The Affections of the Arch of the 
Foot commonly classified 
as Flat-foot. 
BY 
E. W. LOVETT, M.D., and 
JOHN DANE, M. D., 
BOSTON. 
REPRINTED FROM THE 
Wcte "STorfe J&ebfcal 
for March 7, 1896. Reprinted from the New YorJc Medical Journal 
for March 7, 1896. 
THE 
AFFECTIONS OF THE AKCH OF THE FOOT 
COMMONLY CLASSIFIED AS FLAT-FOOT.* 
R. W. LOYETT, M. D., and 
JOHN DANE, M.D., 
BOSTON. 
The present paper must be considered as a preliminary 
one and not as a full discussion of tbe question of flat-foot. 
It is tbe desire of tbe writers to call attention to certain 
subdivisions which might profitably be made in those 
anomalies of the arch of the foot which have heretofore 
for the most part been spoken of as “ flat-foot ” ; to note 
certain imperfections in the methods of studying these 
conditions; and to mention some methods of treatment 
which have been found of use. Tbe study of the condi- 
tions presented in this paper must necessarily be desultory 
and incomplete, but so large was the field opened by the 
line of investigation taken up that it seemed best to offer for 
your consideration the points already elaborated and to ask 
your assistance in the further working out of the problem 
* Read before the American Orthopaedic Association, at Chicago, 
September 18, 1895. 
Copyright, 1896, by D. Appleton and Company. AFFECTIONS OF THE ARCH OF THE FOOT. 
which is presented. The treatment of the severer cases of 
flat-foot which has been so ably discussed by Dr. Whit- 
man will not be considered in this connection. 
The Foot at Birth.—The foot of the infant at birth is 
not flat, although it is so described even in modern anato- 
mies.* At birth, the arch is, in reality, well formed, and 
the scaphoid lies from I*s to two centimetres above the 
plane of the heel. The tracing of the foot of an infant 
premature at seven months, and the photographs of the foot 
intact and dissected, have been described by one of the 
writers in Dr. Botch’s book on Pcediatrics. The tracing 
of the foot of an infant premature at seven months, and 
raised in an incubator, shows an arch of nearly the adult 
type, and the scaphoid lies I*B centimetres above the level 
of the heel. 
It seems as if after birth there forms under the arch of 
the foot a pad of fat, which is apparently Nature’s mode of 
Fig. I.—Ordinary type of foot im- 
print tracing in infants, 
Fig. 2.—Type of tracing in a thin in- 
fant a year and eight months old. 
preventing the arch from breaking down. The real arch is 
not lowered and the scaphoid is above the plane of the 
heel, but the foot appears flat if an imprint is taken of it 
on account of the development of this pad of fat. It 
would seem as if for the first year or two Nature provided 
this mechanical cushion to support the arch. In thin chil- 
dren the print of the foot at this age is not that of a flat- 
foot but of the normal adult arch. 
* Walsham and Hughes. William Wood Company, New York, 
1895. AFFECTIONS OF THE ARCH OF THE FOOT, 
3 
At four or five years the fat is absorbed and the arch 
again appears in the imprint tracing. A tracing convex on 
the inside points to the existence of a real valgus or flat- 
foot. In short, the normal foot in children exhibits at 
birth a well-formed arch, as shown by the tracing. In fat 
children, from two to four or five years old, the tracing is 
that of a foot apparently flat. At four or five years old the- 
arch should appear again in the tracing. 
The Study of the Arch.—The study of the arch of the 
Fig. 3.—Type of tracing described as normal. 
foot and its variations from the normal have for the most 
part been made by a study of the imprint of the foot as 4 
AFFECTIONS OF THE ARCH OF THE FOOT. 
shown upon a piece of smoked cardboard, or by the im- 
print of the wet sole on a piece of paper or on the floor. 
