Page Six P H Y S I O T H E R A P Y July, 1955 PREVENTION OF FOOT DEFORMITIES By T. T. STAM M , f .r .c . s . Orthopaedic Surgeon, Guy’s Hospital. NOW th at the m agnitude o f the foot problem has received m ore general recognition, m uch greater interest is being taken in the developm ent o f preventive measures. A num ber o f local authorities are already considering the institution o f schemes for th e detection and treatm ent of foot defects in their early stages. However, unless those who organize and carry o u t such w ork have a very clear idea of the nature and aetiology o f th e defects th a t cause disability in the adult foot, their efforts will be ineffective and wasteful of tim e an d money. It is therefore necessary first to be able to classify foot defects in th e order o f their frequency an d th e severity o f th e sym ptom s to which they give rise, and then to trace their mode o f developm ent, and finally to assess the factors responsible. Fortunately recent surveys have not only brought to light the frequency o f foot ailm ents am ongst the population b u t have also provided factual inform ation ab o u t their relative frequency and severity a t different age periods. Some generalizations Before discussing individual conditions it is possible to m ake the following helpful generalizatiohs. (1) M echanical defects do n o t give rise to symptoms in children. The significance o f defects noticed in th e feet o f children can therefore be assessed only by w hat is know n o f their likely subsequent history. Such knowledge is therefore an essential p a rt of the quipm ent of those who carry ou t inspections o f th e feet of children. (2) Surveys have shown th a t whereas in children defects affecting the region o f the long arch are the ab n o r­ malities most frequently noticed, by adolescence they have become outnum bered by defects in th e region of the forefoot and toes, while in th e adult th e latter are by far th e comm onest cause o f pain and disablem ent. . (3) T he hallux valgus complex is much the com m onest o f all causes o f pain in the adult foot and affects women m ore com m only th an men in the p roportion of 10 : 1. (4) T he hallux valgus complex is no t encountered in clinical practice as a cause o f pain in people who do no t w ear shoes. I t must be accepted th a t no am ount o f care and atten ­ tio n could obviate all foot troubles. In an imperfect world the most we can hope to achieve is to reduce the incidence a n d severity o f those few conditions which we know are responsible for th e m ajority o f foot ailments. We shall achieve m uch m ore good if our attention and care is con­ centrated on these selected defects, th an if every noticed deviation from the norm al is treated as o f equal im portance. T here are of course a num ber o f m inor foot ailments which can be dealt w ith simply and effectively by routine m ethods. Such transient ailments do not present any special problem s. However, th e m ajor causes o f foot disability require individual consideration, fo r they will need all our care and understanding if they are ever to be brought under control in the conditions o f m odern society. These conditions can be roughly grouped into two m ain categories; (1) long arch defects; an d (2) defects o f the forefoot an d toes. A lthough the latter have been shown to com prise n o t only the m ost frequent but also th e m ost crippling o f the affections o f the foot, it will be m ore convenient to consider first those defects which prim arily concern the long arch. Long arch defects A tru e flattening of th e long arch sufficient to con­ stitute a deform ity is uncom m on. I t occurs congenitally as a result o f abnorm alities o f the talus o r the presence of a calcaneonavicular bar. I t also occurs as a result of disease, th e com m onest being the ra th e r obscure condition know n as “ spasmodic valgus” , in w hich the fo o t becomes fixed in an exaggerated valgus attitu d e due to long con­ tinued spasm o f the peronii. A n appearance o f flat-footedness due to defective posture is however extremely com m on and in the m ajority o f young children it is o f little significahce. The appearance is due prim arily to the fact th a t the fo o t has been allowed to roll over on to its inner border by a m ovem ent o f eversion a t the subtalar joint. The long arch is thus obscured because it is lying over on its side. T his however is not the whole story for if the foot was everted as a whole, its outer border w ould rise off the ground. In fact this does not occur, the forefoot rem aining p lan tar grade. Since the back p a rt o f th e foot has become everted