If you’ve ever been injured you may have been advised by your physician or therapist that your condition was in some part due to some physical imbalance or attribute. How important are some of these physical characteristics, such as foot arch height, in regards to the actual injury? Most are completely irrelevant though so many want to make some correlation between their presence and the complaint. Yet although there is no science to back up the treatment or advice, many still buy into certain ideas behind injury correction and prevention based off assumptions.
Heavy patients are often told that their weight either caused an injury or is contributing to their inability to heal. This is very common for those with low back, hip, and knee problems. Additionally, these overweight patients are told they need more shock absorption in their footwear.
For those who have a foot or ankle injury, the physician will often make a strong correlation between the height, or lack thereof, of the arch and its relationship to the injury.
And for anyone who has ever been to a chiropractor, physical therapist, or other body specialist, they most likely were told that the length of their legs had something to do with their pain or injury.
Developing a treatment and rehabilitation program around such issues often works out very unfavorably for the patient. Let’s learn why!
Arch Height: Overrated.
Arch height or length of the foot arch is rarely an issue when it comes to how well the foot functions and its susceptibility to injury. The base of support of the foot is much more important than whether the main arch of the foot, (the longitudinal arch), is high or low. The support system is naturally built into the foot, with the heel at one end of the arch at the forefoot and toes at the other end. An injured athlete many have lost the natural strength of their foot and perhaps some, or all, of the arch. So they are prescribed support devices such as arch supports and orthotics which unfortunately do nothing to actually strengthen the arch but rather “support” the middle of the arch resulting in further weakening of the arch and other areas of the foot.
There are two types of flat feet, rigid flat feet (RFF) and flexible flat feet (FFF). An individual with RFF has no arch at any time – weight or non-weight bearing. RFF is usually caused by some underlying pathology, which I will not discuss here as it’s not applicable to the content. (If you have RFF then you should be investigating the pathological problem.) An individual with an arch non-weight bearing which fatigues or collapses when they stand or the foot is stressed is said to have FFF. FFF is most often due to ligament laxity (the ligaments connecting the bones together have weakened) or due to muscle or tendon weakness. The tibialis posterior muscle has a major impact on the medial longitudinal arch as it provides much of its support. Therefore, a problem with this muscle can result in FFF as well as other problems associated with tibialis posterior dysfunction – shin splints, plantar fasciitis, and injuries associated with overpronation.
FFF, or some loss of the arch of the foot, is common in athletes who have foot and lower leg injuries. However, if the complete or partial loss of the arch has been present for some time, the athlete may not be able to redevelop this arch. But that doesn’t mean that the injury can’t be fully healed. Regardless of the regaining of the arch, full function can be achieved.
In 2009, Pediatrics published a study of 218 kids aged 11 to 15 and found “no disadvantages in sport performance originating from flat feet”. The kids who had flat feet accomplished all 17 motor skills as well as the group with “normal” feet. Another study of 246 US Army recruits found that trainees with low or flat arches actually had a lower risk of injury than those trainees with high arches during their 12-week infantry training. So again, you can’t make a correlation between arch height and function or even injury rates.
To strengthen your feet and lower legs to not just help prevent an injury but also naturally support your arches, follow the guidelines I describe in the article “Lose Your Shoes” and also check out the Sock Doc video on “Foot Strength & Rehab”.
Body Weight: Weigh More, Think Less.
Physicians and therapists love to tell their patients that either the reason they became injured or are not healing properly is because of their body weight. That means you’re fat and there’s supposedly “too much stress on your joints.” This is also common when a heavy person is advised on footwear; they’re told they need a heavily cushioned shoe to absorb their mighty impact. Both weight related issues actually have no weight. That pun is weak.
Most people who are fat often tend to be carrying around a lot of inflammation as they are body fat. So there is a correlation between the two. An over fat person is most likely to become injured and more likely to have trouble healing. And someone who is over fat most likely will have poor joint function too, from both this inflammation and from lack of proper muscle function. So yes, losing weight (fat) will help, but not because there is less stress on the joint. Simply consider someone who is as heavy but very muscular – isn’t there as much weight stress on their joints? Whether it’s fat above your torso or muscle above that same area, they’re both going to contribute to the same weight “stress” to your injured knee or foot. And let’s not forget the relationship between body fat, estrogen, and ligament health – it’s a big deal when it comes to healing joints.
