PES PLANUS AND ITS ASSOCIATED FACTORS

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Introduction to Pes Planus

Pes Planus , also commonly known as Flat Foot , is a deformity of the foot where there is

a loss of the medial longitudinal arch of the foot resulting in the arch of the foot coming closer or

even making contact with the ground . The medial longitudinal arch of the foot is a tough ,

elastic connection of ligaments , tendons , and fascia between the forefoot and the hindfoot .

It acts as a base of support for the entire body and also helps in managing the forces of

weight bearing and is very important during the gait cycle.

Pes planus may affect either of the legs or the both, and not only increases the weight that

act on the leg structure, but also interferes with normal foot function.The development of foot

arch is brisk between the age of 2 and 6 years . it becomes structurally perfected around the age

of 12 to 13 years.

PREVALANCE

About 20% to 37% of the population is estimated to have some degree of pes planus. A

majority of these cases are flexible pes planus. A 2003 study by Dunn et al. found that the

prevalence among non-Hispanic whites was 17% and greater among African Americans at a rate

of 34% .There is a 1:1 ratio of men to women. It is typically more common in children, but most

children develop a normal arch by age 10. There is a strong genetic component of pes planus,

and it typically runs in families. The radiographic or clinical presence of pes planus may be an

incidental finding in patients and requires clinical correlation.

In a study done by Asian Journal science it was found out that :

Prevalance of normal and flatfoot among genderwise

Gender Normal % Pes planus %

Male 115 32 53 37
Female 240 68 92 63
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Total 355 71 145 29

Prevalance of flatfoot in age wise distribution

Age No of participants Percentage

18 23 16%
19 35 14%
20 21 24%
21 14 14%
22 19 10%
23 8 13%
24 5 6%

ANATOMY AND BIOMECHANICS OF PES PLANUS

The foot consist of 26 Bones and 55 Joints . It is divided into 3 main parts , The

Hindfoot , The forefoot and the midfoot . The forefoot comprises of 5 metatarsals and 14

phalanges . while the midfoot is shaped by the fusion of cuneiform , cuboid and navicular bones .

The Hindfoot ankle complex is formed by the distal end of talus ,calcaneus and tibia-fibula bones

For Balanced walking , appropriate weight distribution , sufficient supports , wide contact

and stability are required . During walking , weight transfer occurs parallelly in the subtalar

joints . In a healthy individual the decrease in the arch height during walking is stabilized by

muscles and ligaments . However in cases such as pes planus , there is increased pronation

which leads to locking at the subtalar joints and excessive mobility at the midtarsal joints during

walking .

The rise in pronation encountered in standing forces the tibia into medial rotation ,

leading to deformities of lower extremity bones such as femur , patella , ilium and sacrum . This

affects the lower extremity due to imbalance in weight distribution , increased stress on foot and

the kinetic chain during walking . Pes Planus also affects the Tibiofemoral connection increasing
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the Q Angle . Instability may occur due to insufficient supination and the rise in pronation in the

foot makes the midfoot hypermobile .

Navicular drop results from pes planus , causing stretching of plantar connective tissue .

In this case , the weight on the plantar intrinsic muscles and tibialis muscle increases causing

muscle fatigue and unnecessary muscle power usage

TYPES OF PES PLANUS

Pes Planus – The Flat Foot is presented in Two Types:

 Flexible - It is the most commonly seen one . In this condition we can see the arches

while standing but the arches disappear when putting weight onto it . It generally onsets

during childhood or teen ages . It worsens with age and tendons and ligaments in the

arches of foot may stretch , tear or swell .

 Rigid – A person having rigid flat foot wont have any arches while standing ( weight

bearing ) and even while not standing ( non weight bearing ) . This condition often arises

during the teen years and progressively worsens with age . It can be difficult to flex the

feet up or down or move them side to side .

 Adult Acquired Flatfoot (Fallen Arch ) – In this condition the foots arch unexpectedly

drops or collapses . It causes foot to turn outward and can be painful . The most common

cause is tear in the posterior tibial tendon that supports the arch .

 Vertical Talus – It is a congenital defect where arches don’t form . The Talus bone in the

ankle is in wrong position . The Bottom of the foot resembles the bottom of a rocking

chair , that’s why its also called Rocker bottom Foot .

CLINICAL PRESENTATION AND SYMPTOMS

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Pediatric Flatfoot range from the painless flexible normal variant of growth , to stiff or

painful manifestation of tarsal coalition , collagen abnormalities , neurological disease or other

underlying conditions.

Most Children with flexible flatfoot doesn’t show any symptoms and doesn’t show any

symptoms and doesn’t require treatment .

In Symptomatic cases , a child can use orthotics , osteotomies , or fusions may be

considered . Arthroereisis (surgical procedure where screws are implanted into sinus tarsi to

realign the foots longitudinal arch ) has gained popularity in Europe but not in other parts of the

globe .

RISK FACTORS

Factors which increases the risk of Flatfoot are –

 Obesity

 Injury to Foot or Ankle

 Rheumatoid Arthritis

 Aging

 Diabetes

 Causes of Pes Planus

 Congenital

 Obesity

 Foot and ankle injury

 Laxity in ligaments

 Genetic Malformations like Down syndrome and Marfan syndrome

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ASSOCIATED FACTORS

A study was done with a total of 474 children aged 6 – 10 years attending a school named

Enugu Metropolis . There were 253 girls and 221 boys . A total of 153 were underweight , while

160 students were either overweight or obese . The prevalence and pattern of flatfoot was

observed and it was found out that -

Association with Age – with various studies , the prevalence of flat foot decreases

significantly with advancing age . In particular , the prevalence quickly drops between the ages

of 6 to 7 years . This maybe due to the improvement of the medial arch , as well as reduction of

rear foot angle with age.

