May 1954 APLEY: Flat Foot 241

quite how to dispose of it the manufacturers havenever explained-it is insoluble and may eventuallycause obstruction to a normal sanitary system.The patient seldom needs encouragement to

take a full normal diet after leaving hospital, but awarning should be given to avoid eating the skinsof certain fruits and vegetables, such as plums andtomatoes, since these can cause an obstructive bolusat the stoma. Extra salt should be taken wheneverthe small bowel discharges become more fluid.Full activity can be undertaken, for it is possibleto play cricket, golf, tennis, football and even swimand dive without disturbing the bag, which beingslender remains imperceptible even under abathing dress. If any complication to the stomaarises which makes the management of theileostomy impossible, the patient must return to

hospital. Prolapse, retraction and fistula can onlybe treated by a revision of the ileostomy performedthrough a laparotomy incision; reconstructiveoperations confined to the stoma are ineffectiveand frequently lead to further trouble.

BIBLIOGRAPHYBENJAMIN, D. (1954), Amer. J. Surg., 87, I27.BROOKE, B. N. (1952), Lancet, ii, o02.BROOKE, B. N. (I954), 'Ulcerative Colitis and its Surgical

Treatment,' Livingstone, Edinburgh.COUNSELL, P. B., and LOCKHART-MUMMERY, H. E.

(1954), Lancet, i, II3.GABRIEL, W. B. (1948), 'Principles and Practice of Rectal

Surgery,' Lewis, London.GABRIEL, W. B., and LLOYD-DAVIS, O. V. (1935), Brit. J.

Surg., 22, 520.HOFFMAN, E., and MACHT, A. (1954), Amer. J. Surg., 87, 140.LAHEY, F. H. (x95x), Ann. Surg., 133, 726.PATEY, D. W. (I95x), Proc. roy. Soc. Med., 44, 423.RANKIN, F. W. (1927), J. Amer. med. Ass., 89, i961.

FLAT FOOTBy A. GRAHAM APLEY, F.R.C.S.

Consultant Orthopaedic Surgeon, Rowley Bristo Orthopaedic Hospital; Assistant to the Dept. of Orthopaedics.St. Thomas's Hospital, London.

IntroductionAmong the foot defects which cause disability,

flat foot is one of the commonest. Normally thebody weight is borne through two half-columnswith the medial border of each foot raised from theground (Wood Jones, 1943). The resulting archmay be high or low, yet still be healthy; but inflat foot the arch is not merely low, it has collapsedinwards (Fig. I).

Aetiology(a) Anatomical Causes

There are four groups of anatomical peculi-arities which predispose to flat foot. Theinheritance of many of these peculiarities explainsthe frequent familial incidence of the disorder.

I. The lower limb may be wrongly 'set' on thetrunk. The entire limb may be externally rotatedor the leg only may be rotated from the kneedownwards In either case, the patient stands likeCharlie Chaplin and the line of body weight fallstoo far medially (Fig. 2). As a result, when thebody moves forward in walking the force of bodyweight imposes considerable strain upon the apexof the arch and tends to topple it over.

2. The leg may be wrongly 'set' on the thigh,

FIG. I

IST NORMAL ARCHES2ND LOW ARCHES3RD FLAT FEET

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242 POSTGRADUATE MEDICAL JOURNAL May 1954

cID ~(Reproduced by courtesy of the Royal Society of Medicine)

FIG. 2.-If the limb is externally rotated or the kneevalgus, the line of weight falls too far medially andthe arch is liable to collapse.

for example, in knock knees. Here, too, as inexternal rotation, the line of body weight falls toofar medially. The combination of knock knee andflat foot is common in children aged two to sixyears.

3. The foot may be wrongly 'set' on the leg.A short calf muscle or Achilles tendon preventsadequate dorsi-flexion of the ankle (unless the kneeis bent). In walking, the knee is straight and, asthe front leg swings forward, the back leg mustdorsiflex considerably at the ankle. If adequatedorsiflexion is hindered by a tight calf the Achillestendon bowstrings across the outer side; this isaccompanied by a topple of the arch to the medialside.

