Flat foot / Pes planus — বাংলা ক্লিনিক্যাল নোট

1) Definition / সংজ্ঞা

Pes planus বা flat foot হলো এমন একটি foot posture/deformity যেখানে medial longitudinal arch কমে যায় বা মাটির সাথে প্রায় লেগে যায়, বিশেষ করে weight-bearing অবস্থায়। এটি দুই ধরনের হতে পারে:

1. Flexible flat foot
   দাঁড়ালে arch হারিয়ে যায়, কিন্তু বসলে / পায়ের আঙুলের ওপর দাঁড়ালে arch ফিরে আসে। শিশুদের ক্ষেত্রে এটি খুব common এবং অধিকাংশ ক্ষেত্রে pain না থাকলে treatment লাগে না।
2. Rigid flat foot
   দাঁড়ানো ও non-weight-bearing—দুই অবস্থাতেই arch ফিরে আসে না; pain, stiffness, subtalar motion limitation থাকতে পারে। এটি clinically বেশি important, কারণ tarsal coalition, arthritis, vertical talus, neuromuscular disease থাকতে পারে।

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2) Etiology / Causes — কারণগুলো

A. Congenital / Developmental cause

• শিশুর physiological flat foot
  ছোট শিশুদের arch naturally কম থাকে; foot-এর fat pad ও ligamentous laxity-এর কারণে arch flat দেখায়। অনেক শিশুর arch ৫–১০ বছর বয়সে ধীরে ধীরে develop করে।
• Familial tendency / Genetic predisposition
  পরিবারে flat foot থাকলে শিশুর flat foot হওয়ার tendency বেশি হতে পারে।
• Ligamentous laxity / Hypermobility
  ligament ঢিলা হলে arch support কমে যায়। Marfan syndrome, Ehlers-Danlos syndrome, Down syndrome-এর মতো connective tissue disorder-এ হতে পারে।

B. Acquired cause — adult বা adolescent-এ

• Posterior tibial tendon dysfunction — সবচেয়ে গুরুত্বপূর্ণ adult acquired cause
  Posterior tibial tendon medial arch-এর প্রধান dynamic stabilizer। এই tendon দুর্বল, inflamed, stretched বা torn হলে arch collapse করে এবং adult acquired flatfoot হয়।
• Obesity / high BMI
  body weight বেশি হলে arch-এর ওপর chronic load পড়ে, arch collapse ও pain বাড়ে।
• Tight Achilles tendon / gastrocnemius tightness
  heel cord tight হলে abnormal pronation বাড়ে, arch collapse worsen করতে পারে।
• Trauma
  midfoot/hindfoot injury, Lisfranc injury, calcaneus/navicular/first metatarsal injury-এর পর acquired flat foot হতে পারে।
• Inflammatory arthritis / degenerative arthritis
  Rheumatoid arthritis, seronegative arthropathy, osteoarthritis হলে ligament/tendon/joint support নষ্ট হয়ে flat foot হতে পারে।
• Diabetic neuropathy / Charcot arthropathy
  neuropathy থাকলে midfoot collapse হয়ে severe flatfoot deformity হতে পারে।
• Tarsal coalition / accessory navicular / congenital vertical talus
  বিশেষ করে rigid painful flatfoot-এ এগুলো rule out করতে হবে।

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3) Symptoms — লক্ষণগুলো

অনেক flexible flat foot asymptomatic থাকে। Symptomatic হলে নিচের features দেখা যায়:

