3.  Pes planus (PP) is the loss of the medial
longitudinal arch of the foot.
 There are various types and causes of
flat feet.
 Usually, treatment is only needed if PP is
new, painful or progressing, or when
there is a fixed deformity or other
associated problem.

5.  The flat arch does not occur in isolation, but
affects the dynamics of the foot. So,
patients standing on a flat foot will usually
have:
› Valgus position of the heel (turned outwards).
› Pronation of the midfoot, usually referred to as
'hyperpronation' (the midfoot turns inwards).
› Valgus (turned out) position of the forefoot.
Note: the definition refers to the foot bones, not the soft tissues.
People with hypertrophied plantar foot muscles (e.g. lifelong
barefoot walkers) might appear to have flat feet, when their
bony arches are normal.2

6.  Types of PP
 PP may be:
 Developmental or acquired
 Flexible or fixed

7.  Children
 Pes planus (PP) can be part of normal development:
› Infants typically have a minimal arch.
› Many toddlers have flattening of the long arch, with forefoot
pronation and heel valgus on weight-bearing.
› There may be ligamentous laxity, which is probably determined
genetically.
› Most of these children spontaneously develop a strong normal
arch by around age 10.
 Abnormal development of the foot, producing PP, may
be due to:
› Neurological problems, e.g. cerebral palsy, polio.
› Bony or ligamentous abnormalities, e.g. tarsal coalition (fusion of
tarsal bones), accessory navicular bone.
› A small proportion of flexible flat feet do not correct with growth.
Some of these may become rigid if the PP leads to bony
changes.

8.  Adults
 Physiological PP:
› There is a lack of normal arch development, probably due to inherent
ligamentous laxity.
› Around 20% of adults have PP. The majority have a flexible flat foot and
no symptoms. However, if there is also heel cord contracture, there may
be symptoms (see 'Contributing factors', below).3
 Adult-acquired PP - causes: 4
› Loss of support for the arch:
 Dysfunction of the tibialis posterior tendon - a common and important
cause.
 Tear of the spring ligament (rare).
 Tibialis anterior rupture (rare).
› A neuropathic foot, e.g from diabetes, polio, or other neuropathies.
› Degenerative changes in foot and ankle joints:
 Inflammatory arthropathy, e.g. rheumatoid arthritis.
 Osteoarthritis.
 Fractures.
 Bony abnormalities, e.g. tarsal coalition.

9.  Contributing factors
 Footwear: shoes which limit toe movement; high heels.
Barefoot walking may be protective.
 A tight Achilles tendon or calf muscles (heel cord
contracture). This may help to cause PP, or may contribute
to symptoms such as foot pain when there is existing PP.
 Obesity
 Other bony abnormalities, e.g. rotational deformities, tibial
abnormalities, coalition (fusion) of tarsal bones, equinus
deformity.
 Ligamentous laxity, e.g. familial, Marfan's syndrome,
Ehlers-Danlos syndrome, Down's syndrome.
 Other factors causing foot pronation, e.g. hip abductor
weakness and genu valgum.

10.  History
 Patients may present with noticeable pes
planus (PP), parental concerns, or foot
pain.
Children:
 History of the PP and any changes.
 Symptoms: walking/running ability and any
foot pain.
 Past medical history: other diseases,
developmental delay.

11.  Adults:
 Is the PP new? Is it symmetrical?
 Is there foot pain or interference with walking?
 Are there any other lower limb symptoms, e.g. knee pain?
 Past medical history: injuries, other related disease
(neurological, rheumatological, musculoskeletal).
 Occupation and hobbies.
 If PP is new, asymmetrical or painful, ask about symptoms
of tibialis posterior dysfunction, which are:
› Pain or swelling behind the medial malleolus and along the
instep.
› Change in foot shape.
› Decreasing walking ability and balance.
› Ache on walking long distances.

12.  Examination 1
 Observe the PP.
› With the patient standing, look at his or her feet from
above and behind. Loss of the arch is visible, with the
medial side of the foot close to the ground. Look at the
feet from behind - with PP the heel moves outwards
(valgus) and the toes may also be pointed outwards.
 Is the PP flexible?
› Ask the patient to stand on tiptoe. With flexible PP, this will
reveal the arch, and the heel will move inwards (varus
position).
 Look for signs of tibialis posterior dysfunction (if history
4
is suggestive of this):
› Ask the patient to do 10 unsupported heel raises (stand on
one foot on tiptoe, unsupported). Patients with tibialis
posterior dysfunction will be unable to do this.
› Further assessment of tibialis posterior dysfunction is
detailed in the reference below. 4
 Assess related problems, if relevant, e.g. neuropathy
or arthritis.

13.  Investigations
 In some cases, standing foot X-rays may be
used to show the degree of deformity:
 Standing lateral view shows the longitudinal
arch and talonavicular joint.
 Standing AP view shows the degree of heel
valgus (talocalcaneal angle).

14.  Is treatment necessary?
 In many cases, pes planus (PP) does not require treatment:
 The arch may develop spontaneously in children under 10
years with flexible PP and no other relevant condition.
 In adults, a 'good' PP is one which has has been present a
long time, is flexible, bilateral, painless, and not
progressing.
 Consider referral or treatment for PP if:
 PP is fixed, new, asymmetrical, progressing, there is foot
pain, or if the patient has another disease which may be
contributing (e.g. neuropathy or inflammatory arthritis).
 There is tibialis posterior dysfunction. This should be treated
in its own right: treatment may involve rest, non-steroidal
anti-inflammatory drugs (NSAIDs), orthotics or surgery.4

15.  Non-surgical treatment
 Heel cord stretching is an important part of treatment, as
a tight Achilles tendon tends to pronate the foot. See box 3
for details.
 Orthotics (inserts or insoles, often custom-made) may be
used. These usually contain a heel wedge to correct
calcaneovalgus deformity, and an arch support.
› This is the usual treatment for flexible PP (if treatment is needed).
› A suitable insole can help to correct the deformity while it is
worn. Possibly it may prevent progression of PP, or may reduce
symptoms. However, the effectiveness of arch support insoles is
1
uncertain. 6,7
› Note: arch supports used without correcting heel cord
contracture can make symptoms worse. 3
› In patients with fixed PP or arthropathy, customised insoles may
relieve symptoms.
 Reduce contributing factors: 2
› Wear shoes with low heels and wide toes.
› Lose weight if appropriate.
› Do exercises to strengthen foot muscles - walking barefoot (if
appropriate), toe curls (flexing toes) and heel raises (standing on
tiptoe).