4. The forefoot may be wrongly. ' set' on thehindfoot. The forefoot may be varus, with thesoles of the feet tending to face each other; thisis sometimes due to a relatively short tibialisanticus muscle, and sometimes to a short orelevatedfirst metatarsal (Morton, I935). Whateverthe cause, as the weight comes on to the forefoot inwalking the first metatarsal head is forced downfrom its elevated position on to the ground; theapex of the arch is pushed downwards and inwardsand flat foot results. Perkins (I948) hasemphasized that the varus forefoot is commonerthan generally supposed, but the deformity maynot be recognised unless the foot is correctlyexamined with the heel held square. Onceweight is on the foot the obvious deformity is thevalgus heel (Fig. 3).There is, in addition, a rare congenital flat foot

in which the foot is convex on its plantar surface(' boat-shaped '), the talus being in the equinusposition and the forefoot dorsiflexed.

(b) Physiological CausesThe bony arch of the foot is potentially unstable.

:I -,3 · ·9

(Reproduced by courtesy of the Royal Society of Medicine)FIG. '3.-A varus forefoot has the sole facing inwards.

When weight is taken the varus forefootmasquerades as a valgus heel.

It is bound together by ligaments, but these arecapable of resisting short term stress only; indeed,their main function is to act as sensory end organs,and when they are stretched appropriate musclesare reflexly brought into action. Even the mostanatomically perfect foot will become rapidlyand grossly flat unless it has muscles of good bulkand tone to support it. The physiological faultmay lie in the muscle itself or in its nervouscontrol.

I. Inadequate nervous control. We are not hereconcerned with the gross and obvious inadequacieswhich result from poliomyelitis or spina bifida, forin these conditions flat foot is overshadowed byother disabilities. An example of inadequatenervous control is infantile flat foot. A babyhas to learn to balance first its head, then itstrunk and eventually to balance the whole bodyon the feet. This difficult art is not requiredduring the early months of life; but sometimesthe balancing reflexes fail to develop even after thechild has begun to walk. In that event the archinevitably collapses with body weight. Myeliniza-tion of the pyramidal fibres to the foot is incom-plete at birth and the plantar responses in babies isextensor. If the infantile flat foot persists intoearly childhood the extensor responses maypersist too, and it is tempting to assume thatbalancing cannot be easily learned until myeliniza-tion is complete (Apley, 1948).

2. Inadequate Muscles. After illness or en-forced recumbency the muscles may temporarilybe weak and the arch consequently falls whenwalking is resumed.A more lasting form of muscle weakness

accompanies a generally poor posture. The child(often a pre-adolescent girl) presents a familiar

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May 1954 APLEY: Flat Foot 243

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FIG. 4.-Spasmodic flat foot; the tendonsstand out clearly.

flabby contour with head stuck forward, mouthopen, chest flat, back rounded and abdomenprotruberant. The gluteal muscles are concernedlargely with posture (Wiles I949). They help tostraighten the hip and knee, and to twist the limboutwards. This twist cannot be imparted to thefoot which is anchored to the ground, and so therest of the limb turns outwards relative to the foot.As a result, the arch is lifted and the line ofweight corrected only when the glutei workproperly.

Relative inadequacy of muscle is well illustratedby the fat middle-aged housewife whose increasein weight imposes great strain upon the arch.Moreover, a housewife stands still for long periodsof time, for example, when washing dishes. Pro-longed standing is more harmful to the feet thanwalking because, during walking, the muscles

supporting the arch alternately contract and relaxwhich is the best training for a muscle.

