What are the treatment options for pain caused by flat feet (pes planus)?

Treatment Options for Pain Caused by Flat Feet (Pes Planus)

The most effective treatment for pain caused by flat feet includes appropriate footwear, custom orthotics, stretching exercises, and strengthening of intrinsic foot muscles, with surgical intervention reserved for refractory cases. 1

Initial Assessment and Diagnosis

When evaluating pain related to flat feet, consider:

• Duration and pattern of pain
• Activity level and footwear assessment
• Risk factors such as obesity, excessive foot pronation, and high-impact activities 1
• Physical examination including:
  • Palpation of the medial plantar calcaneal region
  • Assessment of foot alignment and arch structure
  • Passive ankle/first toe dorsiflexion test 1

Weightbearing radiographs (anteroposterior, lateral, and oblique views) are recommended as the first imaging study to evaluate for associated conditions like plantar fasciitis 1.

Conservative Treatment Options

1. Footwear Modifications

• Select shoes that are 1-2 cm longer than the foot with adequate width at metatarsal phalangeal joints 1
• Avoid tight shoes or those with rough edges/uneven seams
• Consider shoes with open backs to reduce pressure on painful areas 1

2. Orthotic Devices

• Custom or over-the-counter insoles can redistribute pressure and provide arch support 1
• For more severe cases, below-knee customized devices may be necessary for optimal plantar pressure distribution 1
• Orthotic devices have been shown to reduce abnormal pronation during stance phase and decrease strain on plantar ligaments 2

3. Exercise Therapy

• A supervised foot-ankle exercise program focusing on strengthening intrinsic foot muscles and improving ankle mobility for 8-12 weeks 1
• Regular stretching of calf and plantar fascia muscles
• Eccentric exercises for associated tendinopathies 1

4. Pain Management

• Cryotherapy: applying ice through a wet towel for 10 minutes to reduce pain and inflammation 1
• NSAIDs (oral or topical) for pain relief
• Acetaminophen as an alternative for those who cannot take NSAIDs 1

Advanced Treatment Options

For cases that don't respond to conservative measures after 6-8 weeks:

1. Injections

• Corticosteroid injections may be considered for refractory cases
• Avoid injection near the Achilles tendon 1

2. Immobilization

• Cast or fixed ankle walker for persistent cases 1

3. Night Splints

• Maintain dorsiflexion during sleep to prevent morning pain
• Should be used consistently for at least 4-6 weeks 1

4. Surgical Intervention

• Consider for refractory cases with:
  • Joint instability
  • Significant deformity
  • Pain that cannot be managed with conservative treatment 1
• Surgical options include endoscopic approaches for associated conditions or corrective osteotomies 1

Special Considerations

Pediatric Flat Feet

• Flexible flat feet are common in children (affecting up to 14%) and often resolve by adolescence 3
• Asymptomatic flat feet in children typically require only observation 4
• Painful flexible flatfoot may benefit from orthopedic intervention including physical therapy, bracing, or in rare cases, surgical procedures 4

Adult Acquired Flatfoot

• Often caused by posterior tibial tendon dysfunction
• Many patients can be effectively treated with conservative management protocols 5
• The goal is to alleviate pain and correct deformities through proper application of orthotic modalities 5

When to Refer to a Specialist

Referral to a foot specialist is recommended if:

• No improvement occurs after six weeks of conservative treatment
• There are signs of underlying foot pathology or complicating factors 1
• The condition is associated with significant pain or disability

Common Pitfalls to Avoid

• Relying solely on the presence of a radiographic finding for diagnosis, as many asymptomatic individuals may have similar findings 1
• Failing to assess biomechanical factors contributing to foot pain
• Not considering systemic conditions that may contribute to pain 1
• Overlooking the need for regular assessment of treatment response every 4-6 weeks 1

With appropriate treatment, approximately 90% of patients with painful flat feet can experience symptom improvement through conservative measures 1.