PES PLANUS

Clinical Scenario:

Patient Name: Sarah

Age: 35

Occupation: Elementary school teacher

Chief Complaint: Persistent foot pain and discomfort, especially after standing for long periods during teaching hours.

Patient History: Sarah, a dedicated elementary school teacher, presents to her primary care physician with complaints
of persistent foot pain and discomfort. She describes the pain as dull and achy, localized primarily to the arches of both
feet. Sarah mentions that the pain worsens after prolonged periods of standing, such as during classroom teaching
sessions, and is relieved somewhat by rest and elevation.

Symptoms: Dull, achy pain in the arches of both feet Exacerbated by prolonged standing. Partial relief with rest and
elevation

Clinical Examination: Upon examination, the physician notes. Decreased arch height in both feet. Pronation of the feet,
with the inner border of the foot appearing flattened. Tenderness along the medial aspect of the arches. Limited range
of motion in the ankles
Radiology Findings:

X-rays of Sarah's feet reveal:

Reduced arch height, consistent with pes planus (flat

feet)

Mild degenerative changes in the midfoot joints

No evidence of fractures or other significant

abnormalities

This clinical scenario highlights a common presentation

of flat feet in an individual with a demanding occupation
requiring prolonged periods of standing. It sets the stage
for further discussion on the anatomy, pathophysiology,
and management of the condition in your presentation.
Arches of the Foot
Transverse Arch: It is formed by the metatarsal bases, the cuboid and the three cuneiform bones. Supporting
structures:

Muscular support: Fibularis longus, tibialis posterior and transverse head of adductor hallucis

Ligaments: Plantar ligaments and deep transverse metatarsal ligaments

Medial Longitudinal Arch:It is formed by the calcaneus, talus, navicular, three cuneiforms and first three
metatarsal bones. Supporting structures:

a) Muscular support: Tibialis anterior and posterior, fibularis longus, flexor digitorum longus, flexor hallucis,
and the intrinsic foot muscles
b) Ligaments: plantar aponeurosis, plantar Ligaments and medial ligaments of the ankle joint

Lateral longitudinal Arch: It is formed by the calcaneus, cuboid and 4th and 5th metatarsal bones. Supporting
structures:

c) Muscular support: Fibularis longus, flexor digitorum longus, and the intrinsic foot muscles.
d) Ligaments: plantar ligaments and plantar aponeurosis
Pes Planus “Flat Feet”
Flat feet can be:

Flexible - they have normal appearance at rest but flatten with weight bearing, or

Rigid - which appear flat even when not weight bearing and has a reduced range of motion at the
tarsal and subtalar joints.

After birth, the appearance of flat feet is normal due to ligamentous laxity and a thick subcutaneous
fat pad of the sole of the foot

Typically flexible pes planus resolves. As kids age, their fat pad is lost, the lax ligaments grow and
mature, the medial longitudinal arch of the foot becomes visible, and a normal arch develops.

However there are many kids whose pes planus doesn’t resolve. This leads to acquired pes planus
which persists into adulthood, though pes planus can also develop in adulthood without preexisting
pes planus as a child.
Causes: Acquired pes planus is thought to be due to the breakdown of the foot
supporting structures, such as the tibialis posterior tendon which provides dynamic
support of the medial longitudinal arch, and the plantar calcaneonavicular ligament, The
breakdown of these structures may be due to:
obesity, trauma, degenerative or inflammatory arthropathies such as rheumatoid arthritis,
or denervation - such as a neuropathy caused by conditions like diabetes
All lead to a loss of the foot's medial longitudinal arch.
Conditions that may lead to congenital ligament laxity and exacerbate pes planus include
Down syndrome, Marfan syndrome, or Ehlers Danlos syndrome.
Symptoms: pes planus is mostly asymptomatic, especially in children, but when it is problematic it
typically presents with arch pain. However, in time, it can alter the biomechanics of the lower limbs and
lumbar spine causing pain or discomfort in the midfoot, heel, lower leg, knee, hip, and back.

Examination: there’s evidence of flat feet during rest, or excessive pronation of the feet during standing.
One test that can be done is looking at the individual from the back and looking for the “too many toes”
sign. From this view only the fourth and fifth toe should normally be seen, but with flat feet and
excessive pronation more toes will be seen.
MCQs
Which of the following is a common symptom of Pes planus?

A) Sharp, stabbing pain in the toes

B) Chronic foot pain primarily in the arches

C) Numbness and tingling in the heel

D) Swelling and redness of the ankles

What is the primary anatomical feature associated with Pes planus?

A) Increased arch height

B) Supination of the feet

C) Flexion of the feet

D) Excessive curvature of the toes

Which of the following management strategies is commonly recommended for individuals with Pes planus?

A) High-impact aerobic exercise

B) Wearing high-heeled shoes

C) Orthotic devices or arch supports

D) Avoiding physical activity altogether