What is the recommended treatment for a 24-year-old female with bilateral foot pain on long distances, no ankle arthritis, and a positive Coleman block test?

Management of Bilateral Foot Pain with Positive Coleman Block Test

For a 24-year-old female with bilateral foot pain on long distances, no ankle arthritis, and a positive Coleman block test, accommodative shoe wear with medial hindfoot posting is the recommended first-line treatment. 1

Understanding the Coleman Block Test and Its Implications

The positive Coleman block test indicates flexible flatfoot deformity with forefoot supination, suggesting that:

• The hindfoot valgus is secondary to forefoot varus
• The medial column is hypermobile
• The deformity is flexible rather than rigid

Treatment Algorithm

First-Line Treatment

1. Accommodative shoe wear

   • Shoes with adequate arch support
   • Shoes with proper cushioning for long-distance walking
   • Open-backed shoes to reduce pressure on the heel area 1

2. Medial hindfoot posting

   • Provides support to the medial arch
   • Helps correct hindfoot valgus position
   • Reduces strain on the plantar fascia and medial structures 1

3. Supportive measures

   • Regular calf-muscle stretching
   • Activity modification (temporarily limiting long-distance walking)
   • NSAIDs for pain management if needed
   • Weight loss if indicated 2

Second-Line Treatment (if no improvement after 6 weeks)

1. Lateral hindfoot post with first ray recess

   • Addresses both hindfoot and forefoot components
   • First ray recess accommodates forefoot varus 1

2. Custom orthotic device

   • Semi-rigid orthotic with proper posting based on foot biomechanics
   • More effective than prefabricated inserts for pain reduction 3

Third-Line Treatment (if no improvement after 2-3 months)

1. Lace-up ankle brace

   • Provides additional stability
   • Limits excessive motion during long-distance walking 1

2. Immobilization

   • Cast immobilization or walker boot for severe cases
   • Typically used for 4-6 weeks 2

Evidence for Orthotic Intervention

Research shows that custom-made foot orthotics with proper posting significantly reduce pain and improve function compared to prefabricated inserts or supportive shoes alone 3. A randomized clinical study demonstrated that medially wedged foot orthoses effectively reduced pain in runners with pronated feet 4.

Important Considerations

• Avoid corticosteroid injections in the Achilles tendon area due to risk of tendon rupture 1
• Regular follow-up is essential to assess treatment response and make necessary adjustments
• Gradual return to long-distance walking once symptoms improve
• Continued stretching and strengthening exercises are important for long-term management

Red Flags Requiring Further Investigation

• Bilateral heel pain
• Night pain or rest pain
• Neurological symptoms
• History of trauma 1

If symptoms persist despite comprehensive conservative treatment for 3-6 months, referral to a podiatric foot and ankle surgeon for further evaluation and possible surgical intervention may be warranted 2.