Edward Adams

The terms weak foot and flat foot will be used to designate the mild and the severe forms of the same condition which include all the deviations from the normal height of the arch of the foot.

Flat Foot may be congenital or acquired, the former being a very infrequent deformity, and the latter one of the most common pathologic conditions.

Congenital Flat Foot is a deformity of infrequent occurrence, and in some cases is associated with defective formation of the bones of the foot. In this condition the whole foot is displaced outward in relation to the leg; the sole is rolled outward, the inner malleolus is prominent and the foot is abducted on itself, and in severe cases, it cannot be replaced in its normal position on account of the contracted tissues.

Treatment. The foot should be massaged and, by gentle manipulation, forced into its proper position and held by a plaster-of-Paris dressing, changed at the proper intervals. A tenotomy may be required to bring the foot into its proper position.

When the child begins to walk, a well-fitting arch support should be worn.

Acquired Flat Foot. The common form of acquired flat foot is the static variety, which is an expression of a disproportion between the body weight and the sustaining power of the muscles and ligaments.

Common Causes. 1. The use of improper shoes is by all means the most frequent cause of flat foot, and frequently makes all of the following causes more pronounced.

2. Weakness and insufficiency of the muscles, resulting from poor general condition; advancing age; convalescence from acute illness; from childbirth; and from injuries of the leg, especially fractures.

3. Prolonged standing, especially on hard wood and stone floors.

4. Rapid body growth.

5. Rapid increase in body weight.

6. Excessive weight bearing.

7. Shortened condition of the gastrocnemius muscle.

Other causes are rickets; inflammation of the ankle joint, as in tuberculosis; or, as a result of a badly treated fracture of the ankle-joint; or, as a result of paralysis of the muscles of the inner side of the leg.

Pathology of Acquired Flat Foot. The pathologic condition is due to change in the relations of the bones rather than to any change in the bones themselves. The abnormal position is an exaggeration of the normal yielding of the foot under weight bearing. The front of the astragalus rotates inward, and with it the bones of the leg turn at the hip-joint.

The deformity is essentially a displacement of the astragalus on the bones of the tarsus. The scaphoid, cuneiform, and the base of the first metatarsal move downward and inward with the head of the astragalus; the outer border of the foot is made more concave and the inner border becomes convex in extreme cases. In the severest cases, the head of the astragalus, and scaphoid may be displaced below the plane of the other bones. The ligaments are respectively shortened and stretched in the severest cases and there is a loss of motion in certain of the tarsal articulations, due to faulty apposition of joint surfaces, and to constant strain.

Symptoms. The feet burn and tire easily and feel stiff and lame. They may swell, and the size of the shoe worn must be then increased. Later, a painful period generally begins in which walking is avoided and a dragging pain in the arch and behind the inner malleolus is noticed. This is increased by walking and standing and tender points may be found under the scaphoid and on the upper surface of the heel. The foot feels strained and irritated and is a constant source of discomfort. The inner malleolus is generally more prominent and the foot is displaced outward in relation to the leg. The height of the arch is somewhat diminished; it may be much lowered, or it may be flat on the ground.

When the foot is really flattened, it presents two types, one the flexible flat foot, in which the arch can be restored by gentle manipulation; the other, the rigid foot, which is held by structural changes in the position of deformity.

An intermediate type is sometimes seen, in which the peroneal spasm is so great that the foot is held abducted and everted as long as the spasm lasts (spastic flat foot.)

Some symptoms of flat foot that are less generally recognized, which are of great value in diagnosis are: corns, ingrowing nails, callosities on the sole of the front of the foot, enlargement of the great-toe joint, and pain (especially at night) in the calves of the legs and backbone, which is aggravated by standing and walking.

Diagnosis. The diagnosis of flat foot, whether flexible or rigid, is made chiefly by inspection. The difficulty comes in the milder cases, which form the bulk of those seen, and in which the changes in form are slight.

Symptoms. The symptoms, as described by the patient, are the most reliable and points of tenderness under the arch or heel would help to confirm the diagnosis. Some help may be obtained from a wet impression of the foot, on a piece of paper, but the slighter cases show but little changes in the imprint. In most normal feet, the outer border of the foot touches the paper, and in flat foot, only two areas bear the weight, one on the inner side of the front of the foot, and one under the inner part of the heel. An X-ray picture is often of great assistance.

