Rethinking Flat Feet: Clinical Implications for Musculoskeletal Health

Historical Perspective

For much of the last century, clinicians and researchers believed that flat feet significantly increased the risk of musculoskeletal injury during sport and daily activities. This concept was reinforced in 1977 when Root and colleagues introduced the idea of the “ideal foot”. According to their model, feet that did not conform to certain structural criteria were labeled abnormal, less efficient, and more prone to injury due to biomechanical compensations.

This framework became embedded in professional training curricula and clinical reasoning, perpetuating the belief that flat feet represent a pathological risk factor. As a result, patients with asymptomatic flat feet have often been directed toward unnecessary interventions under the assumption that their foot type alone predisposes them to injury.

An editorial by Gabriel Moisan and colleagues from Canada published in British Journal of Sport Medicine in August 2023 challenged this view.

Flat Feet and Injury Risk

Evidence accumulated over recent decades challenges this long-standing assumption. Two meta-analyses identified only a weak association between flat feet and conditions such as medial tibial stress syndrome, patellofemoral pain, and non-specific lower limb overuse injuries. Beyond these limited links, no consistent relationship has been demonstrated. Further systematic reviews confirmed that flat feet are not a risk factor for running-related injuries.

Despite this, the belief that flat feet are inherently problematic persists. Peer-reviewed articles, professional websites, and grey literature continue to suggest otherwise, often recommending interventions such as orthoses or motion-control footwear for asymptomatic individuals. This practice not only misdirects clinical attention but also fosters unnecessary concern among patients about their foot appearance or function.

Overdiagnosis and Overtreatment

The issue of overdiagnosis is increasingly recognized as a critical challenge in modern healthcare. Overdiagnosis occurs when a condition is identified that does not provide net benefit to the patient, leading to potential harm—physical, psychological, and financial. In the case of flat feet, overdiagnosis frequently results in overtreatment, reinforcing patient anxiety and diverting resources away from more meaningful interventions.

Clinicians must therefore differentiate between benign anatomical variation and conditions where altered foot morphology is truly clinically relevant. For example, an acquired flat foot is a hallmark of advanced posterior tibial tendon dysfunction, and in this context, morphological assessment is appropriate for staging and monitoring disease progression.

Clinical Relevance: Beyond Morphology

The current evidence base suggests that assessing foot type as a general risk factor for injury is of limited value. Instead, musculoskeletal health should be understood through a broader, multifactorial lens, which includes:

• Tissue capacity and load tolerance
• Movement and kinetic chain interactions
• Psychological and social factors influencing pain and performance

By shifting focus away from foot shape alone, clinicians can better tailor prevention and rehabilitation strategies to the individual.

Conclusion for Practice

Flat feet, when asymptomatic, should be regarded as a normal anatomical variant, not a deformity requiring treatment. Relying on foot type as a predictor of injury risk is neither efficient nor clinically useful.

For therapists, the key message is clear:

• Abandon outdated beliefs about flat feet as an inherent pathology.
• Avoid unnecessary interventions for asymptomatic individuals.
• Apply sound clinical reasoning that integrates tissue health, loading strategies, and psychosocial context to guide treatment.