Association with Sex – It was seen that Male Children were twice as likely as likely to be

affected by flat foot than female. It can be explained by the greater rear foot valgus and retarded

development of rear foot in boys compared with girls.

Association with Weight – Weight is significantly associated with flatfoot. Obese children

were There and Half times more likely to be diagnosed with flatfoot. It can be explained by the

continued pressure exerted on the longitudinal arch during gait.

DIAGNOSIS, MANAGEMENT AND TREATMENT

DIAGNOSIS

Physical examination-including gait analysis and both weight bearing and off weight

bearing of lower extremity is very important. Gait analysis should be done both barefoot and

wearing shoes.

Radiographs including MRI and CT scan are very helpful in diagnosing Pes Planus

- Special Tests – Tip Toe Standing Test – This test is used to differentiate between flexible

flatfoot and fixed flatfoot.

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- The patient stands on the flat ground . this can be done at a wall or other places where

external supports can be used

- The patient is the asked to stand on tiptoe. In a flexible flatfoot ,the heel will turn inwards

( varus position ) and medial arch become apparent . But in fixed flatfoot , the medial

longitudinal arch will remain unobservable .

- Jack’s Test – This Test is also done to differentiate between Rigid and Flexible Flatfoot .

The patient is to stand in a normal relaxed position The clinician then passively flexes the

1st metacarpal joint If the arch of the foot rises , the leg rotates laterally and a tight band

is noted in the region of plantar aponeurosis , then it is diagnosed to be flexible pes

planus .

MANAGEMENT AND TREATMENT

Conservative management

It consist of making lifestyle modifications like losing weight , footwear modifications ,

immobilization , anti inflammatory medications. Treatment for flexible flatfoot generally begins

with immobilization via a removable cast boot or below the knee cast for up to 6 to 8 weeks.

UCBL orthotics are also used to stabilize the rearfoot , it limits the range of motion of the

subtalar joint and forefoot abduction.

Physical Therapy methods includes Strengthening the foot muscles , stretching the triceps

Surae muscle and taping techniques. If conservative methods surgical interventions are

considered like arthroereisis .

Physiotherapy Management

The aim of Physiotherapy is to minimize pain, increase foot flexibility, strengthen weak

muscles and train proprioception. To minimize pain –

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 Rest

 Activity modification

 Cryotherapy

 Heat Therapy

 Soft tissue massage

 Electrical modalities like Ultrasound

Flexibility Training includes

First, Passive Range of Motion exercises of the Ankle and all foot joints. Stretching of

Calf muscles (Gastrocnemius and Soleus). Stretching of Peroneus Brevis muscles. Rolling

exercises using tennis ball or water bottle.

Strengthening exercises

To prevent Valgus and flattening of the anterior arch , muscles such as the anterior and

posterior tibialis muscles , the flexor hallucis longus , the intrincis , the interosseus plantaris ,and

the abductor hallucis are strengthened.

 Arch muscle strengthening using exercise bands.

 Single leg weight bearing

 Toe Walking

 Squatting using proper foot and leg alignment

 Calf raises

 Toe curls and Toe Raises

Some specialized techniques and manual Therapies:

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 Kinesio Taping

 Ankle Joint mobilization and manipulation

 Cupping Therapy

Lifestyle Modification

 Footwear modification, wear footwear that has proper arch support as well as extra

cushion and additional side foot support

 Orthotics and Braces

 Weight loss through exercises and dieting

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References

View of Pes planus and pes cavus in Southern. (n.d.).

https://annali.iss.it/index.php/anna/article/view/485/339

Raj, M. A., Tafti, D., & Kiel, J. (2023b, May 23). Pes Planus. StatPearls - NCBI

Bookshelf. https://www.ncbi.nlm.nih.gov/sites/books/NBK430802/

Flatfoot. (n.d.). Sciencedirect. https://www.sciencedirect.com/topics/medicine-and-

dentistry/flatfoot

View of Pes planus and pes cavus in Southern. (n.d.-b).

https://annali.iss.it/index.php/anna/article/view/485/339

Prevalence and Clinical factors Associated with PES planus among Children and Adults:

A Population-Based Synthesis and Systematic Review. (n.d.). Researchgate.

https://www.researchgate.net/publication/371327169_Prevalence_and_clinical_factors_associate

d_with_pes_planus_among_children_and_adults_A_population-

based_synthesis_and_systematic_review

Biomechanics and pathophysiology of flat foot. (n.d.). Sciencedirect.

https://www.sciencedirect.com/science/article/abs/pii/S1083751503000846

Prevalence of flat foot in Preschool-Aged children. (n.d.). publications.aap.org.

https://publications.aap.org/pediatrics/article-abstract/118/2/634/69069/Prevalence-of-Flat-Foot-

in-Preschool-Aged-Children?redirectedFrom=fulltext

Flat feet (Pes Planus). (2024, November 20). Cleveland Clinic.

https://my.clevelandclinic.org/health/diseases/flat-feet-pes-planus

Dare, D. M., & Dodwell, E. R. (2013). Pediatric flatfoot. Current Opinion in Pediatrics,

26(1), 93–100. https://doi.org/10.1097/mop.0000000000000039

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Paediatric pes planus. (n.d.). Australian Journal of General Practice.

https://www1.racgp.org.au/ajgp/2020/may/paediatric-pes-planus/

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