Name of the Condition

• Flat foot [pes planus] (acquired), right foot
• Also known as "fallen arches" or "acquired flatfoot."

Summary

Flat foot, or pes planus, is a condition where the arch of the foot collapses, causing the entire sole to come into contact with the ground. It can be acquired over time due to various factors and typically affects the right foot in this instance.

Causes

• Weakening of the posterior tibial tendon
• Injuries or trauma to the foot
• Arthritis or other inflammatory conditions
• Obesity putting excess strain on the arch
• Poorly fitting footwear

Risk Factors

• Aging
• Obesity
• Family history of flat feet
• High-impact sports or physical activity
• Pre-existing health conditions such as diabetes or hypertension

Symptoms

• Pain or discomfort in the foot, particularly in the arch or heel
• Swelling along the inside of the ankle
• Increased pain with activity
• Foot or leg fatigue
• Uneven wear on shoes

Diagnosis

• Physical examination by a healthcare provider
• Imaging tests such as X-rays or MRI to assess bone and tendon integrity
• Gait analysis to observe the biomechanics of walking

Treatment Options

• Orthotic devices to support the arch and improve foot alignment
• Physical therapy to strengthen surrounding muscles and tendons
• Pain relief through non-steroidal anti-inflammatory drugs (NSAIDs)
• Weight management to alleviate pressure on the foot
• Surgical intervention in severe cases, to correct bone or tendon misalignment

Prognosis and Follow-Up

• With proper management, individuals can lead normal lives with minimal discomfort.
• Regular follow-up is crucial to monitor symptoms and adjust treatments as necessary.

Complications

• Untreated flat foot can lead to chronic pain, misalignment of the knees and hips, and the development of further conditions such as arthritis or plantar fasciitis.

Lifestyle & Prevention

• Maintain a healthy weight to reduce pressure on the feet.
• Wear supportive shoes with proper arch support.
• Engage in exercises that strengthen the foot and leg muscles.

When to Seek Professional Help

• Persistent foot pain that affects daily activities
• Swelling in the foot or ankle
• A noticeable change in the foot's appearance or function

Additional Resources

• American Orthopaedic Foot & Ankle Society (aofas.org)
• National Institute of Arthritis and Musculoskeletal and Skin Diseases (niams.nih.gov)

Tips for Medical Coders

• Ensure the correct ICD code M21.41 is used for acquired flat foot specifically affecting the right foot.
• Verify if the condition is acquired and not congenital, as the coding will differ.
• Document any related conditions or complications for comprehensive coding.