It is our particular object to call your attention to the fact 
that this method of studying the breaking down of the 
arch of the foot is a very imperfect one and subject to 
wide error, for the reason that certain grades of painful 
affection ordinarily called flat-foot may entirely escape de- 
tection, For example, take such a case as the following: 
A woman, twenty seven years old, has pain after being 
on her feet constantly, which has lasted two years and ex- 
tends to the knee and hip. It has been so severe that there 
is much swelling of the feet at times. Inspection shows 
Fig. 4.—Tracing of prouated and painful foot. 
plainly enough what we may speak of as pronation of the 
foot—that is, a prominence of the internal malleolus and 
rolling out of the foot (in relation to the leg)—but the 
smoked tracing shows an imprint which any one would con- 
sider normal. The patient was then photographed in the 
following way. A long exposure plate was used, and for the 
first half of the exposure she stood with the muscles all 
contracted to hold the foot in the correct position (that is, 
with the line of the leg passing through the second meta- 
tarsal). In the second half of the exposure the foot was 
allowed to assume its natural position. It may be seen by 
looking at the drawing that there are two distinct positions, 
one with the foot in the normal position and the other with 
the foot in the pronaled position. With pronation is neces- AFFECTIONS OF THE ARCH OF THE FOOT. 
5 
sarily associated anatomically, as may be seen in the draw- 
ing, an abduction of the forward part of the foot. 
Here, then, is a case of painful difficulty in the feet, 
accompanied by a marked degree of pronation at the ankle 
joint, which is not shown by any abnormity of the smoked 
tracing. 
The excursion made by the internal malleolus when the 
foot gives way under these circumstances was measured in 
some cases. In the case of a man, twenty-eight years old, 
who had pronation of the foot for a year, and where under 
Fig. 6.—Outline drawing of a foot 
from a photograph in normal and 
pronated position, showing the for- 
ward excursion of the outline over 
the external malleolus in the pro- 
nated position, as shown in the dot- 
ted outline. 
Fig. 5.—Outline drawing of a 
foot from a photograph in nor- 
mal and pronated position, 
showing the inward excursion 
of the internal malleolus. 
fatigue and constant overwork a painful condition was 
rapidly developing, the measurement was made. The foot 
was placed against an upright without weight bearing. 
The distance from the upright to the internal malleolus 
and to the scaphoid was measured. The weight was borne 
upon the leg and the measurement was made again in the 
pronated position. Every care was taken to have this 
measurement accurate, and it was found that the internal 
malleolus fell in o#B0#8 centimetre, while the internal surface 6 
AFFECTIONS OF THE ARCH OF THE FOOT. 
of the scaphoid fell in o’7 centimetre. Measurements of 
value could not be taken from the external malleolus be- 
cause, as shown in the photograph of this patient, the ex- 
ternal malleolus travels forward with the pronation of the 
foot. 
To study abnormities of the arch of the foot by means 
of the smoked tracing alone is as if one were studying 
Fig. 7.—Tracing of a flat-foot. No symptoms, foot useful. 
typhoid fever with a thermometer which did not register 
below 101°. This would be quite sufficient to detect the 
severer grades of fever, but it would entirely overlook 
slight rises of temperature. This condition should be AFFECTIONS OF THE ARCH OF THE FOOT. 
spoken of as “ pronated foot.” It is not flat-foot, because the 
arch has not broken down, and it would seem best to re- 
serve the term of flat-foot for cases where the imprint of 
the foot showed a real lowering of the arch. It would be 
very desirable to find some means of measuring this pro- 
nation. Possibly estimating the height of the internal 
malleolus from the ground in relation to the length of the 
foot may be of some use in the future, but so far the 
writers have been unable to devise any satisfactory method 
of mathematically estimating this condition. In the expe- 
rience of the writers the pronation of the foot is the one 
element that seems to bear relation to the amount of pain 
in practically all troubles with the arch of the foot, whether 
the arch is broken down or not, and to the study of this 
they would beg to direct attention rather than to imprint 
tracings. 