How about more cushin’ (in your shoe) when you’re pushin’ (the miles)?
The answer to this is not only definitely no, but actually less cushion. Yes, the Sock Doc may have a habit of saying the opposite of the conventional “wisdom” but there is always a valid explanation why; at least I think so.
Peak forces while running actually occur in midstance, not when the heel hits the ground, where the shoe cushion is often most added. Joint torque and stress is highest when the foot is fully planted, with or without shoes. Cushioned shoes cause joints to work harder in midstance and this cushion response is out of sync with the natural increase and decrease of bodyweight through the gait cycle. It just doesn’t work.
So ideally the heavier the runner, the better gait there needs to be to decrease their chance of injury. Often thick, high-heeled, and cushioned shoes disrupt gait. In addition to a good gait, there needs to be less impact through the joints which will only occur if there is not a lot of cushion between the foot and the ground. So if you weigh too much you might want to think too little.
Leg Length: Short Side or Long?
Leg length is commonly evaluated by doctors and therapists who focus on structure. Chiropractors will often report to their patient that one leg may be longer than the other and it is a cause of some of their hip, lower back, or other area of pain. Physical therapists often will tell their patients that one side of their pelvis/hip is rotated anterior (forward) and this rotation is the root of their problem. The rotated pelvis will cause the leg to appear short and often the finding of a short leg has to do with a musculoskeletal imbalance of the pelvis.
Many of these therapists spend much, if not their entire treatment trying to equal out the leg length discrepancy, whether it’s a few millimeters or even several centimeters. They feel this is an abnormality that must be corrected as people should be symmetrical human beings.
Now of course you don’t want your pelvis shifted to the point where you’re off by a great amount, and thus your leg appears “shortened” by a centimeter or two. But achieving perfect balance of the legs alone often does not correlate with an improvement in symptoms, or rate of injury.
These leg length (and pelvis) imbalances are due to muscle imbalances, and the muscle imbalances are due to anything and everything that can negatively affect the nervous system. I’m talking about the physical, chemical/nutritional, and emotional stress that is discussed throughout the SockDoc site in relationship to poor health and injury. This is the cause of the problem, resulting in the symptom – in this case the sign, the perceived short leg of the injured athlete. It’s a correlation.
There is no need for us to be perfectly symmetrical to function optimally and be one-hundred-percent pain free. But again, I don’t want you to think a great asymmetry is necessarily okay; far from it. But there is too much focus put in the leg length discrepancy as well as the high or anterior rotated pelvis. Plus, it’s a very objective finding and can vary based simply upon how the patient is lying on the table or even differences in anatomical landmarks from left to right. Of course if their shoes are left on then that’s a factor too.
One last point on the leg length assessment is the infamous “heel lift”. Many docs and therapists use this to equal-out the leg or pelvis imbalance. Heel lifts make me cringe as much as orthotics. Now if someone truly has an anatomical leg length discrepancy due to an osseous (bone) disease during their growth years or they suffered some accident resulting in the actual loss of bone length, I can understand the use of a lift – sometimes. It depends on the situation. But most people are prescribed a heel lift for the above mentioned musculoskeletal imbalances and of course the heel lift is like putting a muzzle on a barking dog while you’re jumping on its tail.
Some therapists will put the lift under the “short” leg to make up the difference. Problem here is that the short leg is the side of the high pelvis, if you can picture that. If the lift is put under the longer leg, that would be the side of the lower pelvis, effectively raising the pelvis on that side to more even, but also providing a longer contact with the ground. Either way, they still do not correct the problem and often cause more imbalances and compensations.
So the lessons of this article are simple:
- Keep your body within a healthy weight to reduce inflammation on your joints and improve healing.
- Consider less shoe especially if you’re packing on the pounds.
- Don’t worry about your arch height but take note if it’s failing or falling.
- Don’t fret over a short leg or long leg being the cause of your injury but rather why you may have an imbalance somewhere in your body.