The diagnosis of rheumatism is frequently made in flat foot, and is often the source of much misdirected treatment. Rheumatism should be diagnosed only in connection with unmistakable symptoms of rheumatism in the upper extremities.

So-called “rheumatic” pains in the knees and hips may be secondary to flat foot.

Prognosis. As a rule, this condition does not recover spontaneously. Under ordinary conditions, uncomplicated cases should be at once relieved by proper treatment, and in time should be cured.

Unfavorable factors are: great weight; disease of the ankle-joint; the presence of bony spurs under the os calcis.

The prognosis is more favorable in young adults than in persons of advanced age. Patients, who without relief have worn the ordinary supports sold at the stores will, as a rule, manifest extreme sensitiveness as to the fit of any of the supports which may be applied.

Treatment. The foot must be restored and held in its normal position and measures must be adopted to quiet local irritability or inflammation, and to strengthen the muscles. The best treatment does not consist in the permanent wearing of a flat-foot support; the support should be regarded in the same light as one uses a crutch in a fracture of the leg.

As a preliminary to all treatment, the use of proper shoes must be insisted upon. A shoe should be as wide in front, as the unshod foot, when bearing the weight of the body.

Supports. Flexible supports may be made of boiler felt; one objection to these is their liability to stretch. They are of service in young children, in mild cases, and in convalescent cases where it is desirable to have the patient use a flexible instead of a stiff support in order to bring the muscles into play.

Rigid supports are best made of tempered spring steel (18 to 20 gage), forged hot to fit a cast of the foot. They may also be made of phosphor-bronz, celluloid or aluminum.

The shape of the plate is largely a matter of judgment. The easiest way to determine the shape of the plate to be used in a given case is to have the patient stand with the operator’s hand under the inner side of the foot; the operator then places the foot in the normal position and notes where the pressure must be applied to secure the proper correction; when the anterior part of the foot is flattened, a slight dome must be constructed in the front of the plate; when the os calcis is clearly tilted over, the plate must have two flanges at the heel to hold it in place. In general, the plate must reach forward to a point just behind the great-toe joint, and must furnish support as far as the front of the heel. The plate should be higher on the inner side, and a flange formation is generally necessary to accomplish this. An outer flange prevents the foot from slipping off the outer side of the plate. When the foot no longer requires support, the plate should be gradually discontinued.

The “Thomas” sole may be used in mild cases. This is made by building up the inner part of the sole of the shoe one-eighth to one-quarter of an inch higher than the outer side, thus securing a slight inversion of the foot.

Exercise and massage of the deficient muscles should form a part of the routine treatment in all cases of flexible flat foot.

To diminish local inflammation and irritability, the foot should be soaked in hot water; hot and cold alternate douches should be applied, and hot-air treatment and massage should be employed.

Rigid Flat Foot. Rigid flat foot cannot be successfully treated until the position of the foot is corrected. The patient should be anesthetized, and, by the use of a wedge as a fulcrum, the bones should be forced into position. A pressure of about two hundred pounds is generally necessary to effect this reduction. After this, the foot is placed in a plaster cast, in extreme adduction and is allowed to remain thus encased for three weeks. After this, a properly fitted plate should be worn. The results are usually satisfactory.

Operative Treatment. Cases that have resisted all other forms of treatment, may be cured by the removal of a wedge-shaped piece of bone, with the base downward and inward at the point of greatest inward convexity, that is, in the neighborhood of the head of the astragalus. Osteotomy of the front of the os calcis and neck of the astragalus will at times be necessary for a radical cure.

Many other operative procedures have been advised for flat foot and they have been employed with varying successes.

Hallux Flexus or Hammertoe. The upward prominence of a toe (usually the second or third) in a rigid position, is known as hallux flexus or hammertoe. In this condition the toe is flexed in its second joint so that the end bears on the ground, while the junction between the phalanges makes a prominence upward. Helomata and callosities may develop on the end of the toe, but the chief discomfort is in the disturbances which arise on the prominence which presses against the side of the foot-gear.