while the forefoot has n o t moved, the forefoot m ust be relatively inverted (or supinated) in relation to the “ back fo o t” . T hus the relaxed flat-footed attitu d e is the result o f eversion o f the back p a rt o f th e foot, com bined w ith an equal and opposite inversion o f th e forefoot upon it. So far as the relationship o f th e forefoot to the ground is concerned, these tw o rotary movem ents in opposite directions cancel out an d the fore­ foot rem ains plantargrade. The change from this relaxed flat-footed attitu d e to th e strong fully arched posture is achieved by inversion o f the back p art o f the foot com bined w ith an equal degree o f eversion o f the forefoot. In contrast to the movements producing the flat-footed attitu d e which are passive, and im posed by body weight, these are active movements. They are carried ou t prim arily by tibialis posterior and peroneus longus respectively. Since these are rotary movem ents ab o u t an antero-posterior axis th e long arch is n o t so much raised o r lowered, as screwed up o r un­ screwed. T he fully arched “ screwed u p ” posture can only be "m aintained by active muscle tone. I f muscle tone is defective the foot will naturally collapse into the relaxed unscrewed posture, so far as the tightness o f its ligaments will allow. Since nearly all young children are posturally lazy they nearly all look flat-footed when standing a t rest. I t is only when this relaxed posture persists unduly o r is present in an exaggerated degree th at it has any significance. In such cases it becomes necessary to seek the cause. Defective foot posture in children T he com m onest causes o f defective foot posture in a child are the following. Knock knees and bow legs.—T hree com m on variants from the norm al are likely to be observed when any group o f children under the age of ten are examined. Genu valgum.— Some degree o f knock knee, m ost noticeable on standing is extremely com m on in young children. A generation ago they ra n a grave risk o f being supplied w ith irons and night splints. I t is now recognized R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) July- 1955 P H Y S I O T H E R A P Y Page Seven that they nearly all grow o ut o f it by the age o f ten. M ost rhildren help themselves to do so by turning their feet in. Tf they do adopt this “ pigeon toed” attitu d e they can safely he left to look after themselves. I f .however, they give wav to the deformity an d allow their feet to roll out into a valgus flat-footed attitude, an inside wedge to the heel o f the shoe (not the sole) with a valgus lift in the shoe will help to correct their posture. Provided there is no increase in the deform ity when they are re-examined a year later no other measures are necessary. Bowed tibiae.—T he bowing occurs in the lower third of the bone and is usually associated with som e degree of medial rotation. There is a secondary valgus o f th e foot when the child stands, yet the feet d o not point outw ards owing to the ro tatio n o f the tibiae. T his is a congenital deformity, which soon corrects itself. This is fortunate, as it is not possible to correct th e deform ity by any measures less than operation. Bow legs.—In th e com m onest type the deformity occurs a t the upper end o f the tibia and is associated with a lateral rotation o f the tibia below this point. As a result, if the child stands w ith the knees pointed forw ards the feet are swung out laterally. W hereas if the feet are brought together in line, th e knees face inw ards and there is an apparent bow leg. A lthough this makes the child look awkward and “ splay footed” , interference is rarely called for, except in extreme cases. Very occasionally, however, the deformity does persist, and, especially in girls, merits correction by osteotom y at the upper end o f th e tibia. “Short Tendo Achilles” .—A relative shortness o f the calf muscles is com m only found in children an d often persists into ad u lt life. In such cases the foot cannot be dorsiflexed to a right angle a t the ankle jo in t when the muscles are in a state o f norm al tone, as when standing. In order to get the heel to the ground the foot has to be swung out a t th e subtalar joint, in order to get the benefit of the extra range o f dorsiflexion which occurs a t the end of this eversion movement. The foot is thus forced to adopt a valgus attitude. T he condition is referred to as “valgus secondary to short T endo Achilles” , o r m ore accurately as “ valgus secondary to equinus” as it is the muscles not the tendon which are short. I t is im portant that the true nature o f the apparent flat-footed appearance to which it gives rise is appreciated, for the usual so called “ flat foot” exercises in which th e child is encouraged to walk about on tip to e can only do harm by inducing still tighter tone in the calf muscles. In fact ju s t the opposite is indicated; th a t is to say, the child should be encouraged to walk on the heels with the foot elevated, thus prom oting reciprocal relaxation o f the calf mucles by active contraction of the extensors. Supination o f the forefeet.