Treatment of Pes Planus (Flat Feet)
For symptomatic pes planus, initiate conservative treatment with orthotic devices, stretching exercises, appropriate footwear modifications, NSAIDs for pain control, and activity modification, as these interventions form the foundation of management regardless of age. 1, 2
Initial Conservative Management
The cornerstone of pes planus treatment involves non-surgical interventions that should be implemented immediately:
- Orthotic devices are the primary treatment modality, with custom-made orthoses showing superior pain reduction compared to supportive shoes alone (1.5 points reduction on 10-point VAS scale) and significant disability reduction (18.65mm improvement on Foot Function Index) 3
- Footwear modifications including open-backed shoes to reduce pressure on irritated areas and accommodate foot structure 1, 2
- NSAIDs for pain management and inflammation reduction 1, 2
- Stretching exercises particularly targeting calf muscles and anterior compartment to reduce tension 1
- Activity modification with temporary reduction in weight-bearing activities 1
- Cryotherapy (ice application) to reduce inflammation 1, 2
Pediatric-Specific Considerations
For children with pes planus, the approach differs based on symptoms:
- Asymptomatic flexible flat feet should be observed without intervention, as this is often physiologic and resolves with age 4, 5
- Symptomatic flexible flat feet warrant orthotic intervention and physical therapy 6, 5
- Rigid flat feet require immediate referral to orthopedic specialist, as this may indicate underlying pathology such as tarsal coalition or arthritis 4, 5
- Maintenance of healthy weight should be encouraged in all pediatric cases 4
Advanced Interventions for Refractory Cases
If no improvement occurs after 6-8 weeks of conservative treatment:
- Referral to podiatric foot and ankle surgeon is appropriate for further evaluation 1, 2
- Immobilization with cast or fixed-ankle walker-type device may be necessary 1
- Customized orthotic modifications to better accommodate deformity and redistribute pressure 1
- Heel lifts may benefit patients with concurrent Achilles tendinopathy 1
After 2-3 months without improvement, consider:
- Night splinting 2
- Limited corticosteroid injections (avoiding Achilles tendon area to prevent rupture) 2
Surgical Considerations
Surgical intervention should only be considered for:
- Refractory symptomatic cases in children after failed conservative management, though evidence supporting surgery is limited 4, 5
- Procedures may include Achilles tendon lengthening, osteotomies, arthrodesis, or arthroereisis 5
- Rigid pes planus with underlying pathology requiring correction 4, 5
Exercise Therapy Protocol
Beyond basic stretching, implement:
- Eccentric strength training to promote tendon healing if tendinopathy is present 1
- Deep transverse friction massage for affected tendons 1
- Regular calf-muscle stretching to reduce tension 1
Critical Pitfalls to Avoid
- Inadequate footwear modification: Continuing to use tight or inappropriate shoes will perpetuate symptoms 1
- Premature return to activity: Returning to high-impact activities before adequate healing leads to symptom recurrence 1
- Treating asymptomatic pediatric flat feet: Flexible, painless flat feet in children are physiologic and require only observation 4, 5
- Missing rigid flat feet: Failure to identify rigid pes planus delays diagnosis of serious underlying pathology 4, 5