The symptoms of pronated foot and flat-foot are the 
same at the onset. The pain and other symptoms vary 
more in relation to the amount of pronation than in 
relation to the breaking down of the arch. This fact 
has been overlooked. The earliest symptom is generally 
to be found in weariness and discomfort on long stand- 
ing. The feet feel hot and flushed and may prickle. The 
patient is obliged to spare the feet, and there is often diffi- 
culty in getting boots to fit. Pain is the commonest symp- 
tom ; it comes on after long standing and it may radiate 
up the leg and thigh. It is confined to no especial loca- 
tion. Sensitive spots are generally present. The veins 
become enlarged and the feet sweat profusely. After rest- 
ing the feet often feel stiff and clumsy. Patients begin to 
walk with the feet everted and tread over the inside of 
their boots. The gait is clumsy and lacks elasticity. 
Swelling of the feet and legs may occur and abduction of 
the forward part of the foot is rendered likely. Other 8 
AFFECTIONS OF THE ARCH OF THE FOOT. 
symptoms which may be present are backache and some- 
times discomfort in the knees, especially in neurasthenic 
patients ; pain and inflammation in the metatarso-phalan- 
geal joint; ingrowing toenail and sometimes bunion. 
Tenosynovitis of the tendons in front of the external 
malleolus is a common symptom, especially in rheumatic 
patients. 
The causes of pronated foot and flat-foot are the same 
and will be considered together. Pronated foot, although 
most often an early stage of flat-foot, is not necessarily so. 
In general terms, it may he said that either deformity is 
caused by a disproportion between the weight to be borne 
and the muscular power which bears it. The occurrence 
of the deformity is rendered more likely by the shape of 
modern boots. The immediate causes of these two condi- 
tions are the following, in the order of their approximate 
importance: 
1, Bad boots. The most fruitful cause of pronation of 
the foot is undoubtedly to be found in the use of improper 
boots. Merely to illustrate the sort of boots that are be- 
ing worn, the writers would submit the following tracings 
taken from certain young women applying for the position 
of nurse at a hospital where they are under the inspection 
of one of the writers. In each case the foot was placed 
upon the ground and weight borne upon it, and an outline 
in pencil was drawn around the foot. The boot was then 
placed upon the same paper and the outline of the boot 
drawn in another color. The diagrams illustrate the rela- 
tion between the sole of the foot and the sole of the boot. 
They are not extreme instances, but represent merely aver- 
age tracings selected from about a hundred at the writer’s 
disposal. They illustrate the sort of boots that are being 
constantly worn, which must necessarily do much harm. 
They do harm by throwing the big toe outward, crippling AFFECTIONS OF THE ARCH OF THE FOOT. 
9 
the feet, not only by squeezing the metatarsal hones to- 
gether, hut by impairing the usefulness of the flexor longus 
hallucis, which can only work to proper advantage when 
Figs. 8 and 9.—Feet and boots, tracings. The boots are shaded. 
the great toe is in line with the inside of the foot. This 
displacement outward of the great toe deprives the foot of 
its legitimate inside support, the support which should 
keep it from rolling over and pronating. 
In a perfect foot Meyer’s line should pass through the 
central point of the heel. This line is a prolongation back- 
ward of the axis of the great toe. One hundred imprint 
tracings were taken from applicants for the position of 
firemen and policemen, by the kindness of Dr. Morton 
Prince, at the office of the Civil Service Commission, Bos- 
ton, and they were studied with regard to this position of 
the great toe. The applicants were naturally from the 
middle class, where the men were likely to have worn large 
boots, and to have been as likely to develop the normal foot 
.as any class in the community. Yet in no one of the cases 
•could a line be drawn backward from the great toe which 10 
AFFECTIONS OF THE ARCH OF THE FOOT, 
would have fallen even within the outer border of the heel. 
In a series of one hundred tracings of nurses the deviation 
of the great toe was still more noticeable. If one reflects 
upon the symmetrical shoes which children wear, with the 
Fig. 10.—Meyer’s line in a normal foot. 
inside and outside alike, it must be obvious that this pro- 
cess of displacing the great toe outward begins in early 
childhood. It is to this matter that we would especially 
call your attention in speaking of boots, as it seems as if 
Fig. 11.—Meyer’s line in an average foot. 
modern footwear deprived the foot of a legitimate support 
and favored the position of pronation. 
