What is the appropriate management for a patient with neck and back pain and flat feet (pes planus) who does not meet the criteria for medical shoes?

Management of Neck/Back Pain and Pes Planus

For this 37-year-old male with neck/back pain and pes planus, the appropriate management includes prescribing gel insoles and arch supports, ibuprofen 400mg TID PRN, and topical diclofenac (Voltaren) cream, rather than medical shoes which are not indicated based on current guidelines.

Management of Neck and Back Pain

First-Line Treatment

• Strong evidence recommends against interventional procedures for chronic spine pain, including epidural injections, joint-targeted injections, and radiofrequency ablation 1
• Conservative management should be prioritized for neck and back pain:
  • Topical NSAIDs (Voltaren cream) are appropriate for localized pain relief
  • Oral NSAIDs (ibuprofen 400mg TID PRN) are appropriate for systemic pain management
  • Regular stretching exercises for the neck and back should be recommended

Important Considerations

• Imaging is not indicated for acute neck or back pain without "red flags" 1
• Red flags that would warrant further investigation include:
  • Trauma
  • Constitutional symptoms (fever, weight loss)
  • History of malignancy
  • Neurological deficits
  • Immunosuppression or infection risk

Management of Pes Planus (Flat Feet)

Appropriate Interventions

• Gel insoles and arch supports are the first-line treatment for symptomatic pes planus 2
• Custom or over-the-counter insoles help redistribute pressure and provide support 1
• Proper footwear selection is essential:
  • Shoes should be 1-2 cm longer than the foot
  • Width should equal foot width at metatarsal phalangeal joints
  • Adequate height to allow room for toes 1

When Medical Shoes Are Indicated

• Medical shoes are typically reserved for:
  • Patients with diabetes with neuropathy and/or foot deformities 1
  • Severe structural deformities that cannot be accommodated by regular shoes with inserts
  • Failed conservative management with significant functional impairment

Exercise and Self-Management Recommendations

• Recommend daily stretching of calf muscles and plantar fascia
• Advise appropriate footwear that provides adequate arch support
• Suggest foot and ankle strengthening exercises to improve arch support naturally
• Recommend weight management if applicable, as obesity can contribute to both foot and back pain

Follow-Up Recommendations

• Re-evaluate in 4-6 weeks to assess response to treatment
• If no improvement in symptoms after 6 weeks of conservative treatment, consider:
  • Referral to physical therapy
  • Referral to podiatry or orthopedics for specialized assessment
  • Reassessment for any developing red flags

Common Pitfalls to Avoid

1. Prescribing medical shoes when not indicated by guidelines
2. Relying on interventional procedures for neck/back pain as first-line treatment
3. Failing to provide adequate self-management strategies
4. Not addressing proper footwear selection alongside insoles/arch supports
5. Overlooking the importance of regular stretching and strengthening exercises

This approach aligns with current evidence-based guidelines while addressing the patient's specific needs for both neck/back pain and pes planus.