Having flat feet can destroy your knees: Many think wonky feet are a joke – but the effects are often crippling
01:00 GMT, 22 May 2012
Chronic pain: 'People don't expect a 34-year-old to have chronically bad knees,' said Arti Godkhindi
Pregnant with her first child, Arti Godkhindi was determined to do the right thing.
She walked for an hour each day, keen to stay fit and be prepared for childbirth.
What she didn’t anticipate was that her good intentions would leave her with permanent, disabling knee pain at the age of just 31.
The cause of her discomfort
Her flat feet — a condition affecting approximately one in five UK adults.
Like most people, Arti had no idea that flat feet, or indeed any foot fault, can put you at risk of serious damage to your knees if you put on weight (as a result of pregnancy or lifestyle).
At 5ft 7in and weighing about 10 st, Arti had always had a slim build.
Then the IT consultant from Staines, Surrey, became pregnant, and put on 2st.
Although she kept up with the walking, she found it hard to lose the extra pounds after her daughter Anika was born.
So two years after giving birth, Arti joined a gym.
‘I started gently, just going once a week for 20 minutes or so.
'But as soon as I tried to do any running or stretching, I felt this excruciating pain on the inside of both knees.
'I had to give up, which was frustrating because by then I’d managed to get back to my pre-pregnancy weight and the weight crept back.’
The pain gradually worsened over the next two years, to the point where Arti was unable to walk even a short distance.
‘I didn’t know what had happened or why. There had been no sudden injury and I didn’t overdo it at the gym.
'I didn’t think it was connected with my flat feet, as they had never caused me any problems before. My father also has flat feet and they never troubled him.’
She finally went to see her GP who referred her for an MRI scan. This revealed tears of the meniscus — tiny pads of cartilage which act as shock absorbers — within both knees.
At first, doctors thought she could have rheumatoid arthritis, but when she was referred to Dr David Jones, a rheumatologist at London Bridge Hospital, he diagnosed patellofemoral pain syndrome.
‘The patella is the medical name for the knee cap and patellofemoral pain syndrome is the term we use to describe pain at the front of the knee,’ explains Dr Jones.
‘It is most likely to develop during activities, such as when you climb stairs or try to run.’
The condition is one of the most common causes of knee pain and those most at risk are people who put on weight, either as a result of pregnancy or their lifestyle, he adds.
‘It is a particular problem for middle-aged people who become increasingly inactive and gain weight.
Arti now wears custom-made orthotics and gel-based shock absorbers and is having physiotherapy to strengthen the muscles supporting the knee
‘They may have been living with faults in the way they walk, such as overpronation — also known as flat feet (which cause the feet to roll inwards) — or supination, where the feet roll outwards. They manage perfectly well until there is weight gain.’
Flat feet or other faults cause you to carry your weight through the wrong part of the foot, he explains, setting off a chain reaction upwards through the body.
‘Where the knee cap connects with the thigh bone or femur, there is a V-shape groove, to help the knee cap glide up and down.
'If your feet roll inwards, the knee cap doesn’t move smoothly through this groove. We call this bad tracking and, over time, it leads to damage of the cartilage and pain.
‘Extra weight puts even more pressure on the knee cap. I often ask patients to consider how much several bags of sugar weigh and imagine the impact of an extra stone or more on their joints.’
The pain may often appear elsewhere in the body, says podiatrist Rina Bimbashi.
‘Many people with pain in their lower back, hip, knees and ankles are actually suffering due to flat feet.
'Diagnosis is often missed because people imagine if there is no pain in the foot, the foot is not the root cause.’
The pain triggers a vicious circle, adds Dr Jones.
‘Because there is pain, people don’t exercise, which means the muscles needed to support the knee — particularly the quadriceps and hamstrings —become weak, leading to more pain.
'Without exercise, there is also likely to be more weight gain, fuelling the pain.’
In pregnancy, the impact of the weight gain is compounded by the effect of hormones.
‘During pregnancy, there is an increase in three hormones — relaxin, oestrogen and progesterone — which soften the muscles and ligaments in preparation for childbirth, making them more flexible,’ adds Mrs Bimbashi.
The problem is that if, like Arti, you have mild to moderate degree of overpronation before pregnancy, the looseness of the ligaments means your feet can roll in even more.
As a result, you can end up with moderate to severe overpronation (the effects of these hormones are evident in ligaments and muscles for about five months after giving birth).
‘Pregnancy has a huge impact upon your whole joint alignment and your muscles and ligaments need to work much harder in order to maintain stability.
‘I commonly see women who have good, normal foot arches which collapse during pregnancy leading to very excessive pronation.’
Sometimes the problem doesn’t become apparent until you suddenly change what you do, such as taking up running — in Arti’s case it was going to the gym and the increased pressure on the knee that highlighted the damage. The bad news is that the damage is permanent.
‘Some people do need surgery to realign the knee cap, but this is a major procedure which would only be considered as a last resort,’ says Dr Jones.
‘Most people with this type of knee pain can avoid it, although there is no “quick fix”.
‘The focus needs to be on correcting the way you walk, doing prescribed exercises to strengthen supporting muscles and keeping active in ways that do not put excessive strain on your knees.
'If someone is overweight, the most important thing they can do is lose weight.’
Of course, prevention is better than cure — Mrs Bimbashi recommends people with flat feet choose their footwear carefully during pregnancy or if they put on weight.
‘If you are walking for more than 20 minutes or so, trainers are best — certainly not ballet pumps or flip-flops.
'Look for supportive trainers, such as sports designs, or if you wear fashion trainers, insert a three-quarter-length arch insole for extra support.’
She also advises all pregnant women with flat feet to buy over-the-counter insoles or custom-made orthotics.
These are worn in the shoe to support or correct the position of the foot during each step.
Arti now wears custom-made orthotics and gel-based shock absorbers and is having physiotherapy to strengthen the muscles supporting the knee.
She hopes this may enable her to avoid or postpone surgery — but a recent scan showed she has damage inside the cartilage at the back of her knee cap and she’s been told she is now at greater risk of osteoarthritis in her knee.
‘People don’t expect a 34-year-old to have chronically bad knees,’ says Arti.
‘But it is a disabling condition. I work in London but have to drive everywhere, because I cannot stand on a train or manage the escalators at many of the stations.
‘I can’t go to the gym either, but I am trying to get the right balance in my life so I am sufficiently active to avoid losing strength in my muscles and making things worse.
‘The hard thing is that I damaged my knees doing what I thought was the right thing during pregnancy — walking to keep fit.
'But I was in normal flat shoes such as pumps and trainers without any arch supports of shock absorbers.
‘I hope this helps to raise awareness, because flat feet are really common, and I didn’t realise this could happen during pregnancy.’