2. Weakness or insufficiency of the muscles resulting 
from— 
(а) Long standing, especially on hard-wood floors. 
(б) Rapid growth. 
(c) Poor health and debility. 
(d) Convalescence from acute illness. AFFECTIONS OF THE ARCH OF THE FOOT. 
11 
(e) Rapid gain of weight. 
(/) Accident or injury causing disuse of limb. 
3. Excessive weight-bearing, as in the case of profes- 
sional strong men and jumpers. 
4. A shortened condition of the gastrocnemius muscle, 
as described by Shaffer. Unless dorsal flexion of the foot 
beyond a right angle is possible, it is impossible for a per- 
son to complete the step with the leg straight behind him 
and the foot pointing forward. Eversion of the foot is 
necessary, and a completion of the step by rolling over on 
to the inner side of the foot. This, of course, tends to 
produce pronation and breaking down of the arch. 
5. Rickets, for the most part to be observed among 
children. 
6. Infantile paralysis. 
7. Direct traumatism. 
eases, 
8. Locomotor ataxia and similar organic nervous dis 
Pronated foot and flat-foot coexist often with rheuma- 
toid arthritis and neurasthenia. There is also a type of 
intractable flat-foot seen in young adults, accompanied by 
muscular atrophy, where treatment is of little avail. Its 
aetiology is most obscure. 
“ Contracted foot ” is the term which the writers would 
apply to a condition described in part by Dr. N, M. Shaffer 
under the name of non-deforming clubfoot. Contracted 
foot is characterized by a limitation of the dorsal flexion of 
the foot, or by an elevation of the arch of the foot, so that 
the outer border does not rest upon the ground. The latter 
condition is made evident by an imprint tracing, and the 
former by passive manipulation of the foot by the leg held 
straight. Contracted foot may or may not induce prona- 
tion of the foot, and in many instances is probably the early 
stage of flat-foot. AFFECTIONS OF THE ARCH OF THE FOOT. 
The symptoms are similar to those of flat-foot: Pain 
and discomfort in the feet in standing, and particularly on 
walking; pain often located between the fourth and fifth 
Pig. 12.—Tracing of a contracted foot. No symptoms, foot useful. 
metatarsals, often spoken of as Morton’s disease. Pain in 
the knees and backache are among the common symp- 
toms. 
Diagnosis.—The existence of flat-foot can be demon- 
strated by having the patient step with the wet sole upon 
the floor or upon a piece of paper, or more accurately by 
having the patient with the bare foot step upon a piece of 
cardboard blackened with camphor smoke. In either case 
the imprint will show whether the arch is normal or whether AFFECTIONS OF THE ARCH OF THE FOOT. 
13 
it is abnormally higb or low. Tn the former case it is con- 
tracted foot and in the latter case flat-foot. If dorsal 
flexion of tbe foot is limited at a right angle, contracted 
foot is present. The presence or absence of flat-foot proper 
depends entirely upon the study of the imprint tracing. 
Fig. 13.—Pronated foot without breaking down of the arch. See tracing. 
The existence of pronated foot must for the present be de- 
tected by the eye, which will notice whether in standing the 
line of the leg passes, as it should, through the second toe or 
the outer side of the first toe when weight is borne upon the 
foot. It may be noted in passing that in one hundred trac- 
ings of nurses studied the condition of contracted foot, as 
demonstrated by the tracing, existed in one nurse in ten, 
and that a tracing perfectly chaiacteristic of flat foot ex- 
isted in the same proportion of cases in one nurse in ten, 
yet in no one of these apparently abnormal tracings was 
pain or disability present. AFFECTIONS OF THE ARCH OF THE FOOT. 
Treatment.—Pronated foot and flat-foot differ but little 
in treatment, except that in the former support to the arch 
Fig. 14.—Flat-foot—painful. Showing similarity of position to that in Fig. 13. 
of the foot is not always necessary. Remedial measures 
will be considered in order, beginning with the mildest. 
