Fallen arches and flat feet: What the foot arch truly needs

Underlying mechanisms

The human foot skeleton is a complex masterpiece of biomechanics. It consists of 26 bones, numerous joints, and a finely tuned apparatus of ligaments, tendons, and muscles. The medial longitudinal arch extends from the heel to the ball of the hallux. It serves as a natural shock absorber that cushions multiple times one's own body weight with every step and stores energy for the push-off phase.

The bony architecture forms an arch whose apex is formed by the navicular bone, anatomically termed Os naviculare. This structure is supported by the talus, the calcaneus, and the first cuneiform bone. The passive supportive apparatus consists primarily of the plantar ligament, the plantar fascia, and the plantar calcaneonavicular ligament. In clinical terminology, this ligament is frequently referred to as the spring ligament, as it cradles the head of the talus like a cup and prevents it from sinking medially and plantarly.

Dynamic stabilisation is primarily provided by the tibialis posterior muscle. Its tendon runs behind the medial malleolus and inserts onto the underside of the midfoot. With every step, this muscle contracts, elevates the longitudinal arch, and realigns the calcaneus. This activity is complemented by the flexor hallucis longus tendon, the flexor digitorum longus tendon, and the intrinsic foot muscles.

A fallen arch, medically termed pes planovalgus, represents a preliminary stage or milder form. In this condition, the longitudinal arch flattens under weight-bearing, but realigns when non-weight-bearing. If the calcaneus simultaneously deviates outwards, this is referred to as valgus alignment of the heel. Flat foot, or pes planus, refers to the complete collapse of the arch. The plantar surface of the foot rests almost completely flat against the ground, altering the biomechanics of the entire leg.

Clinically, a distinction is also made between a flexible flatfoot and a rigid flatfoot. While a flexible flatfoot can be corrected through muscular effort or passive manoeuvres, a rigid flatfoot is fixed by bony coalitions or advanced arthritic changes. Precise differentiation is crucial for selecting appropriate therapeutic interventions.

Typical signs

An incipient fallen arch often progresses initially without marked discomfort. However, as the malalignment advances, characteristic symptoms appear that individuals should take seriously. A classic sign is a pulling pain along the course of the tibialis posterior tendon, which originates behind the medial malleolus and can extend down to the sole of the foot. These symptoms typically intensify after walking long distances or standing for prolonged periods on hard surfaces.

Overuse pain in the area of the plantar fascia and its insertion on the calcaneus is also common. The inward collapse of the foot continuously overstretches the plantar aponeurosis. In addition, impingement pain frequently develops on the lateral aspect of the foot, within the region of the sinus tarsi. This occurs when the calcaneus and fibula are compressed due to the malalignment.

An altered gait pattern is another clear sign. Affected individuals roll the foot excessively over the medial edge, leading to rapid wear of shoe soles in the medial region. In advanced stages, the silhouette of the foot changes visibly when viewed from behind. The examiner observes the so-called "too-many-toes" sign: due to forefoot abduction, more toes are visible on the lateral side from a posterior view than in an aligned foot.

Functional tests serve simple self-assessment and clinical podiatric assessment. In the single-heel-rise test, the person stands on one leg and attempts to raise onto their toes. If this is unsuccessful or accompanied by severe pain, it indicates weakness or damage to the tibialis posterior tendon. The Jack test, also known as the Hubscher manoeuvre, assesses structural flexibility: if the hallux is passively dorsiflexed while standing, the longitudinal arch should elevate via the windlass mechanism. If this elevation fails to occur, a more rigid form of malalignment is present.

These symptoms must be differentiated from isolated plantar fasciitis, where initial morning post-rest pain predominates, or tarsal tunnel syndrome, which presents with neurological symptoms such as tingling and numbness on the sole of the foot. A thorough podiatric examination provides precise clarification.

Causes in everyday life

The development of a fallen arch or flatfoot is rarely attributable to a single cause. It usually involves an interplay of genetic disposition, functional overload, and daily habits. Modern footwear is a significant factor. Shoes with rigid, inflexible soles, excessive cushioning, or elevated heels severely restrict the natural freedom of movement of the foot. The intrinsic foot muscles diminish in function because their workload is removed.

Likewise, a lack of variable surfaces plays a central role. Walking continuously on level, hard surfaces such as asphalt, tiles, or laminate hardly challenges the sensory system or fine muscular control of the sole. Consequently, the small muscles responsible for actively bracing the foot arches atrophy. The connective tissue becomes more pliable, preventing passive supportive structures from enduring continuous loads.