Another great article, thanks. Twelve years ago, I ran my first half marathon with a one-inch thick “heel lift” in my shoe as Id been told i had a short right leg. I cant believe I finished with that thing in my shoe..and went on to do many more races. I did, however, throw that lift away at the finish line.
If a person is born with flat feet or even a short leg, doesnt your body learn to compensate for the difference as you grow? As you say, adding hardware just muddies the waters when it comes to finding a cause for the pain/injury.
I have very high arches and have completely ruptured 2 plantar fascias in my right foot since beginning a minimalist running shoe program 2 years ago. Way too much way too soon lead to the ruptures. Doesnt the plantar fascia serve a purpose in supporting the foot and wouldnt i, who has been adapted to running with those fascias, need something to take their place….an arch support? I literally feel instant relief on the achilles insertion point when i insert a rigid arch support and it has me thinking “i want my plantar fascias back! “.
Sock Doc says
Yes you will adapt, (hopefully not compensate, but I know what you mean).
The arch support is simply supporting your weak feet because you have not properly figured out why they are weak – some hidden injuries in there most likely. I’ve seen plenty of people who have ruptured their pf and they don’t need artificial support.
Steven Sashen says
When people tell me they have a leg length discrepancy (and they almost always add something like, “and a doctor verified it.”), and ask if I can put a lift on a pair of Xero Shoes, I ask, “How long is a spring?”
When they answer that a spring varies and has no fixed length, I say, “Each of your legs is a spring. Running is just jumping from one spring to another, so your discrepancy is probably meaningless.”
I concede that this *might* be different when walking.
Oh, I just remembered when a FAMOUS sports medicine doctor told me that I shouldn’t be a gymnast because of my flat feet. I said, “Uh… but I’m one of the best tumblers in the world already.” (this was way back when)
Bill P says
Love this article and your comment Steven S.!!!
I can’t wrap my head around the idea that the short leg side is the one with the high hip. Can you explain this a little more?
Sock Doc says
Stand in front of a mirror and put one hand on the front of your hip, each side. Now raise one hip. When you do that, that same leg will rise off the ground, hence becoming the “shorter” leg.
So that reasoning would lead me to think that when a person has a short leg that may not have anything to do with the actual length of their leg bones but a twist or tilt in their pelvis?
Sock Doc says
Yes, and hence my message in the article.
ray mcclanahan says
Very good article Dr. Gangemi! Thank you for the excellent education!
Sock Doc says
Thanks Dr. Ray! Some of what I’ve learned regarding arch height and foot health is from you!
and thank you both for being the dynamic duo that got me functional (as opposed to being nearly in wheelchair) again! -cliff from san diego
Thank you so much for this very informative article, Doctor. I am so grateful for all I have learned through it. Wow I had no idea that the heavier one is, the less shoe cushion they need. I always thought it was opposite. I look forward to checking out your other articles you suggested about shoes. Thank you and God bless!!!
First thank you so much for your exceptional contributions to the world of fitness and nutrition.
I have a question, but I feel I should give you some background first. I am a person who found to love running after reading “Born to Run”. I have spent much time researching health and fitness. I have completely changed my diet, the shoes I wear, and especially the way I train. I have really tried to pay attention to my stress as well as what my body is telling me. I am training with a heart rate monitor and eating mostly a plant based diet.
So, I am 32 yrs old, run in minimalist shoes and have been running 6 – 9 miles in at a 7:45 pace with an avg. heart rate of about 145 bpm. I have been getting upper foot pain. as well as periodic foot pain in middle part of the outside of the underside of my foot. (hope that makes sense) Anyway, my doctor treats the symptoms and not the cause. Continually prescribes ibuprofen (that I don’t take) and just tells me to stop running (which I do) for the suggested amount of time only to be back at square one again. I think I may need to find some gait analysis or a doctor that treats their patients like you. I have used Google to try to find some leads in the N.W. Washington area, but really feel that I don’t know what I am looking at. Is there any suggestions you can give me to ask the doctor or clinic before I spend $400 and get no where. Thanks for all that you do. Take Care.
Sock Doc says
Please read this; thanks!