Treatment. A knowledge of the forces at work will show how futile must be any effort to correct this deformity by strapping or bandaging. There is a shortening of the plantar fibres of the lateral ligament of the joint. The trouble does not lie in the flexor tendons, as it seems, and operations directed to this point fail. Even with incision of the lateral ligaments, followed by the application of a splint, recurrences are common and amputation must be the procedure.

The condition described as hammertoe may exist in several or in all of the toes, the great toe being least often involved. This occurs most often as a result of wearing improper shoes, but is sometimes the consequence of paralysis.

Flexed or Clawed Toes. Extreme flexion of all but the great toes causes the weight to be borne by their dorsal aspect. In this condition the toes, and especially the small ones, develop painful helomata on the prominent joints, and the small toe may become the source of great discomfort.

Treatment. Radical surgical measures are here indicated. Tenotomy or amputation is essential to a cure.

Painful Heel. Painful heel is a suggestive but unscientific term applied to tenderness of the under side of the heel. It is associated with one of the following conditions:

1. Spurs running out from the under side of the os calcis found by the aid of the X-ray.

2. Inflammation of the bursae under the os calcis.

3. Flat foot.

4. Gonorrhoea.

5. Focal infection.

Treatment. Where a spur of bone causes the unpleasant symptoms, the excrescence should be excised.

When focal infections are the primary cause of painful heel, operative procedure to remove the source of infection is imperative and will prove curative.

Palliative measures are: massage, douches, hot air, a metal plate worn under the painful area, rest. The back of the foot should be cut away to relieve pressure.

Metatarsalgia—Morton’s Disease. Metatarsalgia is characterized by an acute pain, cramplike in character, occurring at the base of the third or fourth toes.

The pain comes on suddenly while the foot is in action, and is usually accompanied by a “snapping of the bones.” The pain is so acute that it is not uncommon for the patient to seek relief by taking off the shoe and rubbing the foot.

In persons suffering with this condition it will be regularly noticed that the weight is thrown upon the ball of the foot, on the metatarsophalangeal joints, either because of a weak foot, or because of a tendency of the toes to turn up.

Treatment. 1. Proper strapping to raise the arch and bring the ends of the toes down.

2. A pad across the ball of the foot behind the metatarsal heads, also brings the toes down.

3. Recommend shoes, wide across the ball, with a higher or lower heel than ordinary, as the case indicates.

Hallux Valgus. The term hallux valgus is applied to a deviation or displacement of the great toe outward, toward the outer border of the foot.

In normal feet, the line of the great toe when prolonged backward, should pass through the centre of the heel. This relation in civilized communities is seen only in the feet of infants. In adults it is observable only in the bare-footed races.

Cause. It is frequently associated with flat foot, gout and rheumatism, but it is primarily due to the use of inappropriate foot-gear. It is only considered pathologic when the deviation is more than fifteen degrees.

Pathology. The displacement outward (which reaches 30 to 40 degrees in the average case and may reach 90 degrees) of the phalangeal part of the great-toe joint, uncovers the inner part of the head of the metartarsal bone, and here the cartilage degenerates, and the bone becomes condensed at its outer part. The inner lateral ligament is lengthened and thickened and the sesamoid bones become displaced outward and are often thickened.

Under the skin, at the inner and prominent aspect of the foot, is to be found a bursa, which is liable to inflammation under pressure, and is known as a bunion. The inflammation in this sac may extend to the joint and thus disintegrate it.

Symptoms. The toe is displaced outward and a reddened and shiny condition of the thickened skin exists over the inner prominence and perhaps over the top of the toe joint. The great toe if seriously displaced, must lie over or under the other toes, the former being the more common position. In other cases the second toe may be crowded up as a hammertoe. The joint is painful and the inner toes, being crowded to the outer side of the foot, are the seat of corns and callosities. Flat foot is frequently associated with this condition.

Treatment. In mild cases, the stocking should be split to allow a separate stall for the great toe, and broad toed boots should be worn. If flat foot exists, a support should be supplied for its aid in restoring the position of the great toe. In severe cases, nothing short of an operation is likely to be of value. A toe-post may be worn for a time in mild cases.