—A n inversion twist to the forefoot is a com m on com ponent o f many varieties o f club foot. It m ay occur alone, o r m ore comm only, in associa­ tion with som e degree o f dorsiflexion o r “ calcaneus” deformity. I t is no t an obvious deform ity an d rarely is anything abnorm al noticed until the child begins to walk. I f the forefoot is inverted, then, in o rder th a t it may rest flush on the ground, the foot as a whole m ust be everted. The foot is thus forced to ad o p t the weak valgus o r flat- footed attitude. I t is in fact congenitally “ unscrewed” . A ttem pts to correct the flat-footed appearance by prom oting inversion of the fo o t will, if successful, cause the inner border of the forefoot (that is the “ ball” o f the foot) to rise off the ground. In o rder to get som ething on to the ground on the inner side to steady the foot, the child will flex the great toe, thus using the pad o f the toe instead o f the ball of the foot as a weight bearing point. This throw s a severe strain on the great toe jo in t itself and very soon will cause degenerative changes to occur leading ultim ately to a hallux rigidus. Thus, again, ill-advised treatm ent for apparent “ flat foot” can only do harm , if it achieves anything at all. T he condition does present a difficult problem for which no final answer has been found. In m arked cases in young children repeated m anipulation a n d plaster fixation may prove successful. In m ilder cases reversed wedges, th a t is inside heel an d outside sole, are useful, together w ith exercises designed to correct both prim ary and com pensatory deformities by a com bined contraction o f tibialis posterior with peroneus longus. This is not an easy action to teach, a n d requires th e assistance and supervision o f a trained physiotherapist. Forefoot disabilities H allux rigidus In this condition the great toe jo in t has become stiff as a result o f arthritic changes due to previous injury o r to long standing overstrain on the joint. T he com m onest cause o f the latter is the “ supinated forefoot” discussed above. Any o ther condition which denies the foot a stable area fo r weight-bearing under the ball o f the foot will also induce flexion o f the great toe to provide an alternative area under the p a d o f the toe itself, an d will lead to th e sam e end result, namely degenera­ tion an d arthritis o f the great toe joint. T he only o ther condition which need be m entioned here is another congenital anom aly. In this, the first m etatarsal is unduly m obile like the m etacarpal o f the thum b, and thus becomes displaced upw ards when weight is borne on the foot. Again the toe itself is flexed in an attem pt to provide stability while the m etatarsal becomes fixed, in an elevated position. In this condition again misguided attem pts to correct th e associated flat foot can only do harm . The hallux valgus complex A lthough th e aetiology o f this condition is still not fully understood the following facts are recognized. (а) There are certain types o f feet which are con­ genitally prone to develop this deformity. T he comm onest is the foot th at has a short and varus first m etatarsal. There is little abnorm al to be noticed in the fo o t o f the young child, except th a t the forefoot looks rath er broad and there may be an unduly wide cleft between the first an d second toes. A nother, but less com m on type is the long narrow unstable foot th a t tends to fall over into a valgus attitude on weight bearing. In som e cases the toe itself is not only long but has some valgus angulation at the interphalangeal joint. (б) In none o f the cases o f congenitally prone feet is there any valgus deform ity o f the toe a t birth. The deform ity o f the toe itself is secondary and develops during childhood and adolescence. (c) A lthough obvious deform ity may be present by the age o f ten years, the m ost rapid deterioration o f the fo o t occurs during adolescence. (d ) Footw ear, both shoes an d socks, appears to be the most im portant factor in determining w hether and to what extent deform ity will occur in feet th at are con­ genitally susceptible. (e) T he fashionable w omen’s shoe with a high heel to provide