• Medial arch pain — পায়ের arch-এর ভেতরের দিকে ব্যথা।
• Medial ankle pain — posterior tibial tendon-এর course বরাবর ankle-এর ভেতরের দিকে pain/swelling।
• Long standing বা walking-এ pain/fatigue — অনেকক্ষণ দাঁড়ালে পা ক্লান্ত লাগে।
• Running/jumping/high-impact activity-তে pain বাড়ে।
• Non-supportive sandal/flat footwear পরলে pain বাড়ে।
• Toe raise করতে কষ্ট — single-leg heel raise করতে pain/weakness হলে posterior tibial tendon dysfunction সন্দেহ।
• Heel valgus / ankle inward roll — পায়ের গোড়ালি বাইরে ঝুঁকে যায়, ankle ভেতরের দিকে collapse করে।
• Too many toes sign — পেছন থেকে দেখলে lateral toes বেশি দেখা যায়।
• Lateral ankle pain — arch collapse বেশি হলে lateral impingement-এর কারণে ankle-এর বাইরের দিকে pain হতে পারে।

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4) Clinical diagnosis — bedside diagnosis specific points

Inspection

• Patient-কে barefoot দাঁড় করিয়ে front, side, back থেকে দেখবেন।
• Medial arch height কমেছে কিনা দেখবেন।
• Hindfoot valgus আছে কিনা দেখবেন।
• পেছন থেকে too many toes sign দেখবেন।
• shoe wear pattern ও callosity দেখবেন।

Flexible vs rigid test

• Non-weight-bearing অবস্থায় arch ফিরে আসে কিনা দেখবেন।
• Tiptoe test / single-leg heel raise test
  Flexible flat foot হলে tiptoe করলে arch ফিরে আসে এবং heel varus হতে পারে।
  Painful বা unable single-leg heel raise → posterior tibial tendon dysfunction suggestive.

Jack test / Hubscher maneuver

• Great toe dorsiflexion করলে arch তৈরি হয় কিনা দেখা হয়।
  Arch তৈরি হলে flexible; না হলে rigid বা structural pathology ভাবতে হবে।

Palpation

• Posterior tibial tendon tenderness: medial malleolus-এর পেছন থেকে navicular insertion পর্যন্ত।
• Plantar fascia tenderness।
• Sinus tarsi/lateral ankle tenderness — lateral impingement।

Range of motion

• Subtalar joint movement restricted হলে rigid flatfoot, tarsal coalition বা arthritis consider।
• Ankle dorsiflexion কম হলে Achilles/gastrocnemius tightness।

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5) Investigations — কখন কী test করবেন

No investigation needed

• Asymptomatic flexible flat foot in child — pain নেই, functional limitation নেই, arch tiptoe-তে ফিরে আসে → usually imaging লাগে না।

X-ray — first-line imaging when symptomatic

Weight-bearing foot X-ray — AP, lateral, medial oblique views.

Specific radiographic points:

• Meary angle / talo–first metatarsal angle
  downward apex >4° → medial arch collapse suggestive।
• Talar declination angle

24° হলে flatfoot support করে।

• Calcaneal inclination angle
  <18° হলে pes planus suggestive।
• AP view — talonavicular uncovering, forefoot abduction।
• Medial oblique view — calcaneonavicular coalition সন্দেহে useful।

MRI

Indication:

• posterior tibial tendon tear/degeneration suspected
• spring ligament injury
• persistent pain despite conservative treatment
• surgical planning
• arthritis/coalition soft tissue assessment

Ultrasound

• posterior tibial tendon tenosynovitis/tear dynamic assessment
• cost-effective, operator dependent

CT scan

• suspected tarsal coalition
• complex bony deformity
• pre-operative planning

Lab tests — only if systemic cause suspected

• ESR, CRP — inflammatory arthritis/infection suspicion
• RF, anti-CCP — rheumatoid arthritis
• HbA1c — diabetic neuropathy/Charcot risk
• Vitamin D/calcium — bone pain/osteomalacia suspicion only
• Uric acid — acute gout differential