I’ve been searching this site for a while now and I can’t find anything on a painful arch. I don’t know what is causing it and I can’t seem to make it go away, the pain. When I walk barefoot, I feel a little ripping sensation in the outside of my arch or the in-side of my foot. Instead of curving inward it actually appears that my arch curves outward/sideways if I’m looking down at my feet. I believe my injury started when I was wearing five fingered shoes on an impromptu soccer game which ended up having my toes be higher than my heels, ripped or tore something, and I had severe pain in about four different places from my knee down to my foot. For weeks now I’ve been doing RICE which diminished the pain. I do have some tender spots where you point it out and your calf video and I’ve been trying to do exercises, but it is extremely difficult to raise up on my toes on my left foot and then if I walk I get the ripping sensation. Is there a way I’m supposed to be standing 2 support or strengthen my arch? Should I be forcing myself to stand on the outside of my foot or should I let my ankle role inward just standing?
Sock Doc says
Check out the plantar fasciitis video as well as the articles on foot health.
This question is for my neighbor (who is not internet savvy) so if it’s not as detailed as can be please ask and I’ll find out more information. She states that for 18years she has worn high-heel shoes during, and for, her fulltime job; and now her foot pain is so bad that on some days she literally crawls through her apartment. She has gone to several doctors over the years and like the majority of patients has custom orthotics. But since the pain persist her doctor now wants to operate. She tells me that not only does the doctor say she has flat feet but the cartilage in her feet has deteriorated; and what this operation will do is implant silicone into the bottom of each foot. The operation, from what she tells me, has either a 60 or 40% success rate (I can’t recall which number is correct) but everyone she has asked in waiting rooms at the doctors office tell her, “DON’T DO IT!” Now of course I can (and have) told her what you preach but the combination of foot problems, plus being so far along that her doctor says, “Have the operation or don’t come back,” all these combinations (plus fear) makes her feel she is a unique case; so can you please comment on these types of surgeries and provide some words of encouragement, to her personal story, if it be not too late (as the “doctors” claim).
Sock Doc says
Please read this; thanks!
Karen Eynon says
I am a fit 45 year old who until around 13 years ago was a 3 times a week jogger. I have been struggling with left sided lower back pain for over 13 years now and have tried EVERYTHING, chiropractic, osteopath, physio, sports massage, private podiatirst, National Health podiatrist and now I have finally been sent to an orthotocist who has prescribed a heel lift. I have worn orthotics (made to measure) for around 9 years which helped somewhat. It was always mentioned about my pelvis by chiropracters so now I’m wondering after watching your vid if this is actually the problem?
Now I’m just not sure what to do. I am a healthy weight (5’7″ and 149lbs) I Zumba once a week and walk my dog every day, I have an active job and would love to be able to run again.
Sock Doc says
Please read this; thanks!
Tina Flax says
My daughter is 9 years old and is competitive cheerleading and a part time gymnist. She has been having feet pain with little hard things that poke out on the sides of her feet when she tumbles. This has been happening on and off for about a year. Last fall she ended up with a pulled/torn tendon and took off 2 months of tumbling and did rehab. That seemed to help and heel the problem at the time. She has recently been having feet, ankle and now knee issues. I took her to a new Doctor and they did evaluation of her feet on this amchine and did some feet and lower back X-rays. They said her arches are collapsing (usually hereditory, according to them). From the scan they said she has moderate pronation of the right foot. Her index is 112. They said they can correct this by using very high end foot inserts. What is your thought? I actually have an sppointment on Friday to talk to the doctor to go over her x-rays because we have not done that yet.
Sock Doc says
Please read this; thanks!
I have been reading your site and as a new ‘athlete’ this is all a bit overwhelming to me. I began a regimin to loss weight two years ago. I wore improper shoes and began having PF pain after increasing ellipital use past 45 min. Spinning hurt as did yoga moves like warrior. I eventually bought good running shoes and began running. With in 5 months I completed my first 13.1. I was addicted but hurting. I developed patella tendonitis and was advise to wear night splints for my PF and a band for my patella. By this winter I was training for my second half and after some speed work and some hill work on curved roads I developed horrible pain in my ankles. I saw another sports doc who sent me to PT. I was giving heel lifts, orthotics and told I have leg length issues. Began feeling better, but then relapsed badly. Was put in a half boot for a month, then a full boot for a month. I finally had to take it off because after my MRI showed tendinosis of the peroneal brevis and longis and tibalis as well as tenosynovis I tried another two weeks and found my hips and other leg was beginning to hurt. After 2 weeks with out the boot back in PT I was feeling better. I was given cortisone patches and US treatments. I was pain free for a few days but then She did a heel manipulation and had me off the table in pain. i have been in daily pain for two days now. I am at a loss what to do. It has been almost two years of daily pain. I want to run again… I haven’t since March. I am frustrated and angry and don’t know where to turn to get help. Any clues where to start. I have spent over 1k this year in copays and as a military family this is a lot to put out especially without any relief! Any advice will be appreciated.
