A major problem with all of the studies evaluating the correlation between arch height and injury is that none of them takes into consideration the protective effect of foot strength.
A growing body of research is showing that even if you have extremely low arches, you are significantly less likely to be injured if your feet are strong.
While conventional treatment strategies for people with high and low arches have often focused primarily on the use of orthotics, several studies have shown that you get the best clinical results when you couple orthotics with foot exercises.
The belief that people with low arches are more prone to injury dates back to the late 19th century, when the surgeon Royal Whitman first described the “pathological flatfoot,” which he correlated with pain, excessive pronation and difficulty walking. Over the past 100 years, there have been numerous articles confirming Whitman’s early research showing that people with low arches have poor balance, impaired athletic performance, and are more likely to fall as they get older.1-4
Importantly, it’s not just people with low arches who are injury prone, as research shows that high-arched people are more likely to have rigid feet and are predisposed to high-impact injuries, such as stress fractures and lateral ankle sprains.5-6
But despite numerous papers showing a strong clinical connection between arch height and injury, several studies have questioned the connection.
Flawed Research Suggesting Arch Height Is Not Connected to Injury
In their 2023 editorial published in the British Journal of Sports Medicine, Moisan, et al., stated that “flat feet should be considered as healthy anatomical variants” and that the connection between arch height and injury is an “outdated” notion that needs to be abandoned.7
In the most frequently referenced paper questioning the clinical significance of arch height, Messier, et al.,8 performed a two-year prospective study on 300 runners and determined that contrary to long-held beliefs, arch height is in no way correlated with an increased risk of injury.
Unfortunately, the authors of this study used footprint measurements as a surrogate measure of arch height, which has been proven to be invalid predictors of arch height. Several studies have shown that footprint measurements do not correlate with X-ray measurements of arch height9 and are prone to error, as people with high BMI and/or muscular feet can be incorrectly classified as having low arches even when they have neutral arches.10
Obviously, classifying someone with a neutral foot as a low-arched individual would make it impossible to correctly identify injury risk associated with arch height.
In another frequently referenced paper suggesting arch height is not correlated with injury, Nielsen, et al.,11 used the Foot Posture Index to categorize 927 novice runners as having one of five foot types: extremely low arches, slightly low arches, neutral arches, slightly high arches, or extremely high arches. Once classified, runners began a 12-month running program while being monitored for injuries.
At the end of the study, the authors found no correlation between arch height and injury, except for the unexpected finding that people with slightly low arches were less likely to get injured than people with neutral arches.
Although this paper has been cited over 200 times as proof that there is no correlation between arch height and injury, the authors fail to emphasize they found a robust connection between extremely low arches and injury, as every runner possessing this foot type was injured almost immediately. In fact, not one of the athletes with extremely low arches was able to complete the one-year training program.
The authors claim they did not emphasize the high injury rate in this population because only 2% of the runners in their study presented with extremely flat feet, so the sample size was too small to make adequate conclusions. Apparently, because the authors did not allow people to participate who had previously worn orthotics, the extremely low-arched group was statistically underpowered, making it impossible to draw accurate conclusions about the effect of extremely low arches on injuries.
Research Showing Arch Height Is Connected to Injury
In 2019, researchers from Spain repeated the Nielsen study, this time including a sample population of 600 novice runners in which 11.2% possessed extremely pronated foot postures.12 Using the same Foot Posture Index to identify foot architecture used in the Nielsen study, Pérez-Morcillo, et al.,12 performed a logistic regression model to evaluate the correlation between arch height and injury.
Using this detailed model, these authors showed there is a powerful connection between arch height and injury: Runners with extremely low arches were 20 times more likely to be injured than people with neutral foot postures, and runners with extremely high arches were 76.8 times more likely to be injured.
The authors of this study also point out that in contrast to Nielsen, et al.,11 slightly low and slightly high arches were also associated with an increased risk of running injuries compared to a neutral foot.