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6) Differential diagnosis

• Physiological flexible flatfoot of childhood
• Posterior tibial tendon dysfunction / adult acquired flatfoot
• Tarsal coalition
• Accessory navicular syndrome
• Congenital vertical talus
• Rheumatoid arthritis / seronegative arthritis
• Diabetic Charcot arthropathy
• Plantar fasciitis
• Achilles tendinopathy / tight gastrocnemius
• Cerebral palsy or neuromuscular deformity
• Generalized ligamentous laxity / Ehlers-Danlos / Marfan syndrome

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7) Complications — রোগটি untreated থাকলে কী হতে পারে

• Chronic foot pain — arch, heel, medial ankle pain long-standing হতে পারে।
• Posterior tibial tendon dysfunction progression — tendon stretched → partial tear → arch collapse → deformity fixed হতে পারে।
• Lateral ankle impingement — heel bone outward shift করলে ankle-এর বাইরের দিকে bone impingement pain হয়।
• Gait abnormality — হাঁটার pattern বদলে যায়, endurance কমে।
• Plantar fasciitis / Achilles pain — abnormal biomechanics-এর কারণে।
• Knee, hip, low back pain — excessive pronation lower limb alignment alter করতে পারে।
• Bunion, hammertoe, callosity, shoe-fitting problem।
• Midfoot/hindfoot arthritis — severe rigid deformity বা adult acquired flatfoot late stage-এ।
• Diabetic patient-এ ulcer/Charcot deformity risk — neuropathy থাকলে বিশেষ সতর্কতা দরকার।

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8) Treatment / Management

Core principle

Flat foot-এর মূল treatment medicine নয়।
Main treatment হলো: education, footwear modification, orthosis, physiotherapy, weight control, activity modification. Medicine শুধু pain/inflammation control করে; arch permanently তৈরি করে না।

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A. Non-pharmacological management

Asymptomatic flexible flatfoot

• Reassurance
• Observation
• No routine medicine
• No compulsory expensive custom orthotic
• Child pain-free হলে normal activity allowed
  AAOS অনুযায়ী pain/discomfort না থাকলে flexible flatfoot treatment দরকার হয় না।

Symptomatic flexible flatfoot

• Supportive shoe: firm heel counter, medial arch support, motion-control shoe
• Prefabricated arch support / insole
• Custom orthosis: severe pain, deformity, PTTD, failed simple insole
• Heel cord stretching: Achilles tight থাকলে
• Physiotherapy:
  • calf stretch
  • posterior tibialis strengthening
  • eccentric posterior tibial tendon exercise
  • short-foot exercise
  • toe curls
  • balance/proprioception training
• Activity modification:
  • running/jumping কমানো temporarily
  • low-impact exercise: cycling, swimming
• Weight reduction if overweight

Adult acquired flatfoot / PTTD

• Acute painful stage: rest, ice, activity reduction
• Medial arch support, ankle brace, AFO
• Severe acute pain: walking boot immobilization short course
• Physiotherapy: eccentric posterior tibial strengthening
• Surgery consider if 3–6 months conservative treatment fail or progressive deformity/rigid arthritis থাকে।

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9) Pharmacological management — Bangladesh prescription-style drug list

Important: NSAID একসাথে দুইটা দেবেন না। CKD, peptic ulcer, GI bleed, uncontrolled HTN, heart disease, anticoagulant use, pregnancy—এসব থাকলে NSAID avoid/adjust করতে হবে।