(c) Infective CausesIn all probability there are no' infective ' causes

of flat foot. Gonorrhoea has been blamed butwith inadequate evidence. There is, however, thecondition known as spasmodic flat foot whichbehaves like an infective arthritis of the subtaloidand midtarsal joints. The name is unfortunatefor, although the condition is spasmodic (in thesense that it is associated with spasm) it is not a trueflat foot. The patient, who is usually in his early'teens, develops pain soon after starting an activejob. The peronei and extensors are seen to be inspasm (Fig. 4), and movement at the subtaloidand midtarsal joints is abolished. Althoughspasmodic flat foot is usually thought to be infectivein origin, X-rays sometimes show a bar of bonejoining the calcaneum to the scaphoid (Badgley1927), or bridging the calcaneum and talus (Harrisand Heath, I948). The condition is usuallytreated by rest in plaster or by arthrodesis.Because it is a quite separate entity from flat footit will be omitted from the remainder of this paper.Pathology(a) The Alteration in Shape

i. The apex of the arch ' drops'; it may do soat the talo-scaphoid joint, at the scapho-cuneiformjoint, or at both joints, (Ewan Jack, I953). Theexact site can best be shown by lateral radiographs.

2. A flat foot is one in which the apex of thearch is not merely low but has also shifted medially.The apex having toppled over the heel necessarilybecomes valgus. This valgus heel has often beendescribed as a cause of flat foot and theoreticallythis may be true; it is much more likely, however,to be an inevitable sequel.

3. Shephard (i95i) has shown that the subtaloidand midtarsal joints are functionally one hingejoint comparable with the radio-ulnar joint, andthat supination and pronation are the only move-ments at this composite joint. In the earlierdescriptions I have referred to the apex of the archdropping and shifting medially; these are merelyindividual components of pronation, a movementwhich is also accompanied by slight abduction.As a result, the tuberosity of the scaphoid becomesunduly prominent.

4. The alterations in shape of the foot whichhave been described usually occur slowly over aperiod of months or years. Occasionally, however,they develop quickly as after a long period of bedrest. The rapid stretching of the ligaments whichthen occurs is painful. Presumably microscopictears occur in the ligaments; these tears evoke a

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POSTGRADUATE MEDICAI, JOURNAL Maby 1954

.....

............

t· ·ia rIE..··~~......................... .......................i'iiiii

FIG. 5

(a) The foot is not only flat. (b) Its apex has shifted medially. (c) The scaphoid tuberosity becomes tooprominent

response which is inflammatory in the sense thatit is the initial change towards repair, with swellingand lymphocytic infiltration. This is the condi-tion known as acute foot strain.

(b) The Effects of Flat FootShould alterations in shape persist they are

followed by degenerative changes in the joints.In consequence the foot becomes stiffer (rigidflatfoot), a change accentuated by advancing years.As osteoarthritis supervenes the joints are neces-sarily used near the extremes of range; thecapsule is continually being stretched, and pain isproduced. Fortunately, the owners of stiffish feetoften possess equally stiff boots or shoes, whichlimit the joint excursion and may succeed inkeeping this excursion within the painless range.More serious are the effects upon the forefoot.

The intrinsic muscles function at a disadvantageand are constantly being squashed on to the ground.They therefore weaken, and weak intrinsic musclesresult in claw toes and metatarsalgia, often withpainful callosities. Moreover, the dropping ofthe arch, combined with weak intrinsic muscles,leads to a splaying of the metatarsals. Shoesprevent the great toe from splaying and halluxvalgus with bunion formation results. This is byno means the only factor in the production of ahallux valgus, but it is a significant one. It isimportant to realise that foot troubles, except intheir earliest stages, rarely occur in isolation.Weak muscles result not only in flat foot but alsoin forefoot disorders: and not only do these groupsof conditions arise from a common cause, but onemay predispose to the other. In the foot one

trouble leads to another. The presentingsymptoms, and even the more immediately obvioussigns, are often only distantly related to thefundamental cause.

Clinical Features(a) SymptomsAt one time high arches were much admired.

Later it became fashionable to say that flat footwas a condition which troubled doctor more thanpatient, and that 'fine athletes have flat feet.'Neither statement is true. High arches arenearly always troublesome and flat foot is aconsiderable nuisance even though it may remainpainless until middle life. There are three mainsymptoms:

I. Alteration in Shape. The growth of theschool medical service has made alterations inshape of the foot a common cause for referringchildren to orthopaedic clinics. Almost equallycommon is the complaint of alteration in shape ofthe shoes which wear badly and unevenly, needingrepair or renewal every few weeks. Adults lessoften complain of the altered shape of their ownfeet until secondary changes such as hallux valgussupervene.

