There are two primary reasons why someone would have a flat foot.

1. Medial Column Hypermobility

(Figure 1) In some individuals, the inner part of the foot (the
"medial column") has too much motion. The medial column is
essentially the inside part of the foot - all the structures in the foot
that line up with the big toe. When the medial column is floppy the
base of the great toe fails to take its share of the weight during gait,
allowing the arch of the foot to collapse.
Figure 1: Medial Column Hypermobility

2. A Tight Calf Muscle (Gastrocnemius Equinus Contracture)

The second major cause of a flat foot is a very tight and inflexible
calf muscle. In this case, the foot will flex up through the ankle joint
(dorsiflexion) toward the person and quickly meet resistance from
the tight calf muscle. If the ankle joint does not allow for adequate
upward flexing (dorsiflexion) due to a tight calf muscle then the foot
rotates upward around the joint in front of the ankle (the
talonavicular joint). However, the talo-navicular joint not only
moves up and down, it also moves to the outside. This rotates the
front part of the foot to the outside (abduction) causing the arch to
collapse inwards. A tight calf muscle (usually hereditary) is a fairly
common cause of flat foot. Pediatric flatfoot (flexible flatfoot in a
child) is almost always associated with a very tight calf muscle. This
condition is often asymptomatic but sometimes worrying to parents.

Flat Foot Symptoms

During walking, there is two to three times the weight of the body
going through the foot. This force can take the form of jamming
(compression) forces, which act through the joints, or a pulling
(traction) forces, which act on ligaments and tendons (Figure 2).
Because there is so much movement in the medial column with
flat footed people, all the tendons on the inside of the ankle
(especially the posterior tibial tendon) have to work extra hard to
pull the foot into the shape of a rigid lever prior to the foot pushing
off the ground during gait.

As a result of the exaggerated traction forces acting on the inside of

the ankle, flat-footed people are much more likely to develop
problems related to repetitive overload of the structures on the
inside of the ankle and arch. These problems include: posterior
tibialis tendonitis (acquired adult flatfoot deformity), tarsal tunnel
syndrome, and plantar fasciitis (a list commonly known as the
terrible triad).
Figure 2: Traction and Compression Forces in a Flatfoot Deformity
The compression forces associated with a flat foot go through the
outside of the ankle joint. These forces can actually squash the
outside of the ankle to such a degree that it may eventually wear
out the outside of the ankle joint leading to ankle arthritis. In the
same way, there is also often painful compression in the outside
front part of the subtalar joint (the joint below the ankle joint)
leading to a condition that is commonly called sinus tarsi syndrome.

In addition, it is also common for flatfooted people to experience

repetitive overload of the bases of the second toe because the base
of the great toe does not take its share of the weight during each
step. This "transfers" the force to the base of the second toe
potentially leading to overload metatarsalgia or even a second
metatarsal stress fracture.