1. Paracetamol

• Generic name: Paracetamol / Acetaminophen
• Therapeutic category: Non-opioid analgesic
• Pharmacological class: Para-aminophenol derivative; analgesic-antipyretic
• Why used in flat foot: mild arch/ankle pain control; inflammation কমায় না, কিন্তু pain-safe first choice।
• Adult dose: 500 mg 6 hourly PRN; maximum 3–4 g/day. Liver disease/alcohol use হলে lower maximum.
• Duration: 3–5 days PRN; persistent pain হলে diagnosis review.
• Bangladesh available brand examples:
  • Napa 500 mg tablet — Beximco
  • Ace 500 mg tablet — Square
  • Fast 500 mg tablet — ACME
  • Xcel 500 mg tablet — ACI
  • Tamen 500 mg tablet — Eskayef
  • Renova 500 mg tablet — Opsonin
• Side effects: usually mild; rash, allergy; overdose → severe hepatotoxicity.
• Important interactions: alcohol, enzyme-inducers such as phenytoin/carbamazepine/phenobarbital/rifampicin; long-term high-dose with warfarin may increase INR risk.
  MedEx lists Napa as Paracetamol 500 mg and classifies Paracetamol under non-opioid analgesics; adult tablet dose is 1–2 tablets every 4–6 hours up to 4 g/day, with cautions for hepatic/renal impairment and alcohol-related hepatotoxicity.

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2. Diclofenac sodium gel — topical NSAID

• Generic name: Diclofenac sodium 1% w/w gel
• Therapeutic category: NSAID for musculoskeletal pain
• Pharmacological class: Non-selective COX inhibitor, topical NSAID
• Why used in flat foot: localized medial arch/ankle pain, tendon-related pain, soft-tissue inflammation; systemic side effect কম।
• Adult dose: 2–4 g gel affected area-তে দিনে 3–4 বার apply; rub lightly.
• Duration: 7–14 days; pain persistent হলে review.
• Bangladesh available brand examples:
  • DicloGel 1% w/w gel — Incepta, 50 g
  • Diclomol 1% w/w gel — Mundipharma, 20 g
  • Moov 1% w/w gel — Astra Biopharmaceuticals, 25 g
  • Voligel 1% w/w gel — Beximco, 50 g
  • Voltagel 1% w/w gel — Eskayef, 10/20/50 g
  • Fastfit 1% w/w gel — General Pharmaceuticals, 50 g
• Side effects: local burning, redness, rash, dermatitis; large-area/prolonged useে systemic NSAID effects possible।
• Interactions: systemic absorption কম; তবে oral NSAID, anticoagulant, steroid-এর সাথে caution. Open wound, eye/mucosa, occlusive dressing avoid.
  MedEx diclofenac sodium guidance lists gel dosing as 2–4 g applied 3–4 times daily and lists available Bangladesh gel brands including Diclomol, DicloGel, Moov, Voligel, Voltagel and others.

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3. Ibuprofen

• Generic name: Ibuprofen
• Therapeutic category: NSAID
• Pharmacological class: Non-selective COX inhibitor
• Why used in flat foot: inflammatory pain, tendonitis-type pain, walking-related painful flare।
• Adult dose: 400 mg orally after meal every 8 hours PRN.
• Duration: 3–5 days; prolonged use avoid unless supervised.
• Bangladesh available brand examples:
  • Advel 400 mg — Opsonin
  • Flamex 400 mg — ACI
  • Profen 400 mg — ACME
  • Reumafen 400 mg — Beximco
  • Xflam 400 mg — available as ibuprofen brand
  • Intaflam 400 mg — Incepta
• Side effects: dyspepsia, GI ulcer/bleeding, dizziness, headache, renal impairment, edema, BP rise, bronchospasm in NSAID-sensitive asthma।
• Interactions: aspirin/other NSAIDs, warfarin/antiplatelets, corticosteroids, SSRIs, ACE inhibitor/ARB/diuretic, lithium, methotrexate, cyclosporine/tacrolimus, quinolones.
  MedEx lists ibuprofen indications for mild-to-moderate inflammatory pain including backache, rheumatic pain and muscular pain, its therapeutic class as NSAID, and Bangladesh brands including Advel 400 mg, Flamex 400 mg, Profen 400 mg and Reumafen 400 mg.