a slope for the foot to slide down, and a toe cap designed as a V with a central point, is a perfect in­ strum ent for producing a hallux valgus deformity. ( / ) T he condition is ten times m ore com m on in women than in men. W hen considering the measures th at should be taken to deal with this progressive and crippling condition it m ust be borne in mind th a t no treatm ent, operative o r otherwise, has yet been evolved which will ensure correction o f either the prim ary o r the secondary deformities once they have become established. T he emphasis m ust therefore be on detection an d prevention rath er than on treatm ent; detection by th e regular inspection o f the feet o f school children, prevention mainly by advice and supervision o f their foot­ R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page Eight P H Y S I O T H E R A P Y J u ly , 1955 wear. These measures are the proper concern o f the school and public health authorities, n o t the hospital clinics. Specialist advice should be sought only when the deformity progresses in spite o f adequate care and supervision. Claw toes and pes cavus Clawing o f the toes is a condition th a t results from paralysis o r weakness o f the intrinsic muscles (the interossei and lumbricals). As a result o f the unopposed action o f the long flexor an d extensor muscles the toes become buckled into the clawed attitude. This buckling effect is transm itted back to th e foot itself causing th e secondary cavus deformity. T he whole effect is similar to th at o f a folding screen which is draw n together by tw o cords. W hile this condition may follow frank paralysis, as in cases o f anterior poliomyelitis, o r m ay develop gradu­ ally in progressive diseases such as Freidreich’s ataxia o r th e muscular dystrophies, it m ore often develops w ithout any obvious cause, an d may then be the result o f a transient peripheral neuritis due to one o f the fevers, such as scarlet fever o r diphtheria. A lthough it may give rise to considerable disablem ent, it is fortunately m ore am enable to treatm ent th an most foot deformities. I f the paralysis has been transient or p artial, much can be done by rem edial physiotherapy, while even th e severest cases can be satisfactorily dealt w ith surgically provided the deformities have not been allowed to become fixed. Since pain is a late sym ptom advice is rarely sought at an early stage. I t is therefore only by routine inspection th a t cases will be detected at an early stage when treatm ent will be m ost effective. Retracted toes (“The signpost fo o t”) This is a peculiar condition which is often confused w ith claw toes. It differs from it however in th a t although the toes are acutely dorsiflexed at the m etatarso-phalangeal joints, there is little o r no abnorm al flexion o f the inter- phalangeal joints. It seems to be due to overaction o f the long extensors o f th e toes in an effort to supplem ent the action o f tibialis an terio r and peronii. T he great toe itself is unaffected an d rem ains straight, hence the term “ signpost fo o t” . It should be regarded as a sign o f muscle unbalance in the foot and merits expert advice. Conclusions This brief discussion o f the m ore com m on and im ­ p o rtan t defects o f the foot leads to the following conclusions. (1) The foot problem as a whole can only be tackled successfully an d economically by the adoption o f preventive measures rath er th an by further expansion o f facilities for the treatm ent o f established disabilities. (2) This implies an adequate organization for the detection o f foot defects in their early stages by the regular inspection o f the feet o f school children. (3) Such inspections to be effective m ust be carried out by those who have an adequate understanding o f the nature and significance o f any abnorm alities detected. (4) The treatm ent indicated in the majority o f cases consists essentially in ensuring adequate care an d super­ vision while the foot is growing and developing. (5) This is properly the concern o f the school and public health authorities, not o f the hospital clinics. (6) Cases should only be referred to specialist clinics when th e above measures fail. (7) T reatm ent such as special exercises, o r supports, should not be prescribed indiscriminately an d w ithout careful diagnosis o r they may do m ore harm th an good. (8) While the responsibility fo r carrying out any schemes o f preventive care must fall principally on medical officers o f health, school doctors an d their team s, assistance will be needed from a num ber o f other groups o f people an d especially from physiotherapists, chiropodists, and