Flat feet

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.