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4. Naproxen sodium

• Generic name: Naproxen sodium
• Therapeutic category: NSAID
• Pharmacological class: Non-selective COX-1/COX-2 inhibitor
• Why used in flat foot: longer-acting NSAID; posterior tibial tendinopathy/soft tissue inflammatory painে useful।
• Adult dose option: 250–500 mg orally twice daily after meal; maximum 1000 mg/day.
• Acute musculoskeletal pain option: 500 mg initially, then 250 mg every 6–8 hours if needed.
• Duration: 5–7 days; elderly/CKD/GI riskে avoid or specialist supervision.
• Bangladesh available brand examples:
  • Naprosyn 500 mg — Radiant
  • Naprox 500 mg — Eskayef
  • Napix 500 mg — Modern
  • Napryn 500 mg — Healthcare
  • Anaflex 500 mg — ACI
  • Naproxen 500 mg — Amico / Novatek / Guardian
• Side effects: heartburn, abdominal pain, nausea, diarrhea, dyspepsia, headache, vertigo, drowsiness, edema, GI bleed, renal impairment।
• Interactions: warfarin/anticoagulant, aspirin, SSRI, methotrexate, ACE inhibitor/ARB, diuretic, antacid/sucralfate may delay absorption.
  MedEx lists naproxen for tendonitis, bursitis and pain, describes COX inhibition, gives adult musculoskeletal dosing, and lists Bangladesh brands such as Naprosyn, Naprox, Napix, Napryn and Anaflex.

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5. Diclofenac sodium — oral NSAID

• Generic name: Diclofenac sodium
• Therapeutic category: NSAID
• Pharmacological class: Non-selective COX inhibitor
• Why used in flat foot: moderate inflammatory pain, soft-tissue injury, peri-articular pain; short course only.
• Adult dose: 50 mg orally 2–3 times daily after meal; maximum 150 mg/day.
• SR option: Diclofenac SR 100 mg once daily after meal.
• Duration: 3–5 days; CV/GI/renal risk থাকলে avoid.
• Bangladesh available brand examples:
  • Clofenac 50 mg — Square
  • Diclofen 50 mg — Opsonin
  • Intafenac 50 mg — Incepta
  • Mobifen 50 mg — ACI
  • Fengel 50 mg — Pharmadesh
  • Volcan 50 mg — Biopharma
• Side effects: epigastric pain, nausea, diarrhea, dizziness, headache, edema, rash, GI ulcer/bleed, renal impairment, BP/CV risk।
• Interactions: lithium, digoxin, anticoagulants, cyclosporine, methotrexate, quinolones, other NSAIDs, steroids.
  MedEx lists diclofenac adult FC tablet dose as 75–150 mg/day in 2–3 divided doses, gel dosing separately, interactions with lithium/digoxin/anticoagulants/cyclosporine/methotrexate/quinolones, and therapeutic class as NSAID.

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6. Etoricoxib

• Generic name: Etoricoxib
• Therapeutic category: NSAID
• Pharmacological class: Selective COX-2 inhibitor
• Why used in flat foot: short-term moderate inflammatory pain; relatively less gastric irritation than nonselective NSAID, but cardiovascular risk বেশি গুরুত্বপূর্ণ।
• Adult dose for musculoskeletal pain practice: 60 mg once daily after/without food; severe acute painে 90 mg once daily short course may be used by physician.
• Duration: 3–5 days; lowest effective dose, shortest duration.
• Bangladesh available brand examples:
  • Tory 60/90/120 mg — Square
  • Etocox 60/90/120 mg — General
  • Oricox 30/60/90/120 mg — Incepta
  • Recox 60/90/120 mg — Renata
  • Ribox 60/90/120 mg — Beximco
  • Etorix 60/90/120 mg — Eskayef
• Side effects: edema, BP rise, palpitation, dizziness, dyspepsia, renal impairment, rare hypersensitivity/skin reaction।
• Interactions: warfarin/oral anticoagulants, ACE inhibitor/ARB/diuretic, lithium, cyclosporine/tacrolimus; avoid uncontrolled HTN, ischemic heart disease, heart failure, CKD, pregnancy/lactation.
  MedEx describes Etoricoxib as a COX-2 selective inhibitor, advises the shortest possible duration due to cardiovascular risk, lists important contraindications including uncontrolled hypertension and ischemic heart disease, and lists Bangladesh strengths/brands including Tory and many alternatives.