Amputation of the head of the metatarsal bone gives uniformly good results.

The toe is straightened and flexible; ankylosis with this operation does not occur.

In operations for hallux valgus there are two distinct purposes acting as determining factors in making a choice in a given case as to which is indicated. These are: (1)the radical operation for the correction of the deformity, and (2)the palliative operation for the alleviation of symptoms by the removal of the hypertrophied portion of the metatarsal head which is exposed to pressure. Among operations in the first mentioned class, the one known as the Mayo operation is, in all probability, the best. The entire head of the metatarsal is amputated, and the bursa is turned in over the cut end of bone, to diminish the amount of shortening and to prevent ankylosis of the joint. This latter consideration, however, is an unnecessary one, for in operations within this joint, ankylosis does not occur when the synovial surface of the phalanx is left undisturbed, even when the bursa is not employed as an intervening pad.

In the other class of operations for the relief of symptoms, no attempt is made to straighten the toe. A wedge-shaped piece of the exostosis is removed, against which pressure has caused symptoms.

A palliative operation devised by Dr. Robert T. Morris of this city, is one easy of accomplishment and serves every purpose where a radical operation is interdicted. It is known as the “button-hole” operation because of the fact that only a small incision is made immediately above the protuberant bone through which a sharp chisel is inserted, cutting off the offending “button” of bone.

An operation which in the hands of the authors has proven of distinct value, and which has probably not been previously described eliminates both the deformity and its painful symptoms. This operation which is described below, is less severe than other radical operations and not very much more so than the usual palliative ones.

The incision is made on the dorsum of the great toe over the offending joint and just to the inner side of the extensor tendon. This tendon is held to the outer side, out of the way. The knife penetrates the capsule of the joint and opens it above and laterally.

An effort is made to preserve the integrity of the capsule below (floor) as only the intra capsular end of the metatarsal is removed. These two factors are of the utmost importance. When the joint capsule is slit open along its dorsal and two lateral aspects, sufficient room is obtained for the insertion of the wire saw, and all of that portion of the metatarsal lying within the joint proper is removed. There is thus accomplished a correction of the deformity with very little shortening of the great toe. Usually its length after this operation is about the same as the second toe.

The next step in the operation is closure of the synovial sac or joint capsule. A stitch on either side and two above are all that is necessary. The floor of the sac remains intact and nothing beneath it, in the ball of the foot, has been disturbed. Many operators invade this area and remove the sesamoids. This is unwarranted as the transverse level of the ball of the foot is lost, and the weight is put directly upon the newly formed joint, depriving it of its normal support, or of padding from below.

One other omission in this operation is that of the bursal flap over the raw end. This is found entirely unnecessary as results prove, and its omission hastens healing considerably. The bursa over the metatarsophalangeal articulation in these cases is nearly always inflamed, and consists of a mere fibrous pad. Its dissection from the normal position is a real loss at that site, and of questionable benefit over the cut bone, as motion in the joint is as good or better without it.

The skin closure is made without drainage, and no wet dressing employed for fear of the solution filling the cavity whence the bone was removed and carrying with it infectious material. A dry sterile dressing is all that is required, and a splint to maintain a straight position for the toe.

Four or five days complete rest for the part are ordinarily sufficient. Following this, walking about the room is permitted with the aid of a stick. After ten days, when the patient can get about fairly well without the assistance of a stick, the foot may safely be shod with an “arctic” of sufficient size.

CLUBFOOT OR TALIPES

The most common form of clubfoot, and therefore the deformity of that character most frequently encountered, is characterized by inversion of the sole of the foot, elevation of the heel, and a twisting and turning of the front part of the foot. This deformity is typical of congenital clubfoot, which, as stated, is the most common form of that deformity. The acquired form is usually the result of infantile paralysis.

Congenital Clubfoot is most frequently double, and males are more frequently affected than females; in unilateral or one-sided clubfoot, one side is not more frequently affected than the other.

