Pes Planus - Test for Massage Therapist

What is the Pes Planus
- It is a decreased medial logitudinal arch and a pronated hindfoot and flat foot
- = Hindfoot valgus
- Pronation foot : eversion of the calcaneus, Abduction of the foot, some dorsiflexion at the subtalar joint

Types of Pes planus
1. Functional pes planus
  - Ligamentous lacity or muscle weakness
  - It can be corrected
2. Structural or rigid pes planus
  - bony malformation or change
  - It can not be altered by positional changes or voluntary effort

Arches of the foot
1. Medial longitudinal arch
  - This arch are the calcaneus, talus, navicular, three cunieforms and three medial metatarsals
  - This arch is not a true arch, since its configuration is not formed ny the shape of the bones alone
  - Related soft tissues on the medial longitudial arch
    1. long and short plantar ligaments
    2. Plantar calcaneuonavicular(spring) ligament
    3. plantar aponeurosis
    4. Tibialis anterior, posteiror
    5. Peroneus longus, brevis
    6. Flexor hallucis longus, flexor digitorum longus, intrinsic muscles of the foot
2. Anterior transverse arch
  - It composed of the five metatarsal head and muscles support from the lumbricals and interossei
3. Lateral longitudinal arch
  - True architectural arch with the cuboid bone, between the calcaneus and the fourth and fifth metatarsals

Development
- Newborn babies lack all three arches : normal for infants to have pes planus
- The medial longitudinal arch begins to develop after about two years of age
- Varus of knee is normal before 1.5 year old
- Valgus of knee is normal before 1.5 years old to 3 years old
- Knee become straight to 6 years old

Causes
- Hypermobility in the foot due to joint capsule and ligamentous laxity.
- poor biomechanic of the subtalar joint and midtarsal joint
- shortened musscles ; gastrocnemius, soleus, achilles tendon, peroneus longus, brevis and tertius, IT band
- weakness of the muscles ; tibialis posteior and anterior
- habitual poor posture : standing with the feet wide apart
- footware
- congenital abonoramlities in the bones of the foot, leg and thigh
- nerve lesions to common peroneal or posteior tibial nerve
- trauma to the foot or ankle

What happens in the soft tissues of the foot and leg? (Symptoms)
- Talar head is displaced medially and inferiorly from the navicular bone
- Foot is pronated
- Pain may or may not be present. It is most frequently noticed on the palntar surface.
- Short and hypertonic muscles : peroneus longus, brevis, tertius, gastrocnemius and soleus, dorsal muscles of the foot
- Lengthened and weak muscles ; tibialis posterior, tibialis anterior, long toe flexors, intrinsic muscles of the foot, plantar muscles of the foot
- Adhesion may be present around the peroneal and Achilles tendon.
- Ankle joint and superior tibiofibular joints may be hypomobile.
- Plantar fascilitis
- valgus of the knee
- Medial rotation of tibia
- IT band contracture —> IT band friction syndrome
- Anterior tilt of hip
- Hyperlordosis
- Hyperkyphosis
- Shoulde and neck forward position
- TMJ dysfunction
- Tension headache

SOAP
1. Subjective information : health history
2. Objectibe information
  1. Observation
    - Gait Assessment : Pronation occurs throughout the stance phase(normal gait : pronation occurs 15 to 20 percent into the contact phase)
    - Postural Assessment
      1. Mild : 4 to 6 ° // Moderate : 6 to 10 °// Severe : 10 to 15°
      2. Valgus knee
      3. internal rotation of hip
      4. flat and pronated foot
      5. Talar head bulges medially
      6. Bunion may be noticeable
      7. Forefoot abducted
  2. Palpation
    1. Tenderness : spring ligament, long plantar ligament, plantar fascia
    2. Trigger points are likely in peroneus longus and brevis
  3. Testing
    - ROM
      1. AF ROM
        Eversion : greater than 10°
        Dorsiflexion : limited with sever pes planus
        Increased internal rotation with femoral anteversion
      2. PR ROM
      3. AR ROM
        Tibialis anterior, tibialis posterior and extensor hallucis longus may reveal reduced strength
    - Length test : gatrocnemius, soleus and the peroneals may be shortend
    - Special test
      1. A functional or structural pes planus test : Functional/Structural Pes Planus Test – Clinical Examination of the Musculoskeletal System (pressbooks.pub)
      2. Morton’s neuroma test : Morton’s Neuroma: Best Clinical Test! – YouTube
3. Treatment Plan
  - Treatment for the tight muscles : heat. deep massage, trigger point release, stretch, home care(stretch)
  - Treatment for the losse muslces : cold, stimulating massage, home care(strengthening exercise)
    1. Fascia on lateral side of leg, calf area
    2. Trigger point on gastrocnemius, peroneus longus, brevis
    3. Friction on Achilles and peroneal tendons and on the lateral border of the foot
    4. Passive stretch
      1. soleus, gastrocnemius, extensor digitorum longus (Fore foot is not used as a lever, since this places a stress on the overstretched midtarsal joints. intread, the calcaneus is used)
      2. Passive relaxed dorsiflexion and inversion of the ankle
    5. Joint play techniques : hypomonile superior tibiofibular joint and anke, excluding the hypermobile medial arch
      1. G3 posterior glide on 1st metatarsophalangeal joint
      2. G3 anteriorl glide oscillation on Talocrural joint
    6. RIP : lengthen peroneus longus, brevis, tertius
    7. Tibialis anterior, tibialis posterior, toe flexors and intrinsic foot muscles ; brisk repetitive petrissage, tapotement, point kneading( Avoid long stretching technique)
  - Self -care
    1. Avoid activites without supported footware. Client shoud wear support sandals instead of walking in bare feet
    2. Contrast foot bath for stressed feet
    3. Apply ice locally if there is any inflammation(plantar fasciitis)
    4. Self massage to leg, foot and ankle
    5. Stretch shorthend muscles: gastrocnemius, soleus, peroneus longus, brevis and tertius –> Dorsiflexion, Inversion of foot,
    6. Strengthen weak muscles :
      1. Active resisted strengthening using a theraband or rubber band : Inversion, dorsiflexion, adduction of foot ( To strengthening of tibialis anterior)
      2. Grip pencils or pebbles, or to scrunch up towels with toes(To strenghen the intrinsic muscles)
    7. Refer the client
      1. referal to orthopedic doctor
      2. At first, client wear the orthotics for one or two hours and gradually increase the time spent wearing them.