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7. Esomeprazole / Omeprazole — gastroprotection when NSAID is necessary

Esomeprazole

• Generic name: Esomeprazole
• Therapeutic category: Proton pump inhibitor
• Pharmacological class: H+/K+ ATPase inhibitor
• Why used: NSAID-induced gastric ulcer risk reduction, dyspepsia, GERD.
• Dose: 20 mg once daily before breakfast while taking NSAID; high-risk patients may need longer physician-directed course.
• Duration: usually during NSAID course; NSAID ulcer healing/risk reduction indicationে 20 mg once daily.
• Bangladesh brand examples: Maxpro MUPS 20 mg — Renata; Maxpro 20 mg; DP/other local PPI brands vary.
• Side effects: headache, nausea, abdominal pain, diarrhea/constipation, flatulence; long-term useে hypomagnesemia, B12/iron absorption issue, fracture risk, C. difficile risk.
• Interactions: diazepam via CYP2C19, ketoconazole/iron/digoxin absorption pH-dependent, methotrexate caution.
  MedEx states esomeprazole is used for prevention/treatment of NSAID-associated gastric ulcers and lists risk reduction dosing as 20 mg once daily; therapeutic class is Proton Pump Inhibitor.

Omeprazole

• Generic name: Omeprazole
• Therapeutic category: Proton pump inhibitor
• Pharmacological class: H+/K+ ATPase inhibitor
• Why used: NSAID-associated duodenal/gastric ulcer treatment or prophylaxis.
• Dose: 20 mg once daily; ulcer healing usually 4 weeks, continue further 4 weeks if not healed.
• Bangladesh brand examples: Seclo 20 mg capsule — Square; Losectil 20 mg; PPI 20 mg.
  MedEx lists Seclo as Omeprazole 20 mg and includes NSAID-associated ulcer treatment/prophylaxis with 20 mg once daily.

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10) Bangladesh doctors commonly prescribe what and why

Flat foot/pes planus pain নিয়ে orthopedic/medicine/GP prescription-এ commonly দেখা যায়:

1. Paracetamol 500 mg
   mild pain; safest first-line analgesic; inflammation কমায় না।
2. Topical diclofenac gel 1%
   localized arch/ankle painে; oral NSAID-এর GI/renal risk কমাতে।
3. Ibuprofen 400 mg after meal
   short-term inflammatory pain, tendonitis-type flare।
4. Naproxen 250/500 mg after meal
   longer duration pain control; tendonitis/bursitis-like painে।
5. Diclofenac 50 mg or SR 100 mg
   moderate inflammatory painে short course; GI/CV/renal risk দেখে।
6. Etoricoxib 60/90 mg
   selected adult patientে short-term pain; GI risk কিছুটা কম হলেও CV/HTN risk বেশি—careful selection দরকার।
7. PPI: Esomeprazole 20 mg / Omeprazole 20 mg
   NSAID দিলে gastric protection, dyspepsia বা ulcer risk থাকলে।

Not routine for simple flat foot: antibiotic, steroid, opioid, muscle relaxant, calcium/vitamin D, uric-acid drug—unless separate diagnosis exists.