The Overlooked Importance of Foot Strength
Though rarely discussed, a major problem with all of the studies evaluating the correlation between arch height and injury is that none of them takes into consideration the protective effect of foot strength. This is unfortunate, as a growing body of research is showing that even if you have extremely low arches, you are significantly less likely to be injured if your feet are strong.
This was clearly demonstrated in 2019, when Zhang, et al.,13 used ultrasonography to show that people with painful flat feet had considerably smaller abductor hallicus, flexor digitorum longus and peroneal muscles than people with low arches who were pain-free. (Fig. 1)
FIG 1 The flexor digitorum longus (FDL) and quadratus plantae muscles (QP) are considerably thinner in people with symptomatic flat feet. These muscles are important in stabilizing the arch in people with flat feet because recent research shows that unlike people with neutral arches, people with low arches tend to have a convex base to their fourth metatarsal (A), which allows the midfoot to collapse as the outer metatarsals move upwardly during propulsion (curved arrow). 20 To prevent this upward motion, FDL creates a compressive force along the lateral metatarsals (B) that prevents the midfoot from collapsing during propulsion. According to Dygut, et al.,21 FDL is the only muscle capable of stabilizing the fourth and fifth metatarsals.
In 2025, Haelewijn, et al.,14 evaluated three-dimensional motion and muscle volume in people with symptomatic and asymptomatic flat feet; they determined that flexor digitorum longus and quadratus plantae were considerably thinner in people with symptomatic flat feet. Per the authors, “our findings support a shift from structural assessment towards performance-based clinical evaluations.”
Note that weakness of the flexor digitorum longus is easily evaluated using a toe strength dynamometer, which has excellent interrater reliability.15
Help Patients Prevent Injury and Improve Performance
Given the recent research showing a connection between foot strength and injury, low-arched individuals with weak feet should begin an aggressive foot strengthening program. A recent study out of Brazil showed that simple foot strengthening exercises performed for just eight weeks resulted in a 240% decreased rate of running injuries over the following 12 months.16
Foot strengthening exercises are particularly advantageous for individuals with low arches. Sulowska, et al.,17 demonstrated that, in comparison to those with neutral arches, people with low arches experience more significant improvements in running speed and power following structured foot strengthening interventions.
Strengthening should also be considered for individuals with high arches, as they often present with weakness in the peroneal muscles that can easily be addressed with specific exercises.
While conventional treatment strategies for people with high and low arches have often focused primarily on the use of orthotics, several studies have shown that you get the best clinical results when you couple orthotics with foot exercises,18-19 which are inexpensive and easy to perform.
References
de los Ángeles Gómez-Benítez M, Gómez-Benítez A, Ramos-Ortega J, et al. Fatigue in children with pronated feet after aerobic exercises. J Am Podiatric Med Assoc, 2021 Mar 1;111(2).
Bresnahan PJ, Juanto MA. Pediatric flatfeet - a disease entity that demands greater attention and treatment. Front Pediatrics, 2020 Feb 11;8:19.
Fu F, Wang S, Shu Y, et al. A comparative biomechanical analysis the vertical jump between flatfoot and normal foot. J Biomimetrics, Biometerials Biomed Eng, 2016;48:26-35.
Menz H, Lord S, Fitzpatrick R. A structural equation model relating impaired sensorimotor function, fear of falling and gait patterns in older people. Gait Posture, 25:243-249.
Williams D, McClay I, Hamill J. Arch structure andinjury patterns in runners. Clin Biomech, 2001;16:341-347.
Williams D, McClay I, Hamill J, Buchanan T. Lower extremity kinematic and kinetic differences in runners with high and low arches. J Applied Biomech, 2001;17:153-163.
Moisan G, Griffiths I, Chicoine D. Flat feet: deformities or healthy anatomical variants? Brit J Sports Med, 2023 Dec 1;57(24):1536-7.