Obesity presents a substantial mechanical overload for the medial longitudinal arch. With every step, the spring ligament must support a higher load, leading over the years to gradual overstretching. Hormonal changes, such as during pregnancy or menopause, can also loosen collagen tissue and promote arch collapse.

Occupational stresses, such as standing for hours on concrete floors in retail, trades, or healthcare, strain the fatigue threshold of the foot musculature. Once the muscles are exhausted, the ligaments absorb the load alone. Over time, these give way. Improper load patterns during sport, such as increasing training volume too rapidly when running without sufficient recovery, also contribute to overloading the tibialis posterior tendon.

Finally, previous injuries, such as ankle sprains or midfoot fractures, can permanently alter biomechanics. If a ligament sprain does not heal fully, persistent instability remains, which negatively affects the arch structure.

When medical evaluation is required

Podiatric prevention and care are sufficient and highly effective in many cases. However, certain clinical red flags necessitate a thorough medical investigation by an orthopaedic surgeon or specialist doctor. These include a sudden-onset flatfoot that develops within a few days or weeks. Such an event frequently indicates an acute rupture of the tibialis posterior tendon.

Persistent resting pain, which continues at night while lying down, also requires prompt medical diagnostics. If marked swelling, redness, or localized heat occurs around the medial malleolus or the dorsum of the foot, an inflammatory process must be investigated. Neurological deficits such as numbness, burning, or tingling sensations on the sole of the foot likewise require specialist evaluation.

Particular caution is required in patients with underlying conditions such as diabetes mellitus, rheumatoid arthritis, or peripheral arterial disease. In these cases, structural malalignments can rapidly lead to dangerous pressure points, ulcerations, or, in the case of diabetic neuro-osteoarthropathy, known as Charcot foot, severe osseous changes. In these instances, podiatric care is always delivered in close coordination with the treating physician.

When passive correction of the arch is no longer possible and the foot remains completely rigid in malalignment, imaging modalities such as radiographs or magnetic resonance imaging should be utilized. Only through these can bony fusions or advanced joint changes be reliably assessed.

What podiatric treatment can achieve

Modern podiatry is a specialised discipline focused on the prevention, treatment, and rehabilitation of foot complaints. For a fallen arch or flatfoot, care always begins with a detailed medical history and a thorough visual and manual clinical examination. Static foot alignment standing, dynamic gait patterns, and skin and nail conditions are precisely analysed.

Due to altered pressure distribution with a collapsed arch, increased callus formation occurs at specific areas of the plantar surface. Painful hyperkeratoses or corns typically develop beneath the heads of the first and fifth metatarsal bones and along the medial heel margin. Within professional podiatric treatment, these excessive keratinisations are debrided painlessly using sterile rotary instruments and scalpel techniques. This leads to immediate, noticeable pressure relief.

An important component of the podiatric scope of practice is the fabrication of custom pressure and friction protection orthoses made from medical-grade silicone. These custom devices cushion malalignments, protect sensitive bony prominences, and optimise toe positioning. They are moulded precisely to the patient's foot, remaining durable and hygienically washable.

Furthermore, comprehensive patient education forms an extensive part of care. Podiatrists analyse patient footwear for torsional stiffness, fit, and cushioning properties. We provide specific recommendations on what to look for when purchasing shoes and explain the interplay between footwear, orthotics, and intrinsic foot musculature. When necessary, we advise on custom orthotic insoles and collaborate closely with medical supply stores.

Treatment intervals depend on clinical findings. For patients with a marked tendency towards hyperkeratosis or recurrent pressure points, a four- to six-week interval has proven effective. This maintains long-term skin health and allows early detection of structural changes in the foot. Find out more about our range of services in the section our services.

What you can do yourself

Passively supporting the foot with orthotic insoles alone is insufficient to stabilise a functional longitudinal arch in the long term. Active strengthening of the stabilizing muscles is essential. The following exercise program has proven effective in practice and should be performed daily for approximately ten to fifteen minutes.