Sock Doc says
Please read this; thanks!
I hope u r still helping ppl out. I have flat feet both and they are FFF and I have been playing cricket and football regularly and lead an active life with daily dose of 15 min exercise and I have never experienced any pain though it happened occassionally after long matches my feet wud hurt. And now I’m gearing myself for armed forces and they too don’t require flat feet. Cud u plz suggest me what shud I follow. Cuz I was gonna buy orthotic and stumbled in ur site and now I ain’t buying it so I need to know wat shud I be doing.
Sock Doc says
Plenty of free advice on this site on what you can, and should not do, to strengthen your feet and the rest of your body. 🙂
Dorien Barone says
I am planning on walking 100km on the Camino Satiago and have started training and am having pain on the top of my right foot. Do you have any advice on how to train to a 20km walk a day.
Sock Doc says
Check out the Sock Doc Training Principles.
If you have scoliosis and a shorter leg, what course of action would you recommend? I’ve had orthotics for years but they do nothing. I was suggested to use a heel lift on the short side to balance me out. Not sure I buy into that theory but I can’t find anything thing to disprove it. How can you determine which leg is longer. My left foot is much flatter than my right so does that mean my right leg is longer? This is driving me nuts.
Sock Doc says
You’d really need to see a qualified therapist to go over those concerns fact to face.
hi i have had PF for the past year and have visited a podiatrist who has given me an insert,not only for the PF but a lift as i have a leg discrepancy of 8m this was last October but now i have chronic back pain do you think i should take the insert out to see if the pain eases? i have had this discrepancy all my life and only now has been given the lift that this back pain is here
Wow — useless advice. If you have pain up and down the entire kinetic chain of one leg, which i do, on the side on which i have a collapsed arch, SOMETHING is causing this pain. It is logical to start looking at the biomechanics of that foot and leg.
I’ve had the pain for years, but it is getting worse as i age. Custom orthotics, mbt rocker shoes, ankle strenthening exercises, accupuncture, PT, heat laser, focus on posture — NOTHING works.
Because NO ONE can actually pinpoint the root cause of my over-rotation, I have found NO relief in 6 months of trying.
Frustrating as hell!!
Dr. Stephen Gangemi "Sock Doc" says
If might try reading the article before you comment.
Great information! Thank you!!!
I fell off a bike at low speed about 1 year onto my PSIS/SI joint on one side. Unremarkable Xray and ultrasound of my pelvic area. Had some pain in my groin and inguinal ligament area, and low back, all to one side. Took a couple weeks off running, cycling, and general exercise and it felt a lot better. During the following 2-3 months the pain continued to subside, as I ramped my training back up to 30+ mi of running per week and 50+ cycling + cross training etc. What I failed to realize (even though in hindsight I saw the signs) is that I developed an antalgic gait during activity, and antalgic posture while standing around / static. I was even sleeping to one side in a new unique way (I’m guessing to lessen muscular/skeletal pain) and failed to act and correct all this before dysfunctional movement patterns became layered and embedded. It was just a matter of a couple months until I started having lower limb tendinopathy for the first time in my life, which appeared insidiously and continued to get worse regardless of treatment and completely curbing any athletic activity. My posterior tibialis tendon was slacking out, my arch was falling and my lower leg muscles, primarily calf were atrophying. I visited multiple GP doctors, consulted an orthopedic doctor, and a couple physical therapists. After months of diligently following PT instructions, wearing orthotics etc, the consensus was that I was being too active and not letting my injury heal and must not be following my treatment as prescribed. My life was revolving around healing this injury, doing everything I was instructed including wearing arch supports, and I was told I was continuing to run too much … when I hadn’t even run in many months! (Not new to activity, I’ve always been fairly athletic, as a kid hockey, football. soccer, baseball etc.. later skateboarding, snowboarding, surfing, distance runner for about 5 years, cycling forever on and on etc)
I had enough. I started seeking additional help outside the traditional paradigm, mainly self-help searching for info. Your page here is one that helped me discover more about what I was dealing with and although I am not completely healed (yet) the progression of my injuries has seemingly arrested, and seems to be reversing.