Etiology. Very little is known as to the cause of congenital clubfoot but it is not infrequently associated with other congenital deformities. It appears to be hereditary in a great many instances. The greater number of cases appear without definable cause, except perhaps from intra-uterine pressure. There are, however, a number of these cases that are associated with malformation of the bones of the foot and leg, such as absence of the scaphoid; defect of the tibia; fusion of a number of the tarsal bones.

Pathology. The sharp adduction and plantar flexion, at the tarsal joints, produce a deformed position of the foot. As a result of these, the heel is small and elevated; the dorsum of the foot is prominent; and the outer border usually, and, in extreme cases, the dorsum of the foot, bears the weight of the body in walking and in standing; the sole of the foot is bent sharply in, and twisted at the tarsal joint. In fact, all the bones are changed in shape, and the inner muscles, tendons and ligaments are shortened by contraction, while the ones to the outer side are lengthened.

The distortion of certain individual bones is of importance. The astragalus is the seat of the most important changes. It is tipped downward at its front end, and its posterior part articulates with the tibia, its anterior articular surface projecting under the skin; its neck is elongated and bent inward and downward, so that its scaphoid articulation faces inward and downward and not forward.

This is the most important change in clubfoot, because the anterior end of the astragalus, the head of the bone, carries inward and downward with it the scaphoid, the three cuneiforms, and the inner three metatarsal bones. The scaphoid articulates with the inner side rather than the front of the astragalus and, in extreme cases, forms a joint surface with the inner malleolus. It may be somewhat changed in shape, being flattened and drawn inward and upward.

The os calcis is generally poorly developed, and its front end is rotated downward, and bent inward; the outer surface of the bone is more convex and the inner surface more concave than normal, and since the anterior facet looks inward and downward, it carries with it the cuboid and the two external metatarsal bones. The changes in the other bones are not important; the chief obstacles to reduction lie in the os calcis and in the astragalus.

Soft Parts. The muscles, ligaments, tendons, and fascia at the lower and inner side of the foot are shortened, and lengthened at the outer and upper side. The plantar fascia being one of the chief obstacles to reduction, the tendons are displaced, especially those on the inner side of the foot.

Symptoms. Double clubfoot is usually accompanied by an awkward and unsteady gait, in which each foot is in turn lifted high to clear the foot on the ground, and the toeing in is, of course, excessive. The weight is borne on the outer side of the foot, and all elasticity of gait is absent.

On the outer border of the foot, where the weight is borne, callosities and bursae develop; the calves of the legs are small, and the knee joint may be lax.

The gait in single clubfoot is less awkward, but characterized by the same features. The foot is rigid in the deformed position, and in cases of marked deformity, the foot cannot be manipulated into the normal position.

Diagnosis. Congenital clubfoot cannot be mistaken for any other condition. The diagnosis is self-evident.

Prognosis. There is no tendency of this deformity to right itself, or to improve. Early and proper treatment will, if continued long enough, insure a cure in children and an improvement in adult cases; but it must be remembered that there is a decided tendency to relapse, even after operation, unless the foot is kept in an overcorrected position for a number of years.

Treatment. In young infants, treatment should be begun as early as two weeks after birth and should consist in frequent gentle massage and manipulations. After the part can be brought into an overcorrected position by gentle manipulation, it should be put up in a plaster cast, for a period of three weeks and this treatment should be continued until the position of the foot is corrected.

The manipulations consist in grasping the dorsum of the foot gently but firmly with one hand, and holding the leg with the other. The foot is then dorsally flexed and everted. This treatment should be repeated at least three times a day and should not be rough enough to cause the infant to cry.

Treatment of clubfoot in older children and adults is a much more difficult proposition and consists in the combination of two or more methods of procedure.

In order to correct the extreme adduction in these cases, extreme force must sometimes be employed. This may be accomplished by bending and bearing down on the foot, with its outer border resting on the apex of a wooden wedge. The rotation of the foot is corrected by grasping the foot in one hand, and the heel in the other, and twisting with the necessary amount of force. The inversion of the sole is also corrected by the use of this wedge as a fulcrum.