2. Pain. Pain resulting from flat foot is rare inadolescents, and almost unknown in children.If spasmodic flat foot is excluded the pain in youngpeople is due to rapid stretching of ligaments.This acute foot strain is rare, and occurs eitherafter unaccustomed prolonged standing or follow-ing recumbency. Pain is felt exactly where theapex of the arch is toppling, that is, on the inner

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Mat I954 APLEY: Flat Foot 245

side of the sole of the foot underneath thc scaphoid,an area which is also tender.

Adults not infrequently complain of painfulflat foot. The inner border of the foot aches, andthe ache increases as the day goes on, sometimesradiating up the shin. When flat foot has beenpresent for many years, and especially if stiffcramping shoes have been worn, pain occurs as aresult of osteo-arthritic changes. The foot is stiffand the joints may be tender.

3. Associated foot troubles. In middle life flatfoot is often accompanied by splaying of themetatarsals, hallux valgus, claw toes and meta-tarsalgia. All these disorders may result from theflat foot or may share with it a common aetiology;and all these conditions sometimes produce pain.The pain may occur at the site ot a bunion, underthe metatarsal heads, or on the dorsum of ahammer toe. The important point is that treat-ment is required for the foot as a whole and notmerely for the forefoot.

(b) SignsGeneral examination. First, the patient as a

whole must be assessed. The age and build arenoted. If the foot changes are severe a neuro-logical examination may be advisable.

Examination of the foot. A simple routine willbe described during which certain questions mustbe answered: Is it a true fiat foot ? It so, are thereany underlying anatomical abnormalities ? Is themusculature adequate ? And are there anysequelae ?The patient stands on a stool with both lower

limbs bare from the mid-thigh downwards. Thefeet should be pointing forwards and so shouldthe patient's face-this is important for if he looksdown at his feet he loses balance and the footassumes an abnormal posture. The legs areinspected for abnormal rotation and for knockknees. Next, the feet themselves are examined;if the arch has toppled over the scaphoid tuberositywill appear unduly prominent in addition to thearch being too low. The patient is now asked toturn round. In a flat foot the heel is valgus, thetendo achillis angulating laterally near its insertion.The patient should n-ext stand on his toes. Unlessthe foot is rigid the arch re-forms, the prominentscaphoid tuberosity disappears and the tendoachillis straightens.The patient now sits and each foot is examined

in turn while held with the heel square. It is thenpossible to see if the forefoot is varus and if thefirst metatarsal is short and elevated. Theforefoot is also examined for associated disorderssuch as hallux valgus, hammer toe and callosities.

Next, the foot is palpated for tenderness: firstunder the arch, then at the midtarsal region and

finally at the forefoot. \With the heel still heldsquare and the knee straight, movements of the footare tested. First the ankle; does it dorsiflex abovea right angle ? If there is a tight tendo achillis,this dorsiflexion does not occur without the heelmoving into valgus as the tendon takes its shortcut. The subtaloid, midtarsal and metatarso-phalangeal joints are each examined in turn todetermine their range of movement.

TreatmentAn arch which is merely low is not pathological

and should not be treated. The treatment of atrue flat foot may be summarised thus:-

I. Treatment of the Anatomical Causes (mainlyin children).

2. Treatment of the Physiological Causes (atall ages).

3. Treatment of the Pathological Sequels(mainly in adults).

(a) Treatment of the Anatomical CausesI. Limbs which are externally rotated pre

dispose to flat foot. There is no good method ofcorrecting this rotation. Teaching the child towalk with toes turned in is difficult and probablyuseless.

2. Because knock knee leads to the stress ofbody weight falling too far medially, it is customaryto compensate by raising the inner side of the heelof the shoe; up to the age of five an eighth of aninch, and three sixteenths in older children.This traditional treatment elevates the child's heeland the mother's morale, but does little more.Fortunately the legs have nearly always grownstraight without treatment by the time the childreaches six years of age.