My pelvis appears “twisted”, making one leg appear functionally shorter, and as a result the arch is falling on the contralateral “longer” leg side to compensate. The side that the innominate bone is significantly rotated posteriorly, the leg is shorter. I have significantly less internal, and a bit less external rotation, and end range of rotation is slightly painful as opposed to “oh here’s the end of range” feeling that every other joint has ever had. It affects my gait when I walk, run, or even just standing on one leg or both my center of gravity is affected. When I ride a bike my sit bones both no longer touch the saddle at the same time unless I tilt my torso to the posteriorly rotated side, which throws off my balance while riding the bike, most noticeably when riding with no hands.
I hope this is all simply postural, muscular and maybe just a few ligaments involved. While in a way I feel lucky (and stupid for not intervening!) that I recall the progression of dysfunctional posture that took place in my case, hoping that knowing more about what I did, will help me undo it. How I started standing to avoid the pain in my hip, groin, and back. I stood deeply sunken into that hip, essentially almost all weight shifted to that side. (I see people casually stand like that in public, usually for short periods of time) How while consistently standing around like that for weeks and months, I later noticed it led to my contralateral femur externally rotating, followed even weeks later by that contralateral foot externally rotating and excessively pronating while standing around… At the time I was in denial or oblivious to the ripple effect down my kinetic chain, that’s around the time my posterior tibialis tendon started hurting after runs, I stopped training, and sought help. I initially only presented the ankle pain and arch issue as at the time I hadn’t yet holistically self-assessed I was unaware of having normalized this dysfunctional gait and hip posture that is now crystal clear. I was told my arch was starting to collapse “just because”, it was just a part of aging as an athletic big guy (6’3″ 200ish lbs under 35) and I would forever need arch supports / orthotics and need to stop being active (especially impact sports) to let it heal.
I should have known this bad sunken-into-my-hip-on-one-side posture (while standing, gravity… can also appear “hip hiked” and rotated at times) and related dysfunctions were going to get programmed into my movement and “stick” in my muscle memory… I am no longer using arch supports or orthotics, and working as hard as possible to reverse all this. It took many months to program all this dysfunction and cause injury, so I assume it will take many months to reprogram proper function back into my body and allow things to heal. I’m doing all kinds of core work and stretching/ straightening all kinds of muscles surrounding my lumbo pelvic hip complex to try to restore things and remove the gross asymmetry and unilateral atrophy that developed. About 30-40 types of stretches and exercises in a methodical and periodized order. Banded distraction, balance discs, foam rolling, tennis ball/soft ball/ jack knob trigger point and myofascial release… Certain muscles are unilaterally short and or tight all the time on the posteriorly rotated/short leg side(QL, Adductors, IllioPsoas, Rectus Femorus, Sartorious, Glute Med, Glute min, and others) I’m throwing everything I can at this to get my endurance sports and active lifestyle back. It’s been less than 2 months of all this self-help active correction, even with signs of progress sometimes I lose faith and think none of what I am doing is really working, that I’m doing more harm than good, or failing to address some underlying unidentified condition like SIJD, FAI hip impingement or something similar…
Again I really appreciate the information you have provided. Sorry for the long read, but hopefully some key words may steer others here for help too. In light of all my details, do you have any further advice for me, what I am experiencing, my self analysis, and my course of action to correct it?
Rupali Khiste says
So Dr you mean that leg length discrepancy is due to pelvic lift one sided? Is it not possible that pelvic got tilted due to leg length descrepancy and over pronation?
Dr. Stephen Gangemi "Sock Doc" says
Yes, that is most common. The pelvis can be tilted from some other source, or course, but true leg length discrepancy is not very common.