Fig. 15.—800t of improved pattern (the inner edge is not quite so straight as it 
should be theoretically). 
1. Boots.—Proper boots should be insisted upon. The 
essentials of a good boot are the following: 
[a) A straight, or nearly straight, inside edge. 
(6) The sole of the boot should be as wide as the sole AFFECTIONS OF THE ARCH OF THE FOOT. 
15 
of the foot -when weight is borne upon it, across the front 
of the foot opposite the metatarso-phalangeal joint. 
(c) The shank should not he cut away on the inside, 
but should be moderately high and should support the arch 
of the foot. 
(d) The forward part of the boot should be at an angle 
to the back part, so that the foot should be held in the 
position of adduction. In short, the sole of the boot should 
be constructed on a curve with the convexity outward. 
Pronation, it has been seen, is necessarily associated with 
abduction. Anything which tends to diminish abduction 
tends to prevent pronation. Consequently, the boot which 
holds the foot in the adducted position is most likely to 
prevent the occurrence of pronation. 
Practically the same points are essential in the boots 
for children. 
2. Raising the Inside of the Boots.—In cases with 
troublesome pronation, but with no breaking down of the 
arch of the foot, it is desirable to raise the inner side of 
the sole and heel of the boot an eighth or a quarter of an 
inch, or more if necessary. This is done by making the 
inner side of the sole and heel thicker than the outer side. 
This throws the foot more to its outer side and changes 
the bearing of the foot. This may be done whether or not 
plates or pads are used. 
3. Supports.—lf the arch has broken down, or if rais- 
ing the inner side of the boot until the correct position of 
standing is induced is not sufficient, a brace may be applied 
with a pad over the internal malleolus which shall throw 
the foot over on to its outer side. A pad or a plate may 
be applied to hold up the arch of the foot and, by sup- 
porting the weight in that way, to throw the foot on to 
its outer side. In the hands of the writers the use of a 
simple silicon-bronze plate, accurately shaped to fit the 16 
AFFECTIONS OF THE ARCH OF THE FOOT. 
arch of the foot, has produced the best results. The limits 
of this plate are shown in the figure. The use of pads of 
felt or leather, of elastic springs, and of other devices has 
not, as a rule, been as satisfactory in the hands of the 
Fig. 16.—Flat-foot plate—right foot. 
writers as that of a metal rigid plate. Pads of leather or 
felt tend to break down the shank of the shoe, and in time 
to make it convex downward. It is, to our mind, of the 
greatest importance that the plate should fit accurately, and, 
if possible, patients should be fitted by the workmen where 
the plate can be bent hot. This measure has been adopted 
by the writers because it was found that sore spots in the 
sole of the foot were not reproduced if the plate was fitted 
on a plaster cast, and that the comfortable fitting of the 
plate was a matter of precision only to be obtained in this 
way. The writers would wish to insist most strongly on 
this accurate adjustment of the plate. Plates are not ap- 
plied with the idea of furnishing a permanent support. 
They are put in, on the contrary, with the idea of being 
removed as soon as the foot shall have been restored to its 
normal condition. In certain cases there seems to be what 
one would almost call a reflex irritation in these feet, which 
leads to a breaking down of the arch. That is to say, if 
these feet are padded or soothed by plates or by rest, the 
arch is, to a certain extent, restored temporarily, and it is a 
common experience in the use of accurately fitting plates 
that after a month or so a patient becomes uncomfortable, 
and it is found by inspecting the marking on the plate that 
the arch has raised so that the plate fails to support it and AFFECTIONS OF THE ARCH OF THE FOOT. 
the plate must he arched still more in order to he a sup- 
port. The writers can recall three recent patients, one a 
woman weighing one hundred and ninety pounds and the 
mother of four children, who have been able to go without 
plates after wearing them from six to ten months. This 
the writers do not attribute entirely to the use of plates 
but also to the general treatment. 