3. A tight tendo achillis is easily compensated byraising the child's heel. Two extra thickness ofrubber usually suffice. Some surgeons maintainthat a tight tendo achillis can be stretched byphysiotherapy. I have tried asking the physio-therapist to treat only one foot and my impressionis that treatment has no effect; some tendonsbecome normal and others do not. Probably theforce of manipulation is expended upon the mid-tarsal joint and leaves the tendo achillis unaffected.There is a peculiar fear that high heels are a firststep on the primrose path. Mothers are nearlyalways reluctant to allow an adolescent daughterto wear a raised heel. It is not necessary, however,to raise the heel more than I in. above the normal,though flat sandals require raising by at least i in.Some surgeons advise operative elongation of

the tendo achillis. This procedure alters theshape of the calf, and should never be done ingirls. The heel should be raised until the girl isold enough to wear shoes which are normally made

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I.

(Reproduced by courtesy ofthe Royal Society of

Medicine)

FIG. 6.-External rotation of the limb restores the arch. The ball of the great toe must press firmly into the ground.

with a higher heel. Even in boys the operationis very rarely indicated and then only if shorteningpersists and is not compensated for by a i in. raiseof the heel. If operation is required it is bestdone, not by subcutaneous tenotomy, but by aformal exposure, lengthening the tendon andsuturing it in the elongated position. The legshould be held in plaster for six weeks.

4. Treatment of a varus forefoot is difficult.It is tempting to raise the inner border of the soleof the shoe, a method which may sometimesprevent the arch from toppling over, but whichperpetuates the causal deformity and should not beemployed in children. On the contrary it is betterto raise the inner side of the heel and either leavethe sole unaltered or to raise its outer side; this isat first uncomfortable, but has the advantage thatevery step forces the forefoot to untwist (pronate).Catterall (1952) employs a spring pronating deviceattached to the shoe, which serves the samepurpose. A quicker method is to manipulate thefoot under anaesthesia with two Thomas'swrenches; plaster is then applied in the over-corrected position for three months. If the varusforefoot is due to a short elevated first metatarsal,osteotomy has been advocated (Lambrinudi, 1937)to correct the deformity, followed by a bone graft,and Stamm (1953) now uses a curved osteotomyfor this purpose.(b) Treatment of the Physiological CauseA child who needs shoe adjustment should also

be given a short course of muscle training, becausethe faulty position of the foot so often leads tofaulty muscle balance. In addition, the physio-logical faults should be dealt with as follows:-

Infantile flat foot due to delay in learning tobalance cannot be treated. There is no way ofhurrying myelinisation. Having made quite surethat there is no spina bifida the surgeon shouldreassure the mother that in almost every child thesereflexes will develop, but that, as with otherprocesses such as speech, the onset may be delayedin an otherwise normal child. Once the plantarresponse has changed to become flexor, the archusually develops within three to six months.It is customary to wedge the inner side of the heel,a practice which delights the mother and makes itonly slightly harder for the child to walk.Weak muscles following rest should be treated

before the patient gets up. Regular intermittentcontractions of the long and short muscles shouldbe taught and practised, and faradic foot bathsmay help. When the patient first gets up it shouldbe for short periods of time only, which should bespent in walking rather than standing. If theperiod of bed rest has lasted many months, spongerubber insoles may temporarily be worn; they arenot a substitute for training but an addition to it.More often inadequate muscle is part of a

general postural disorder. Treatment is thendesigned to ' tone up ' the body by outdoor games,gymnastics, postural training and the like. Manypreadolescent girls cannot be taught to stand

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May 1954 APLEY: Flat Foot 247

correctly, and continue slouching until the agewhen they hold themselves more correctly as partof the process of normal sexual display.

Inadequate muscle is common also in middleage; not only should the muscles be strengthened,but any obesity also requires treatment.