18.  Tendo-achilles [Heel cord] stretching exercises
› These stretch and lengthen the Achilles tendon and
posterior calf muscles.
Instructions:
 Stand facing a wall with your hands on the wall at
about eye level. Put the leg you want to stretch about
a step behind your other leg.
 Keeping your back heel on the floor, bend your front
knee until you feel a stretch in the back leg.
 Hold the stretch for 15-30 seconds. Repeat 2-4 times.
 Do this exercise 3-4 times a day.

19.  Surgery
 Common indications for surgery are:
› Cerebral palsy with an equinovalgus foot, to prevent
progression and breakdown of the midfoot.
› Rigid and painful PP.
› To prevent progression, e.g. with a Charcot joint.
› Tibialis posterior dysfunction, where non-surgical
treatment is unsuccessful.
 Possible surgical procedures include:
› Achilles tendon lengthening.
› Calcaneal osteotomy, to re-align the hindfoot.
› Reconstruction of the tibialis posterior tendon.
› For severe midfoot collapse of the arch, triple
arthrodesis may be indicated.

20.  Physiological pes planus (PP)
› It is generally stated that physiological PP is unlikely to
cause significant foot problems.1,3 However, some authors
suggest that excessive foot pronation (which usually
occurs with PP) may contribute to the development of
foot pain and foot problems such as:2
› Tibialis posterior dysfunction (because hyperpronation
stretches this tendon).
› Hallux valgus (because more weight is borne by the
medial metatarsals when the foot hyperpronates).
› Metatarsalgia (for the same reason).
› Plantar fasciitis.
› Knee pain: one study found that off-the-shelf foot orthoses
were beneficial for patellofemoral pain.8 Another study
suggested that foot deformity may be linked to greater
disability from knee osteoarthritis.9
› PP may reduce the shock-absorbing features of the foot,
potentially contributing to low back pain.3

21.  Other types of PP
 Depending on the cause, PP can deteriorate, with
loss of the longitudinal arch leading to collapse of the
midfoot. With deterioration, a flexible PP can
become rigid and/or painful. This can cause
significant difficulties with walking and may require
surgery.
Situations where deterioration is likely without
treatment include:
 Neuropathy, e.g. with a Charcot joint there may be
rapid and progressive loss of the arch.1
 Tibialis posterior dysfunction.4
 Cerebral palsy.3

22.  Non-Weight Bearing (Sitting) and
 Weight Bearing (Standing).

23.  Sitting: active foot rolling.
The patient tries to draw an 'O' with his/her big
toe. For the right foot clockwise; for the left foot
anti-clockwise.
 Sitting: trying to pick up a duster.
A duster is placed under the foot, and the
patient tries by using both feet to screw the
duster into a ball, then inverting (raising the
internal arch of) both feet, he/she tries to throw
the duster into the air and catch it. Similarly the
patient can be encouraged to pick up balls,
match boxes, etc., with the feet.
 Sitting with strong extension of the knees:
dorsi-flexion, holding them in position.

24.  Sitting: alternative toe clawing.
The toes of one foot are actively flexed as far as
possible, gripping the floor and pulling the heel of
the foot two or three inches forwards. The toes are
extended, and the opposite foot is similarly
exercised. In other words, the toes pull the foot a
short distance along the ground. Care must be
taken to ensure that the patient does not push the
foot along using the leg muscles.

25.  Sitting: sliding the sole of one foot up the
leg of the other.
 Sitting: foot shortening.
The foot is slightly inverted (the internal
arch is raised), but the sole is not turned
upwards. That is to say, the height of the
arch is increased, whilst the toes are still
gripping the ground.

26.  Sitting: foot-closing.
 An attempt should be made to close the
foot, like a fist.
 Sitting: toe adduction and abduction.
This means the toes are pulled away
from then towards one-another.
 Sitting with both feet crossed and
inverted. Holding them in position.

27.  Walking on the outer borders of the foot.
Each foot should be lifted over the other one at each step.
 Standing: heel raising and lowering to the outer borders.
The patient starts with the feet inverted, raises the heels, and
lowers the outer borders.
 Standing with the feet inverted. Holding this position.
 Standing on a book:
the edge of which is placed immediately under the metatarso-
phalangeal joints. The toes are then flexed and extended.
 Standing: foot shortening.
 Walking along a straight line.

28.  Correct heel and toe walking:
The patient is taught to walk with the feet along parallel
lines.
Any tendency towards slaying must be immediately
corrected. The heels should first be placed on the
ground, the outer border next, the toes finally..
The weight should not at any time in this procedure be
taken on the inner border.
The heel is then cleanly raised from the ground, the five
metatarsals used as the fulcrum, and the big toe for a
concluding propulsion to a straight leverage.
The heel and toe walk brings all the muscles into equal
action, and ensures normal balance.

29.  All the above exercises should only be
undertaken when the patient is rested and
not tired.
 The amount and frequency of the exercises
would be decided by the patient's
Physiotherapist.

30. Thanks for your
attention………..