+DEFORMITIES+
+PES PLANUS, OR FLAT FOOT+
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. Gonorrhœa.
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.