With regard to the general and local treatment other 
than the use of proper hoots and plates, the writers would 
wish to lay great stress upon the value of massage and ex- 
ercises for restoring the use of the muscles at fault. In 
pronated foot and flat-foot it is common for the circulation 
to he poor, the veins to be enlarged, the feet to sweat pro- 
fusely, and for the general circulation of the feet to be in a 
very unsatisfactory condition. It is obvious under these 
circumstances that massage and manipulation are strongly 
indicated, and in cases where these are not obtainable that 
exercises should he prescribed which should call into activ- 
ity those muscles which support the arch of the foot and 
tend to produce an adducted position. Forcible adduction 
of the forward part of the foot against resistance, rising on 
tiptoe, and similar exercises are types of the requirements 
in this respect. 
With regard to the treatment of contracted foot, cer- 
tain cases, especially if acute, are relieved by placing a pad 
of felt or a metal plate under the abnormally high arch. 
Other cases are not quieted by this measure, and require 
stretching of the gastrocnemius muscle by Dr. Shaffer’s 
shoe, a remedy which is also useful in certain cases of pro- 
nated foot associated with limitation of dorsal flexion. 
Patients with contracted foot, as a rule, find comfort in 
wearing hoots with moderately high heels. 
It is difficult to present a summary of a paper which at 
best is only a brief mention of many points. What the 18 
AFFECTIONS OF THE ARCH OF THE FOOT. 
writers would particularly wish to call to your attention are 
the following points: 
There are three well-marked conditions which give rise 
to much the same symptoms, which are associated with 
some abnormity of the foot. These are pronated foot, 
flat-foot, and contracted foot. 
Pronated foot and flat-foot are most often favored by 
bad boots which render the feet vulnerable and improperly 
supported. 
The setiological relations of contracted foot are entirely 
obscure. 
The treatment of these conditions consists in the use of 
boots which shall allow the foot to be placed upon the 
ground in its proper relation and which favor a correct po- 
sition of standing. 
If the arch is broken down, some appliance should be 
used to support it so that the foot may rest in the proper 
position. 
These appliances are used merely as temporary meas- 
ures, and should only be applied in connection with exer- 
cises and manipulation intended to restore the muscles to 
their normal function. The New York Medical Journal 
A WEEKLY REVIEW OF MEDICINE. 
EDITED BY 
FRANK P. FOSTER, M.D. 
THE PHYSICIAN who would keep abreast with the advances in 
medical science must read a live wreekly medical journal, in which 
scientific facts are presented in a clear manner; one for which the 
articles are written by men of learning, and by those who are good and 
accurate observers ; a journal that is stripped of every feature irrelevant 
to medical science, and gives evidence of being carefully and conscien- 
tiously edited ; one that bears upon every page the stamp of desire to 
elevate the standard of the profession of medicine. Such a journal 
fulfills its mission—that of educator—-to the highest degree, for not 
only does it inform its readers of all that is new in theory and practice, 
but, by means of its correct editing, instructs them in the very important 
yet much-neglected art of expressing their thoughts and ideas in a clear 
and correct manner. Too much stress can not be laid upon this feature, 
so utterly ignored by the “ average ” medical periodical. 
Without making invidious comparisons, it can be truthfully stated 
that no medical journal in this country occupies the place, in these par- 
ticulars, that is held by The New York Medical Journal. No 
other journal is edited with the care that is bestowed on this; none 
contains articles of such high scientific value, coming as they do from 
the pens of the brightest and most learned medical men of America. A 
glance at the list of contributors to any volume, or an examination of 
any issue of the Journal, will attest the truth of these statements. It 
is a journal for the masses of the profession, for the country as well as 
for the city practitioner; it covers the entire range of medicine and 
surgery. A very important feature of the Journal is the number and 
character of its illustrations, which are unequaled by those of any other 
journal in the world. They appear in frequent issues, whenever called 
for by the article which they accompany, and no expense is spared to 
make them of superior excellence. 
Subscription price, $5.00 per annum. Volumes begin in 
January and July. 
PUBLISHED BY 
D. APPLETON & CO., 72 Fifth Avenue, New York.