This document discusses pes planus (flat foot), including its causes, classification, presentation, diagnosis, and management. Pes planus is characterized by loss of the medial longitudinal arch of the foot. It can be flexible or rigid. Diagnosis involves examination of footprints, x-rays, and mobility tests. Management for flexible pes planus focuses on orthotics, footwear, stretching, and strengthening exercises. Rigid pes planus may require surgery. Physiotherapy aims to reduce pain, increase flexibility, and strengthen weak muscles.

1. PES PLANUS
Dr. Priyanka

2. PES
PLANUS/PES
PLANOVALGUS
/FLAT FOOT
Loss of medial longitudinal arch of foot
Heel valgus deformity
Medial talar prominence
Medial arch of foot coming closer to the ground
or making contact with ground
Infants feet are born with flexible flat feet and
arch development 3 year of age
Attaining adult values in arch height between 7
and 10 years of age

3. Classification
Two types :
1. Arch of height
2. Heel eversion angle

4. Arch height
• medial longitudinal arch structure was
found to be a ratio of navicular height to
foot length .

5. Heel eversion
angle
• Heel eversion or hindfoot valgus
• Child foot posture and calcaneal eversion to reduce degree
every 12 month to vertical position by 7 years .
• A vertical heel is optimal for foot function .
• Foot angle for children from 6 to 16 years is 4 degree

6. Foot structure type
FLEXIBLE FLAT FOOT RIGID FLAT FOOT

7. Flexible flat
foot
• The longitudinal arches of foot are present on heel
elevation and non- bearing but disapper with full weight
bearing on the foot

8. Rigid flat foot
• The longitudinal arch of foot are absent in both heel
elevation and weight bearing

9. causes
Congenital pes planus
General hypermobility
Cerebral palsy
Subtalar joint morphology
Acquired pes planus
Diabetes
Rupture of posterior tibial
tendon
Arthritis, muscular
dystrophy
Traumatic injury
Posterior tibial tendon
transfer

10. Other
condition of
congenital pes
planus
• Peroneal spasm
• Congenital Vertical talus
• CTEV
• Ligament laxity
• Down syndrome and marfan syndrome

11. Pathophysiology
The arch fails to develop result if tightness in calf muscles
,laxity in the achilles tendon or poor core stability in other
areas around of hips

12. Dynamic
factors
• Soft tissue factors:
1.Insufficency of posterior tibial tendon
2.Peroneal spastic flat foot
3.Muscle weakness by poor posture
• Neurology factors:
1.Myelination of the pyramidal fibers to the foot is
incomplete at birth .

13. STATIC
FACTORS
• Bony architecture of the medial longitudinal arch .
• Fixed or rigid pes planus is due to structural abnormality.

14. Clinical
presentation
History :
1. In adult frequent ankle rolling /ankle sprains
2. Children presenting with pes planus asymptomatic
3. Pain (mid foot ,heel, lower leg, knee, hip, back )
Observation:
1. Foot may flat or rocker bottom
2. In standing –calcaneal valgus and foot eversion
3. Gait : walking on heel
4. Viewed from posteriorly looking for the 'too many toes
sign '
5. Look at running or walking shoes uneven distribution of
body weight with resultant one sided wear of shoes
leading to further injuries

15. Palpation :
 Contracted achilles tendon may show limitation of
dorsiflexion
 Test subtalar and transverse tarsal motion
 Subtalar motion : stabilises ankle with one hand
, calcaneus other hand. The calcaneus is then inverted
and everted .Normal range of motion is between 20
degree and 60 degree. Inversion being 2x the ROM of
eversion
 Tarsal motion : grasp the calcaneus is one hand and
forefoot in other . The normal adduction of forefoot is
about 30 degree ,abduction about 15 degree

16. Diagnosis :
Footprints
X-rays
Supination resistance test
Foot –posture index
Jacks test and Feiss angle
Tip-toe
Ankle range

17. Supination
resistance test
Test used to estimate the mangnitude
of pronatory moments
The foot is manually supinated
The higher force required , the greater
the supination resistance and the
stronger the pronatory force

18. Jacks test and feiss angle
• Hallux is manually dorsiflexed while child is standing
• If medial longitudinal arch rise due to dorsiflexion of hallux the foot is considered
flexible flat foot
• If medial longitudinal arch unchanged the considered rigid flat foot
• Purpose this test to check the flexibility of foot
• Feiss line is the line interconnecting malleolus medialis ,navicular, and first
metatarsal head
• The inclination of this line with ground increases when the first
metatarsophalangeal joint is dorsiflexed ( jack test )
• Dorsiflexion activates forefoot supination and rises the arch height ( 140degree
plus and minus 6 degree )

19. Ankle range
Children ankle range assessment
generally an unreliable measure
typically assessed when child non
weight bearing
So it is suggested that therapists look
at child ability to squat ,heel walk and
increase stride length

20. Management
Flexible pes planus :
1. Foot orthoses produces improvement in
children with pes planus
2. The child should be fitted with flat lace up
shoe with a firm heel and MLA , a broad and
deep toe box and the ' toe break' at the
junction between the anterior third and
posterior two third of the shoe .
3. In children 10 years old , flexible flat foot is
considered permanent ,therefore long term
orthotics can be used to prevent secondary
problems

21. Management
Rigid flat foot:
1. Surgery is required
2. Tendon transfer , osteotomies , arthrodesis
3. Others surgery fails then , triple arthrodesis is
performed

22. PHYSIOTHERAPY MANAGEMENT
AIM: 1. TO REDUCE PAIN 2. TO INCREASE
FLEXIBILITY
3. STRENGTHEN
WEAK MUSCLES
4. PATIENT
EDUCATION AND
REASSURANCE

23. Pain management
Rest
Activity modification
Cryotherapy
Massage
Nonsteroidal anti-inflammatory drugs
Ultrasound
Pulsed electrical stimulation

24. Exercises
• Walking bear foot
• Flexibility exercises are passive ROM exercises
of all ankle and all foot joints
• Stretching of gastrocnemius soleus complex
and peroneus brevis muscles to facilitate varus
and foot adduction
• Heel cord stretch for the achilles tendon and
calf muscles to relief tight heel cord

25. Strengthening
• Strengthening exercises are given to anterior and
posterior tibialis muscle and the flexor hallucis
longus , intrinsic, interosseus plantaris muscles
and abductor hallucis to prevent valgus and
flattening of anterior arch .
• Arch muscle strengthening exercises with
theraband
• Global activation of the muscles known to
support the medial longitudinal arch and the
varus with and without resistance
• Single leg weight bearing
• Toe walking

26. Proprioception
Toe and heel walking
Single leg weight bearing
Descending an inclined surface are exercises
Toe clawing of towel and pebbles
Forefoot standing on stair
Toe extension
Toe fanning / spreading
Heel walking