In this way the tendo Achillis and the plantar fascia are stretched, and the dorsal flexion is secured by laying the patient on the face with the knee bent and the front of the thigh resting on the table. The lower leg is then vertical, and by bearing down on the front of the foot with the necessary amount of force, dorsal flexion of the foot is secured, and by hooking the fingers around the os calcis, its position is improved.

A modified Thomas wrench may be used in the correction of clubfoot; but this must be done with great care, as the violence practised in this method, the tearing of the ligaments and other soft parts, is often attended with great danger; osteomyelitis, tuberculosis, neuritis, and even death from fat embolism, and extensive sloughing of the soft parts are not infrequently seen after the use of this and other bone crushing instruments.

The removal of a wedge of bone from the outer side of the foot and the removal of the neck of the astragalus are employed. Tenotomy and the transplantation of tendons are also often practised, when other methods of treatment fail.

Acquired Clubfoot. The cause of acquired clubfoot maybe infantile paralysis, joint disease, traumatism, or it may be due to affections of the brain or spinal cord.

Paralysis. Infantile paralysis affecting the muscles of the front and outer side of the lower leg, will result in a condition similar to congenital clubfoot. Other paralytic causes are: spastic or cerebral paralysis, hereditary ataxia, etc.

Traumatic. A condition resembling clubfoot may result from improperly treated fractures of the ankle-joint or tarsal bones.

Joint Disease. In tuberculosis, arthritis deformans, and other diseases of the ankle-joint, a condition similar to clubfoot is sometimes seen as a result of muscular contraction.

Talipes Equinus is rarely congenital. It is usually due to infantile paralysis of the extensor muscles, or to cicatrical contraction of the calf muscles, as a complication of hip disease. It varies from inability to flex the ankle beyond a right angle, to walking on the heads of the metatarsal bones. The astragalus is partially displaced forward and forms a prominence on the dorsum of the foot; the plantar fascia is shortened and callosities and bursae are formed under the heads of the metatarsal bones. Primarily, the obstacle to reduction is the tense Achilles tendon, and in advanced cases the shortened plantar fascia and posterior ligament of the ankle-joint constitute obstacles.

Talipes Equino-Varis (down and in foot) is the most common form of this deformity.

It is either congenital or acquired, and in the latter case it is due to infantile paralysis of the extensor and peroneal muscles. The heel is drawn up, and the anterior half of the font is drawn inwards and inverted. The inner border of the foot is shortened, and in neglected cases the patient walks on the outer side of the cuboid, under which a bursa is formed. Secondary contraction of the plantar fascia, ligaments, and short plantar muscles follows. There is a great increase in the obliquity of the neck of the astragalus in congenital cases, so that the scaphoid and anterior half of the foot, together with the dorsal tendons are carried inward. As a result of the equinus, the upper surface of the astragalus projects forward, and only its posterior portion comes in contact with the tibia and fibula. The ligaments of the inner side of the foot are shortened and the shape of the other tarsal bones is secondarily altered.

Talipes Equino-Valgus (down and out foot). This condition is rare as a congenital deformity. The anterior half of the foot is deflected outward, and the inner border comes in contact with the ground. The scaphoid is placed outward, and the head of the astragalus projects into the sole.

The acquired variety results from paralysis of the tibialis posticus and flexors, with secondary contraction of the peronei muscles.

Talipes Calcaneus is rare as a congenital deformity. It is usually the result of infantile paralysis of the muscles of the calf. The patient walks on the heel, and the anterior half of the foot is drawn up. Valgus or varus are associated with it; the more common form is talipes calcaneo-valgus.

Talipes Cavus (Pes Cavus), or hollow foot, is a condition in which the arch of the foot is greatly exaggerated. It is rarely congenital but is frequently seen in connection with clubfoot, especially in its paralytic forms. In its mildest form, it exists in a highly arched foot, often hereditary. It may also be the result of too short shoes (Chinese ladies’ foot).

Treatment. The condition is best remedied by division of the contracted soft parts, a forcible reduction of the bones, held in place by plaster of Paris. When the patient begins to walk, it is advisable to have a stiff, flat, steel plate placed in the length of the shoe between the layers of the leather sole, running from which, over the dorsum of the foot, is a stout leather strap. At each step, downward pressure is thus exerted on the dorsum of the foot.