In almost all instances of flat foot, however,whether the cause is primarily anatomical orphysiological, muscle training is worth while.The normal exercises taught by physiotherapistsare those of walking on tiptoe, walking on the outerborder of the foot and picking up objects with thetoes. All these are useless, and walking on theouter side of the foot is actually harmful if theforefoot is varus. Much the best method is toteach the patient to twist his knees outwards whilekeeping the forefoot on the ground: the ball ofthe great toe must not be allowed to lift, or theexercise loses its point (Fig. 6). When thisexercise is correctly performed a normal arch oftenforms and, if the training is enthusiastic andprolonged, good results are often possible. It issurprising how young a child can be taught thisdrill, and how soon the habit of standing correctlyis acquired. The rotation exercise described isparticularly valuable in children with a varusforefoot. The exercises are sometimes worthwhile in older people, in whom they may be sup-plemented by faradic foot baths, though manysurgeons doubt whether electrical stimulation isof any value.

(c) Of the Pathological SequelsI. When the arch has toppled over it can to

some extent be restored by a support. So longas the foot is supple this support should be softand pliable: it is best made of sponge rubbercovered with leather and should only support themedial longitudinal arch. Like a suit, it fits betterif made for the individual and not bought 'offthe peg.'Ewen Jack (I953) advocated naviculo-cuneiform

fusion in young patients if the ' break ' in the archoccurs at this joint and if conservative treatmentfailed.

2. Acute foot strain is rare, and is easily treated.If severe, the patient should spend 48 hours in bed.As a rule, exercises, faradic foot baths and asupport bring relief within two or three weeks,

and when the muscles become adequate thesupport may be gradually discarded.

3. Once the flat foot has become rigid, painfulosteoarthritis is likely to develop. Treatment isdesigned to limit the excursion of the affectedjoints: pain is prevented by avoiding stretchingthe fibrosed capsule. For a labourer a strongboot with a thick rockered sole (like the Armyboot) is often sufficient. In other patients asupport helps; only if the foot is very rigid shouldthe support be made of thin spring steel, thoughthis type is commonly sold for all manner of flatfeet. Pain which is not relieved by these simplemeasures can be treated by arthrodesis of theosteo-arthritic joints, and giving the patient arockered sole to his shoe.

4. In adults flat foot is often accompanied byforefoot troubles. These should be dealt withsecundem artem. Bunions and hammer toesmay be treated conservatively or by operation.Painful callosities and metatarsalgia require re-distribution of pressure which is achieved byadding to the arch support a strip of spongerubber at the level of the metatarsal necks. Inaddition, exercises to strengthen the intrinsic footmuscles should be practised.

AcknowledgmentsI should like to thank Professor George Perkins,

M.C., F.R.C.S., for permission to reproduce thediagrams in Figs. 2, 3 and 6. The Departmentof Clinical Photography at St. Thomas's has alsobeen most helpful and I must especially thankMr. Kenneth G. Moreman for his co-operation.

BIBLIOGRAPHYAPLEY, A. G. (1948), Proc. Roy. Soc. Med., 41, 263.BADGLEY, C. E. (I927), Archives of Surg., 15, 75.CATTERALL, R. C. F. (I952), Proc. Roy. Soc. Med., 45, 89i.HARRIS, R. J. and HEATH, T. (I948), .. Bone & 7t. Surg.,

3oB (4), 624.HARRIS, R. J. and HEATH, T. (I948), J. Bone C Jt. Surg.,

30A (I), I6.JACK, E. A. (I953), 7. Bone & Jt. Surg., 35B (I), 75.JONES, F. WOOD (I943), 'Structure and Function as seen in

the Foot,' BaillMre, Tindall & Cox.LAMBRINUDI, C. (I937), Proc. Roy. Soc. Med., 31, I273.MORTON, D. J. (1935), 'The Human Foot; Its Evolution,

Physiology and Functional Disorders,' Columbia UniversityPress.

PERKINS, G. (I948), Proc. Roy. Soc. Med., 41, 3I.SHEPHARD, E. (I95i), J. Bone & S.srg., 33B (2), 258.STAMM, T. T. (1953), personal communication.

Copies of Title Page and Index for Vol. 29 of The Postgraduate Medical

Journal are now available on request. See page 257 for binding particulars.

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