Surgery, with Special Reference to Podiatry Part 24

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 a.s.sistance.

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 f.l.a.n.g.es 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 f.l.a.n.g.e formation is generally necessary to accomplish this. An outer f.l.a.n.g.e 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 ma.s.sage 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 ma.s.sage 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 a.s.sociated 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. Gonorrha.

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: ma.s.sage, 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 pa.s.s 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 a.s.sociated 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 s.h.i.+ny 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 a.s.sociated 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.