Treatment Approach for Patients with Pes Planus
The recommended treatment for pes planus should follow a stepwise approach, beginning with conservative management for flexible flatfoot and progressing to surgical interventions only for rigid or symptomatic cases that fail conservative measures.
Diagnosis and Classification
Types of Pes Planus
- Flexible pes planus: Normal arch during non-weight-bearing or tiptoeing, with flattening on standing 1
- Rigid pes planus: Arch remains collapsed regardless of weight-bearing status 1
Diagnostic Assessment
- Clinical evaluation to distinguish between flexible and rigid flatfoot
- Weight-bearing radiographs to assess severity and structural abnormalities
- MRI for suspected tendon pathology (83.9% sensitivity for tendinopathy) 2
- Ultrasound as an alternative diagnostic tool (100% sensitivity for tendon tears) 2
Treatment Algorithm
1. Conservative Management (First-Line)
For Asymptomatic Flexible Pes Planus
- Monitoring without intervention, especially in children where the condition typically resolves with age 1
- Maintenance of healthy weight 1
For Symptomatic Flexible Pes Planus
Orthotic Devices:
- Custom foot orthoses to support the medial longitudinal arch
- Bracing is preferable to taping for long-term management 2
Physical Therapy:
- Proprioception exercises
- Strength training (particularly foot intrinsics and eversion)
- Coordination exercises 2
Phased Rehabilitation Approach:
| Phase | Focus | Duration |
|---|---|---|
| Initial | Pain control and protected range of motion | 0-4 weeks |
| Intermediate | Progressive strengthening exercises | 4-8 weeks |
| Advanced | Activity-specific training | 8-12 weeks |
- Pharmacological Management:
- NSAIDs as first-line treatment for pain and inflammation
- Ibuprofen 1.2g daily (can increase to 2.4g if needed)
- Can combine with acetaminophen (up to 4g daily) for inadequate relief 2
2. Surgical Management (Second-Line)
Indications for Surgical Consultation:
- Persistent pain despite 3-6 months of well-managed conservative treatment
- Functional limitations significantly impacting quality of life
- Progressive joint degeneration evident on follow-up imaging 2
Surgical Options Based on Patient Characteristics:
For Children
- Limited evidence supports surgical intervention for refractory symptomatic pediatric pes planus 1
- Surgical options include:
- Single calcaneal osteotomies
- Extra-articular arthrodesis
- Double calcaneal osteotomy
- Calcaneo-cuboid-cuneiform osteotomy
- Arthroereisis 3
For Adults with Posterior Tibial Tendon Dysfunction (Common Cause)
- Staged approach based on severity
- Surgical options may include tendon transfers, osteotomies, or arthrodesis
For Neuropathic Pes Planus with Medial Column Ulcerations
- Minimally invasive approach combining:
- Achilles tendon lengthening
- Arthroereisis implantation
- Advanced cellular tissue product application 4
Return to Activity Criteria
Return to full activity is permitted when the patient demonstrates:
- Complete resolution of pain during and after activity
- Full range of motion compared to uninjured side
- Strength symmetry >90% compared to uninjured side
- Successful completion of functional tests 2
Special Considerations
For Children with 22q11.2 Deletion Syndrome
- Pes planovalgus may be associated with nonspecific lower leg/foot pains
- May benefit from orthotics 5
- Consider screening for scoliosis and other musculoskeletal issues
For Children with Cerebral Palsy
- Pes planus is the most common foot deformity
- Multiple surgical options exist, but there is currently no clear evidence on optimal surgical treatment 3
- Multidisciplinary approach involving rehabilitation physicians, orthopaedic surgeons, physiotherapists, orthotists, and podiatrists is recommended 6
Pitfalls and Caveats
- Avoid unnecessary treatment for asymptomatic flexible flatfoot in children
- Rigid flatfoot requires referral to a specialist 1
- Consider underlying conditions (rheumatologic, neuromuscular, genetic) that may cause pes planus
- Surgical intervention should be reserved for cases that fail conservative management