Messier S, Martin D, Mihalko S, et al. A 2-year prospective cohort study of overuse running injuries: the runners and injury longitudinal study (TRAILS). Am J Sports Med, 2018 Jul;46(9):2211-21.
Colbey J, Sella E. Standardizing methods of measurement of foot shape by including the effects of subtalar rotation. Foot Ankle, 1981;2:30-36.
Wearing S, Hills A, Byrne N, et al. The arch index: a measure of fat or flat feet? Foot Ankle Int, 2004;25:575-581.
Nielsen R, Buist I, Parner E, et al. Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study. Brit J Sports Med, 2014 Mar 1;48(6):440-7.
Pérez-Morcillo A, Gómez-Bernal A, Gil-Guillen V, et al. Association between the Foot Posture Index and running related injuries: a case-control study. Clin Biomech, 2019 Jan 1;61:217-21.
Zhang X, Pauel R, Deschamps K, et al. Differences in foot muscle morphology and foot kinematics between symptomatic and asymptomatic pronated feet. Scand J Med Sci Sports, 2019 Nov;29(11):1766-73.
Haelewijn N, Staes F, Vereecke E, Deschamps K. From structure to function: Biomechanical markers of symptomatic flatfoot during running and a single leg drop and hop. Clin Biomech, 2025 Oct 14:106682.
Xu J, Goss D, Saliba S. A novel intrinsic foot muscle strength dynamometer demonstrates moderate-to-excellent reliability and validity. Int J Sports Phys Ther, 2023 Aug 1;18(4):997-1008.
Taddei UT, Matias AB, Duarte M, Sacco IC. Foot core training to prevent running-related injuries: a survival analysis of a single-blind, randomized controlled trial. Am J Sports Med, 2020 Dec;48(14):3610-9.
Sulowska I, Mika A, Oleksy Ł, Stolarczyk A. The influence of plantar short foot muscle exercises on the lower extremity muscle strength and power in proximal segments of the kinematic chain in long-distance runners. BioMed Res Int, 2019;2019(1):6947273.
Kirmizi M, Sengul YS, Akcali O, Angin S. Effects of foot exercises and customized arch support insoles on foot posture, plantar force distribution, and balance in people with flexible flatfoot: a randomized controlled trial. Gait & Posture, 2024 Sep 1;113:106-14.
Shim SR, Kim JY, Shin J, et al. Optimizing flatfoot management with foot orthoses: a systemic review and meta-analysis. Am J Phys Med Rehabil, 2025 May 12:10-97.
DeSilva JM, et al. Midtarsal break variation in modern humans: functional causes, skeletal correlates, and paleontological implications. Am J Phys Anthropol, 2015;156(4):543-552.
Dygut J, Piwowar M. Muscular systems and their influence on foot arches and toes alignment - towards the proper diagnosis and treatment of hallux valgus. Diagnostics, 2022 Nov 25;12(12):2945.
It’s a new year and many chiropractors are evaluating what will enhance their respective practices, particularly as it relates to their bottom line. One of the most common questions I get is: “Do I need to be credentialed to bill insurance, and what are the best plans to join?” It’s a loaded question – but one every DC ponders. Whether you're already in-network or pondering whether to join, here's what you need to know.
The term tongue tie or ankyloglossia is well-known to all pediatric-focused chiropractors. In the past 15-20 years, the prevalence of this diagnosis has skyrocketed. What this means to the pediatric chiropractor is that we are seeing breastfeeding babies in much greater numbers in our offices. Parents are seeking our help with this mysterious “tongue tie,” as are lactation consultants, pediatric dentists and many other members of the breastfeeding care team. Let’s look at some clinical aspects of this scenario that are well within the chiropractic scope.
The first article in this series discussed the chiropractic approach to squaring off the geriatric aging curve: the steps to reduce the steady decline in vitality that occurs with aging. The research is clear that strength, agility, flexibility, and cardiovascular fitness are all synonymous with longevity. Now let’s discuss seven low-tech exercises to promote lifegevity – squaring off the geriatric curve.
