What Happened To My Arch??

I cannot count the number of times over the past 22 years that patients have told me “I USED to have an arch, but not anymore”.  Is it true that you can actually lose your arch as you get older?  The answer: YES.  So what happens?  Many doctors attribute a loss of your medial arch height to a condition labled posterior tibialis tendon dysfunction or PTTD. Your posterior tibialis muscle lies deep under your calf and it’s tendon inserts into your midfoot.  It is responsible for turning your ankle inwards and “reinforcing your arch height.”

PTTD typically presents as a progressive increase in tendonitis pain which can lead to partial or complete rupture. The loss of PTT integrity has been hypothesized to produce a gradual change in the alignment of your foot. However, recent evidence shows that a partially torn or ruptured PTT is NOT the definitive reason for an adult acquired flatfoot.  Let me show you. A study by Yeap et al   followed 17 patients who underwent a surgical transfer of the PTT to a different part of the midfoot in order to control a drop foot. At a 5 year follow-up, none of the patients had a clinical flatfoot deformity. In other words, “losing” the PTT tendon by attaching it to a different part of the foot did NOT cause a flat foot.  In light of this one study, there is sufficient evidence to rebuke the PTT as the sole reason for an adult acquired flatfoot.

Another study by Deland et al   attempted to produce an adult acquired flatfoot in cadaver models by cutting the PTT. This produced only a minimal drop in height. It wasn’t until they severed the ligaments and plantar fascia on the underside of the arch that a complete arch collapse was achieved. Researchers Chu and Myerson confirmed the results of this study as well. So the evidence is here. A major contributing factor to the loss of arch height as we age is the loss of ligamentous integrity in the foot.

Did you know that women are 3 times more likely to be diagnosed with PTTD? It is most frequently found in women in their 50’s.  Although a definitive hormonal link has not been established, PTTD appears to peak during the perimenopausal period. An interesting study performed at USC in 2011  found that women with PTTD compared with a control group had significantly decreased endurance and strength of hip muscles. Strengthening your hips may help to strengthen your arch. More evidence that everything is connected!

Can you raise your arch by strengthening the muscles in your feet? Did you know that there are 18 muscles in the arch of your foot? What does the research tell us? In my previous article on running technique, I mentioned an article by Robbins who showed radiographic changes in arch height after runners ditched their shoes and started walking and/or running barefoot. This should be a very slow process, but many coaches and therapists advise walking barefoot on grass or sand as a starting point. Two other studies by Fiolkowski et al  and Headlee et al also show that when muscles in the arch weaken, the arch falls.

So what, specifically, can you do about your fallen arches?

Number 1 :  Custom Foot Orthotics. You need to control the pain and unload the injured structures first. We are attempting to control some of the mechanical imbalances by fabricating foot orthotics that “hug” your midfoot. We utilize both rearfoot and forefoot posting (angling of the orthotic) in combination with motion control shoes to control your excessive motion.  For more severe cases, some research shows better control of the twisting or internal rotation of the leg using braces such as ankle-foot orthoses.  The Richie Brace is one example.

Number 2:  Exercise!! Yes, it is very important. The articles above prove it. In order to “raise” your arch height with exercise, you need to be very consistent and compliant with your program.  I have mentioned HOW to exercise in a previous post. I want to emphasize that, if you have flat feet, your arches will fall every time you stand or take a step if you don’t train yourself to prevent it. This means using the appropriate intrinsic muscles in your arch in combination with active joint repositioning. If you can master this, you will be in a constant state of muscle retraining and joint stabilizing while bearing weight on your feet.

You could then add barefoot walking on grass or sand as an adjunct to your program. My next post will highlight the research on the muscle training effects of minimalist shoes such as the Nike Free.  Stay Tuned! Now, check out my videos on foot intrinsic training and an effective hip strengthening exercise called Clams.

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