shoe m anufacturers and retailers. T he role o f these indivi­ dual groups in dealing with the foot problem will be described in succeeding articles in this series. (Reprinted by kind permission fro m the February, 1954, issue o f “The British Journal o f Physical M edicine," published by Butterworth and Co. Ltd.). GENERAL T he Private Practitioners’ Register is still in th e process o f com pilation. I f any m em ber, who has n o t previously applied, wishes to be included in this Register, please contact M r. A. R othberg, W .N .L.A . R ehabilitation Centre, E lo ff Street Extension, Johannesburg. It is hoped to publish this Register before the end o f th e year. + + + It has been suggested th at Post-graduate courses lasting fo r longer th an a week-end may be ru n from time to time. T his w ould enable m ore subjects to be covered and may m ake a long journey m ore profitable fo r those who have to come from o th er centres. Ideas an d comm ents on this suggestion will be welcomed by Miss Blair at the M edical School, University o f th e W itw atersrand. + + + We welcome to the Society:— Miss P. R . Chenik, c /o Physiotherapy D epartm ent, K rugersdorp H ospital, T ransvaal; Miss N . K . M aier, Physiotherapy D epartm ent, M iddelburg H ospital, T ransvaal; Miss K . O. Mansfield, 148> Beach R oad, N ahoon, East L o n d o n ; M iss G. D . M orris, “ M elrose,” M ain R oad, St. Jam es’, C ape; Mrs. O . H . M uller, 6, D an ita C ourt, N ew Street, K roonstad, O . F .S .; Miss K . V olker, Physiotherapy D epartm ent K lerksdorp H ospital, T ransvaal; an d M r. T. W. W oodgate, 3, Ivy C ourt, M ain R oad, Plum stead, C ape Town. + + + T he S.A.S.P. has been granted space in the Scientific Exhibition o f th e 40th South A frican M edical Congress to be held in Pretoria from 17th—22nd O ctober, 1955. Miss H azel Baines will be the C onvener o f our Exhibition, an d any suggestions will be welcomed by her. P h o to ­ graphs an d “gadgets” will be especially acceptable. + + + T he following were successful in the exam ination in / E lectrotherapy held in A pril o f this year by th e South's A frican M edical an d D ental Council. They are thereby entitled to registration as physiotherapists. Miss A. D annecker, M rs. Fiedler, Miss N . K . M aier, Miss I. M. O ckert, Mrs. M. E. Rehfeld, M rs. Ribaric, Miss R . Schubert, Miss K . Schlosske, Miss O. Volker, Miss O. von Britzke, Miss Y. von Schrader an d M rs. W aechter. + + + T he O .F.S. B ranch is to furnish a stall at th e N ational Council o f W om en’s exhibition o f “ W hat W omen A re D oing and C an D o ” being held in B loem fontein on A ugust 28th, 1955. + + + T he University Towns Festival raised over £93,000, and the organisers wish to thank all students and members o f th e Society who so willingly gave their help in raising this magnificent sum. + + + T he C onstitution C om m ittee o f the Society is meeting regularly to draft a new C onstitution, a n d it is hoped that this will shortly be ready. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) July, 1955 P H Y S I O T H E R A P Y Page Nine TARIFF o f FE E S FO R P H Y S IO T H E R A P IS T S (To tak e effect from 1st August, 1955). The following T ariff o f Fees fo r M edical A id Cases has been accepted by the Johannesburg Private P racti­ tioners and comes into effect on 1st A ugust, 1955. N egotia­ tions are still proceeding to increase the rates fo r travelling. N O F U R T H E R N O T IF IC A T IO N O F TH IS T A R IF F W IL L BE G IV E N . Massage only ... ............................ "1 Remedial exercises only .................... Electrical treatm ent only .................... £0 12 6 Joint o r Spinal m anipulation o r spinal | traction ............................................. J Combined treatm ents ............ ............................ 0 15 0 D iatherm y o r U ltrasonic treatm ent (with o r without massage) ............................................. 0 15 0 G eneral M assage ..................................................... 1 1 0 Colonic Lavage ..................................................... 0 17 6 Electrical reaction tests: (a) Per single nerve, one group o f muscles o r tendons ............................................. 0 15 0 (b) Per one limb ............................................. 2 2 0 (c) Per whole body .................................... 5 5 0 Skin tem perature tests: (a) Skin tem perature tests in reference to reflex heating............................................ 3 3 0 (b) Skin tem perature tests in reference to reflex cooling............................................ 3 3 0 (c) Cold sensitivity test ............................ 