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11) Prevention — কীভাবে prevent/control করবেন

• Body weight normal রাখুন।
• Supportive footwear ব্যবহার করুন; worn-out shoe avoid।
• Long standing হলে arch-support insole ব্যবহার করুন।
• Sudden running/jumping increase করবেন না; activity gradually increase করুন।
• Daily stretching:
  • calf stretch
  • Achilles stretch
  • plantar fascia stretch
• Strengthening:
  • towel curl
  • short-foot exercise
  • heel raise
  • resisted inversion with band
• Diabetes, RA, obesity, hypertension control করুন।
• শিশুর painless flexible flatfoot নিয়ে panic করবেন না; কিন্তু pain, asymmetry, rigidity, limping হলে orthopedic evaluation।
• Adult-এ new-onset painful flatfoot বা single-leg heel raise unable হলে early referral—PTTD progression prevent করার জন্য।

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Overview / Summary

Pes planus হলো medial longitudinal arch collapse। শিশুদের flexible painless flatfoot অধিকাংশ ক্ষেত্রে physiological এবং reassurance যথেষ্ট। Adult acquired painful flatfoot-এর সবচেয়ে গুরুত্বপূর্ণ কারণ হলো posterior tibial tendon dysfunction। Diagnosis প্রধানত clinical—weight-bearing inspection, tiptoe test, Jack test, too many toes sign, single-leg heel raise। Painful/rigid/progressive case-এ weight-bearing X-ray first-line; MRI tendon/ligament pathology বা surgical planning-এ useful। Treatment-এর foundation হলো footwear, orthosis, physiotherapy, weight control; drugs শুধু pain/inflammation control করে।

Actionable Plan / Steps

1. Pain নেই + flexible child → reassurance, observation.
2. Pain আছে → supportive shoe + arch support + calf stretch + posterior tibialis strengthening শুরু।
3. Acute pain → ice, activity reduction, topical diclofenac gel ± paracetamol.
4. Moderate inflammatory pain → একটিমাত্র NSAID short course; GI risk থাকলে PPI.
5. Red flags: rigid flatfoot, unilateral progressive deformity, severe medial ankle swelling, unable single-leg heel raise, diabetic neuropathy, inflammatory arthritis signs → orthopedic referral + imaging.
6. 3–6 মাস conservative treatment fail হলে specialist surgical evaluation।

Reference List

Textbook / Orthopedic reference

1. Solomon L, Warwick D, Nayagam S. Apley & Solomon’s System of Orthopaedics and Trauma, latest ed. Foot deformities / foot and ankle disorders section.
2. Coughlin MJ, Mann RA, Saltzman CL. Mann’s Surgery of the Foot and Ankle, adult flatfoot and posterior tibial tendon dysfunction chapters.
3. Canale ST, Beaty JH. Campbell’s Operative Orthopaedics, adult acquired flatfoot / pediatric foot deformity chapters.

Guideline / consensus / clinical sources

1. AAOS OrthoInfo. Flexible Flatfoot in Children.
2. AAOS OrthoInfo. Progressive Collapsing Foot Deformity / Posterior Tibial Tendon Dysfunction.
3. ACFAS Clinical Consensus Statement: Appropriate Clinical Management of Adult-Acquired Flatfoot Deformity. DOI: 10.1053/j.jfas.2019.09.001.
4. AAFP. Deu RS. Tendinopathies of the Foot and Ankle. 2022.

Peer-reviewed journals with DOI

1. Mosca VS. Flexible flatfoot in children and adolescents. J Child Orthop. 2010;4:107–121. DOI: 10.1007/s11832-010-0239-9.
2. Henry JK, Shakked R, Ellis SJ. Adult-Acquired Flatfoot Deformity. Foot & Ankle Orthopaedics. 2019. DOI: 10.1177/2473011418820847.
3. Dars S, Uden H, Banwell HA, Kumar S. Foot orthoses for paediatric flexible pes planus: systematic review update. PLOS ONE. 2018;13:e0193060. DOI: 10.1371/journal.pone.0193060.
4. Herchenröder M, et al. Evidence for foot orthoses for adults with flatfoot: systematic review. Journal of Foot and Ankle Research. 2021;14:57. DOI: 10.1186/s13047-021-00499-z.

Md.Rafiqul Islam Lipu,Date:-15-06-2026 Monday,Time:-07-18-12 Pm