The optimal arch height for a patient with functional flat foot may depend on the goals of

orthotic management. Studies suggest that arch height directly affects excessive motion,
but that controlling dynamic balance may require a more tailored approach.
By Stephen D. Perry, PhD, E. Anne Cunningham, Msc, CPed, and Kelly M. Goodwin, BSc
The interaction between the foot and its environment is critical in all forms of gait. During running,
the foot provides a flexible landing structure that is adaptable for placing and accepting weight
during initial contact. Then during push off, the foot provides a rigid structure to permit the
transmission of forces created by the lower leg muscles to propel the body forward. In walking,
the forces are much smaller, but now the foot acts as a neuromechanical conduit that provides
both sensory information and the transference of mechanical forces to maintain the body’s
stability. All of these functions occur in all forms of gait, but the prominence or importance of
each of these roles is determined by the type of gait considered. Due to the importance of this
type of interface between the foot and its environment, the application of in-shoe foot orthotics is
critical to preserve these functions.

Flatfoot deformity or pes planus is the most common foot pathology in patients of all ages.1 The
deformity may be associated with discomfort and pain, instability, serious foot, ankle, knee, and
lower back joint problems, misalignments, and postural strain. However, individuals with this
deformity can also be non-symptomatic. Within pes planus, the functional (sometimes termed
“flexible”) flat foot (FFF) is defined as a hypermobile foot with excessive hindfoot valgus and
minimal medial-longitudinal arch height when weight bearing (Figure 1A; arch is evident when
not weight bearing, Figure 1B).1 Most often, FFF is treated with custom orthotics to aid in arch
realignment and to provide stability. The research that will be discussed here will look at two
aspects of gait; one will be the kinematics of the lower leg and foot, during running, exhibited by
individuals with functional flat foot when an arch support is used. The other will be the impact of
these arch supports, worn by the functionally flat footed individuals, on dynamic balance control
during walking.

Indications for orthoses

Figure 1A

Currently, orthotic prescription is recommended for individuals with symptomatic FFF in order to
control the excessive motion of the lower extremity during running. The main reason that
orthotics for FFF individuals are targeted to control motion during running involves the higher
forces experienced during running, which may cause more motion and injuries/pain.2 Even so,
the orthotics recommended could be used in other activities. There is general agreement in the
literature with respect to the clinical effectiveness of orthotic intervention among runners. In
particular, the use of foot orthotics has been positively associated with patient satisfaction2,3and
pain reduction,3-6 enabling individuals to return to running.2 Currently, researchers are attempting
to understand the mechanism by which orthotics produce these encouraging symptomatic
reductions. It has been speculated that orthotics may realign the lower extremity, decreasing the
excessive motion of the rearfoot and tibia that is typically seen among individuals with FFF.7-
9 However, it seems that for every study that indicates a positive mechanical effect of orthotics in
reducing excessive motion of the lower extremity,4, 7-10 there is a study reporting that orthotic
intervention has no such effect.4,10-13
With regard to dynamic balance control during walking, the only studies that could be located
involved cadaveric models and the application of orthotics in static situations. As we age,
unintentional falls cause debilitating injuries. Although falls are complex and many factors are
involved, footwear and foot problems play a major role in the control of balance to avoid
falls.14 Imhauser and colleagues15quantified and compared the efficacy of orthoses in the
treatment of flatfoot deformity of cadaveric models in a static

Figure 1B

situation and determined that orthoses stabilize and restore the medial longitudinal arch.
Furthermore, Kitaoka et al16 demonstrated a significant improvement in arch alignment and
structural alignment of the lower limbs with the use of orthoses in cadavers. Given the limitations
of the literature, however, the transferability of the findings has little clinical value as all studies
have focused primarily on static conditions.
Our current ongoing research interests include foot function,17,18 footwear,19,20 and orthotic
interventions,21,22 including studies of functionally flat footed individuals. These individuals were
deemed eligible to participate in these studies if they met predetermined functional flatfoot (FFF)
criteria (these criteria were predetermined in consultation with a certified pedorthist and have
been reported elsewhere (Cunningham and Perry, submitted)). In addition, all participants
completed a screening questionnaire and were excluded from the study if they demonstrated any
neurological or physical condition that affected the use of their lower extremity. Ethics approval
for these studies was received from our institutional ethics review board.
All participants (running study n=19 and walking study n=10) were functionally flat footed
bilaterally with little or no pain. Each subject had both their feet casted in a subtalar neutral
position by a pedorthist. The research studies presented here both utilized arch inserts (Figure
2). Each participant’s subtalar arch height was determined by aligning a ruler at the medial edge
of both the first metatarsal and heel regions, then measuring the height from the medial edge of
the ruler down to the casting along a vertical axis (Figure 3). Arch inserts of 0%, 33%, 66%, and
100% of the subtalar neutral arch height were created for each participant (Figure 4).