2 2 0 (d) Sweating test ............................................. 2 2 0 (e) Oscillometric readings ............................ 1 1 0 The num ber o f treatm ent adm inistered to any one patient is lim ited to 15. F urther treatm ent m ay be administered after consultation w ith the M edical Aid Society o f which the patient is a member. Portable fee (i.e. attendance outside room s) 0 2 6 Mileage fee (to be charged in addition to po rtab le fee). For distance~travelled-both-w avs from the room s o r resi­ dence, whichever is th e nearer to tK c~point-of_call, 1 /3 per mile for every mile in excess o f 8 miles provided th a t the condition o f th e p atien t is such th at the patient could not attend for treatm ent at the rooms. CHANGES OF ADDRESS M r. V. G . Lerm to 2nd F loor, U nited Building, Plein Street, Stellenbosch, C.P. M rs. R . Brem ner to P.O . Box 250, U m tali, S. R hodesia. Miss D . van der Merwe to c /o M atron, W ynberg M ilitary H ospital, C ape Town. M rs. V. C ohen to 43, Blyton Avenue, Savoy Estate, Johannesburg. Mrs. M . E. H ah n to R idge R oad, Linksfield Ridge, Johannesburg. Miss F. D . K . K night to c /o T. C. K night, Esq., P.O. Box 424, Pretoria. Miss E. K ope to c /o M rs. M yer, 7, O akley C ourt, Protea R oad, C larem ont, Cape Town. Miss G . D . M orris to “ M elrose,” M ain R oad, St. Jam es’, Cape. Mrs. J. Lugg, to 1, H arew ood D ene, H arew ood Drive, N ahoon, E ast L ondon. Mrs. H . Judge to 1, Sandow n R oad, Stirling, E ast London. Mrs. D . B aum ann to 1, T u dor C ourt, 14, St. M atthew ’s R oad, E ast L ondon. SOUTH AFRICAN S O C IE T Y OF P H Y SIO T H E R A P IS TS GROUP ENDOWMENT FUND We have pleasure in announcing th at a G roup Endow m ent F und has been inaugurated fo r members o f th e South A frican Society o f Physiotherapists and will be underw ritten by The Colonial M utual Life Assurance Society Limited (hereinafter referred to as the Underwriters). The Fund \yill enable members of the Society to obtain assurance at a lower cost than is possible with individual contracts and will enable them not only to insure their lives for the benefit of their dependents but to save for their retirem ent by deduction of regular monthly contributions from salary. M em bers of the Society who wish to insure under this scheme must complete a short Proposal Form together with a Stop O rder for the deduction of contributions monthly from salary. T he Trustees o f th e F u n d will hold a t th e Society’s headquarters a m aster policy o n the schedules o f which will be entered full particulars o f each m em ber’s assurance. T he benefits consist o f guranteed am ounts payable at the age selected by the mem ber, or o n p rio r death, an d are subject to increase by an n u al bonus additions. A dditional benefits in th e form o f Cash Payments subject to increase by bonus additions as declared in the U nderwriter’s A ccident D epartm ent and waiver o f future contributions are payable upon disablem ent due to certain contingencies prior to the selected age as set o u t o n th e m aster policy. B E N E FIT S W ILL D E P E N D U P O N : (1) The member’s age on entry into the scheme; (2) The monthly contribution to be paid; (3) The selected age a t which the sum assured is payable. A L L M EM BERS W IL L R E C E IV E A C E R T IF IC A T E O F E N R O L M E N T G IV IN G F U L L D E T A IL S O F C O N T R I­ B U T IO N S A N D B EN EFITS. In the event o f a m em ber leaving the Society, the enrolm ent will be converted into an ordinary policy with the underw riters. Benefits an d contributions will rem ain unchanged b u t future co n trib u tio n s will require to be paid direct to the underw riters. Such a policy on the life o f a female m em ber m ay, in certain circumstances, be converted into a policy on the life o f her h u sb an d i f he is insurable and n o t m ore th an 10 years h er senior. T h e F u n d is sim ilar to th a t which has o p erated f o r the b en e fit o f m em b ers o f the S o u th A fric a n N u rsin g A sso cia tio n f o r m a n y y e a r s a n d the E x e c u tiv e o f y o u r S o c ie ty hope th a t a ll m em bers will g iv e the F u n d their f u l l support. CUT HERE. To the T R U STEES G R O U P E N D O W M EN T FUND, S.A. SO C IET Y O F PH Y SIO T H E R A PIS T S, P .O . BOX 1106, PR ET O R IA . Please supply me w ith details. N a m e ............................................. A d d re ss .................................... .... D ate o f B irth................................. W here em ployed........................................................... H ow m uch can you afford to pay each m onth: R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )