die.

Though I know that my case is toward the severe end of the spectrum, it still surprises me that, given the prevalence of flat feet in general, its history is one of societal and medical neglect. No one medical profession has claimed responsibility for this issue, not even the orthopedic surgeons upon whom foot problems are officially dumped.

However, there was one American doctor in the mid 20th century named Simon J. Wikler, D.S.C. (Doctor of Surgical Chiropody), who did take this matter seriously and, through his research, discovered the consequences of footwear fashion. The general principle of his work is that, especially for children, “shoes should be worn outdoors only during inclement weather and indoors only for infrequent, dress-up occasions.” In other words, barefoot is better, and the more closely one can simulate walking barefoot on earth or sand, the better for having strong and healthy feet. Although Dr. Wikler did not realize that foot problems are incredibly multifaceted, and that the recoveries he was witnessing occurred most likely only in his flexible flat-footed patients, this idea generally holds true. Even people with rigid flat feet like me feel most comfortable with bare feet on soft ground, and not with hard, tall, plastic orthotics.

So, regardless of increasing awareness about the chronic pain associated with flat feet and the fact that one in four people in the U.S. will see a doctor for flat feet during their lifetime, this condition is still the laughingstock of ambulatory handicaps. But it hurts. It affects the choices I make. It leads to some awkward, embarrassing, and even disappointing moments. So yes, it sounds “lame” that I can’t serve in the army, but trust me—you don’t want to depend on me to keep up with you on the battlefield. And no, I can’t go to that Zumba class with you, and it’s not because I don’t want to be your exercise buddy—I just can’t jump for 45 minutes straight. And no … I couldn’t run in the Susan G. Komen 5K to support my grandmother after she was diagnosed with breast cancer, even though I really wanted to.

And yes, I will skip out on the Seth Meyers lecture because, funny as he is, I might not be able to laugh through the pain it would take to get there.