1. Short foot exercise (Janda): Sit on a chair with feet parallel on the floor. Attempt to pull the ball of the hallux towards the heel without curling the toes. The longitudinal arch visibly elevates. Hold the contraction for five seconds and release slowly. Perform 3 sets of 10 repetitions per side.
2. Tibialis posterior strengthening with a resistance band: Sit on the floor with legs extended. Loop an exercise band around the forefoot of the target side and hold the ends securely. Invert and slightly plantarflex the foot against the resistance of the band. Perform the movement slowly and in a controlled manner. 3 sets of 15 repetitions.
3. Heel raises with a ball: Stand upright and squeeze a small tennis ball or fascia ball between your heels. Slowly raise your heels while actively squeezing the ball. This forces calcaneal inversion and activates the calf muscles as well as the tibialis posterior. 3 sets of 12 repetitions.
4. Calf muscle stretch: Stand facing a wall in a staggered stance. Keep the rear leg straight with the heel firmly on the ground. Push the pelvis forward until a distinct stretch is felt in the calf. Hold the position for 30 to 45 seconds per side. This reduces tension on the Achilles tendon and facilitates arch elevation.
5. Barefoot walking on varied terrain: Take opportunities to walk barefoot on grass, sand, gravel, or woodland floors. Uneven surfaces challenge the micromovements of the foot bones and naturally activate intrinsic foot muscles.

Consistency is more important than intensity in all exercises. Tendons and muscles require time to adapt to new stimuli. Initial progress usually appears after six to eight weeks of consistent training.

Common errors

In clinical podiatric practice, we regularly observe typical misconceptions and behaviors that can delay recovery or exacerbate pain. You should strictly avoid the following points:

• Relying exclusively on passive support: Relying solely on orthotic insoles causes foot muscles to lose further strength. Insoles provide support, but do not replace active exercise.
• Transitioning too rapidly to barefoot shoes or un-cushioned walking: Switching overnight from highly supportive shoes to prolonged barefoot walking on hard surfaces severely overloads the spring ligament and tibialis posterior tendon. The transition must occur gradually.
• Incorrect footwear choice despite insoles: Squeezing custom insoles into shoes that are too narrow or shallow creates high pressure on the dorsum of the foot and toes. This results in nail deformities, ingrown nails, and blister formation.
• Ignoring tendon irritation: Sharp pain on the medial aspect of the foot is often dismissed as harmless muscle soreness. Continuing high-impact sports despite tendon inflammation can cause irreversible tissue damage.
• Rushing into rigid soles without acclimation: New orthotics or orthoses must be worn in gradually. Begin with two hours per day and incrementally increase wearing time over two weeks.

Reliable clinical guidance helps avoid these pitfalls. Information regarding our practice concept can be found under about me and our practice.

Current research and clinical appraisal

Medical research provides clear evidence supporting the efficacy of conservative therapeutic approaches for flexible fallen arches and flatfeet, as well as tibialis posterior tendon dysfunction. A landmark study by Kulig et al. demonstrated that targeted eccentric training of the tibialis posterior muscle combined with a custom orthosis significantly reduced pain in patients with stage I and II tendon dysfunction and restored tendon load capacity [1].

In a long-term clinical study by Alvarez et al., a structured non-operative treatment protocol consisting of physical therapy, targeted exercise, and orthotic devices successfully prevented surgery in over 80 percent of patients with flexible flatfoot and tendon insufficiency [2]. The authors highlighted the importance of early intervention before bony fixation occurs.

Further research by Unver et al. investigated the effects of specific exercises for intrinsic foot muscles, particularly the short foot exercise. The results demonstrated a statistically significant improvement in arch height and a reduction in navicular drop in individuals with flexible pes planovalgus [3]. This underscores the role of active muscle training as a central pillar of therapy.

Additionally, Menz et al. examined the relationship between foot deformities, pain, and fall risk in older adults. Data clearly demonstrated that pronounced flatfeet correlate with impaired balance, an increased risk of falls, and knee joint complaints [4]. Timely podiatric and orthopaedic care therefore holds high preventive significance in geriatrics as well.

Treatment in Memmingen

At the FREITAG® Podologie GmbH practice in Memmingen, we offer patients from the Unterallgäu, Allgäu, and Upper Swabia regions a qualified, professional centre for foot health. Owner Helga Maria Freitag is a state-recognised podiatrist and, since March 2026, qualified as a sektorale Heilpraktikerin für Podologie (sectoral practitioner for podiatry). This additional qualification allows direct clinical assessment and initial diagnosis within podiatry without a prior doctor's referral.

Our practice at Kempterstr. 25 is modernly equipped and adheres to the highest hygiene and treatment standards. We combine classical podiatric treatment methods with innovative approaches such as cryotherapy to manage inflammatory processes and tissue strain effectively. If you have questions regarding your foot biomechanics or require professional debridement of pressure points, you can contact us directly at any time. Learn more about the legal framework and benefits of direct diagnostic assessment in the article sectoral practitioner.