Kinematic study
 Figure 2A

In the running study, athletic tape was used to adhere the arch supports to the plantar surface of
the foot, specifically to the medial longitudinal arch. Participants reported that the taping
technique did not limit normal movement of the foot. In the walking study, participants were sized
and fitted with identically styled laboratory walking shoes (Rockport, World Tour Classic Model;
Canton, MA) and custom-sized, flat insoles with the arch inserts adhered to them (Figure 3). In
both studies, arch inserts of different heights were worn in random order during experimentation.

The running study had each participant run at a velocity of 2.0 m/s and 3.0 m/s on a treadmill
while three-dimensional angular kinematics were recorded using multiple infrared markers placed
on the lower leg and foot. Kinematic variables measured included rearfoot angle (frontal plane
motion of the foot relative to the leg) and tibial rotation (relative rotation of the lower leg about its
long axis). Both measures were represented relative to a static standing trial. Each participant
ran with each of the arch inserts adhered under the medial arch during both velocity conditions.
All participants were physically active but not competitive runners.

Figure 2B

The results from the running study (only data for the 2.0 m/s velocity condition are presented)
suggest that as the degree of orthotic intervention (arch insert height) increased, there were
significant (p < 0.001) decreases in maximum rearfoot angle and maximum internal tibial rotation
angle among this population (Figure 5). However, rate of rearfoot motion and rate of internal tibial
rotation were not affected.

Dynamic balance study

The walking study had each participant walk across a series of inclined platforms that simulated
uneven surfaces (described by Perry et al23) in order to test dynamic balance control. A 21-
marker setup was used to estimate the three-dimensional motion of the center of mass (COM) of
the body and the base of support (BOS), defined as the contact surface of the feet. Dynamic
balance control was determined by measurement of the lateral stability margin, as defined by the
distance (in the transverse plane) between the lateral border of the BOS and the position of the
COM during the single support phase of gait (as described in Perry et al18) Again, each
participant had each arch height placed on the blank insole and then into the standard footwear.
 Figure 2C

Increases in arch insert height were associated with demonstrated statistically significant
changes in dynamic stability. The greatest improvement happened at the 66% arch height
(Figure 6). During the single support phase of gait, subjects wearing the 66% arch height insert
exhibited the lowest maximum and highest minimum values for medial-lateral COM-BOS
difference (p < 0.04).

The decrease in rearfoot angle (commonly referred to as a good indication of foot pronation24)
and internal tibial rotation (which has been shown to have a tight relationship with foot
pronation25) with increased orthotic intervention (arch insert height) during running demonstrates
the direct link between orthotic height and foot/leg mechanics. However, without an associated
significant decrease in the rate of rearfoot angle and rate of internal tibial rotation, the exposure
of the lower extremity to quick angular change, which is thought to be a major contributor to
injuries, may not be reduced to the extent that had been expected. The results of the walking
study indicate that individuals with functional flatfoot experience increased dynamic stability when
wearing arch inserts that are 66% of their subtalar neutral arch height.

Conclusions
These findings emphasis that orthotics are effective in reducing the motions of the foot and lower
extremity in FFF individuals. They also indicate that an incremental increase in orthotic height
does have a direct relationship to how much change will be observed in terms of maximum
rearfoot and tibial internal rotation angles.

Figure 3

Additionally, our findings suggest that the more complex area of orthotics and dynamic balance
control does not seem to be as straightforward. Rather than a direct relationship, each individual
may have an optimal orthotic height that provides optimal dynamic balance control. These two
studies suggest the importance of giving consideration to both the benefit of reduced foot and leg
motion and the optimization of dynamic control. Either of these mechanisms, excessive motion or
a loss of balance, could result in a disabling injury.

Stephen D. Perry, MSc, PhD, is an associate professor in the department of kinesiology &
physical education at Wilfrid Laurier University in Waterloo, Ontario, Canada. E. Anne
Cunningham, MSc, CPed is a pedorthic intern in Waterloo, Ontario. The running studies were
part of her MSc at Wilfrid Laurier University. Kelly M. Goodwin, BSc, MD (candidate) is a medical
student at the University of Ottawa. The dynamic balance studies were her BSc senior thesis
project at Wilfrid Laurier University.

Figure 4

Acknowledgments: This work was supported by an operating grant from the Canadian
Institutes of Health Research (MOP-77772) and equipment was supported by the Canadian
Foundation for Innovation, the Ontario Innovation Trust and Wilfrid Laurier University.
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Figure 5
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Figure 6

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Figure Captions
Figure 1: A. Demonstration of arch collapse during weight bearing, B. Evidence of arch formation
without weight bearing.

Figure 2: A. Medial view of arch insert, B. Medial-Superior view of arch insert, C. Superior view of
arch insert.

Figure 3: Determination of arch height from subtalar neutral foot cast.

Figure 4: Arch inserts placed on custom-fit insoles.

Figure 5: Effect of orthotic intervention on rearfoot motion and internal tibial rotation while running
at 2.0 m/s.

Figure 6: Effect of orthotic intervention on maximum and minimum centre of mass-base of

support (COM-BOS) in the medial-lateral direction.