Reprinted from 
ANNALS 
OF 
SURGERY 
** EDITED BY 
i- S. PILCHER. A M., M.D, J. WILLIAM WHITE. M D, 
FREDERICK TREVES. F.R C.S. ~ 
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THE UNIVERSITY OF PENNSYLVANIA PRESS, 
PHILADELPHIA. PA. 
London: Balliare. Tindall & Co». jo Kine William Street, Strand. 
JANUARY, 1893. 
Additional Notes on Forcible Over-Correction, in the 
Treatment of Rigid Flat-foot. 
By Royal Whitman, M. D., M. R. C. S., 
"New York. ADDITIONAL NOTES ON FORCIBLE OVER-COR- 
RECTION, IN THE TREATMENT OF RIGID 
FLAT-FOOT. 
ROYAL WHITMAN, M. D., M. R. C. S., 
OF NEW YORK. 
IN considering the question of the radical cure of flat-foot as 
distinct from simple relief of symptoms, it is very evident 
that the proper position and functions of the foot must be re- 
gained before we may hope for permanent cure. 
When the normal foot rests upon the ground the weight line 
of the body falls through the centre of the heel behind and in a 
line with the second toe in front. 
The foot is perfectly balanced by its various muscles ; flexion 
is combined with abduction, extension with adduction, and in 
order that the normal walk may be perfectly carried out these 
movements must be free and unrestrained. 
The outer border of the foot, solidly braced by ligaments and 
usually in direct contact with the sole of the shoe bears, the first 
shock of weight, while the inner, freely movable portion, 
terminating in the powerful great toe, supplies the elastic element 
or spring at the termination of the step when the foot is extended 
and adducted. 
In the flat-foot in addition to the sunken arch, as a result 
and consequence of weakened muscles and displacement of com- 
ponent parts, there is not only an abduction at the medio-tarsal 
joint, so that the weight line falls inside the great toe, but in addi- 
tion a voluntary eversion of the foot to avoid activity, which has 
become painful. Thus the patient walks with the cloddy everted 
step, substituting flexion at the knee and the simple up and down 
or hinge motion at the ankle-joint, for the normal activity of the 
foot itself. More and more strain is thus brought upon the arch 
and upon its ligaments which should be perfectly protected by 
muscular activity. 2 
ROYAL WHITMAN. 
Thus the affection progresses, the deformity becomes more 
marked and disabling, and with the malposition follow develop- 
mental changes in the shape of the bones and the low grades of 
inflammation usually classed as rheumatic. 
On examination then of a well developed and painful flat-foot 
we shall inevitably find that one motion, the most important of 
all, that of adduction or the power of turning the foot inward at 
the medio-tarsal joint, is lost. The muscles which should carry 
out this motion are weakened and atrophied from disuse, while 
those on the front and outer border of the foot are spasmodically 
contracted and resist passive correction of the deformity. There 
are inflammatory adhesions between the bones, contraction and 
shortening of ligaments on the outer, and relaxation and lengthen- 
ing of those on the inner aspect of the foot. It is in this class 
of cases that etherization and forcible reposition are essential, and 
the manner in which this is accomplished is of the first importance. 
Dr.Wood, in his excellent paper on flat-foot in the Annals 
of Surgery for November, mentions the method employed by 
Willett, and it is to be inferred that this is the forcible correction 
which he would recommend. Mr. Willett’s manner of operating 
is described by Mr. Howard Marsh in Vol. 18 of St. Bartholo- 
mew’s Hospital Reports (Notes on Orthopedic Surgery) as follows: 
“ The foot is kept as nearly as it can be at a right-angle to 
the leg, its internal border is then turned upwards and its anterior 
segment is then carried far inwards by rotation at the ball and 
socket joint, between the astragalus and scaphoid.” 
According to Mr. Marsh it may be necessary to repeat the 
operation in aggravated cases. The foot is kept for one month 
in a plaster bandage and further treatment carried out by pro- 
longed rest alternating with tip-toe exercises and massage. Mr. 
Marsh is inclined to be dubious as to the advantage of braces in 
after treatment, but describes a rather cumbersome appliance 
composed of an upright leg support to which a foot brace is 
connected by a leather strap. This manner of forcible correc- 
tion is very similar to that employed by the German surgeons. 
Hoffa minutely describes the procedure as follows (Lehrbuch der 
Orthopadischcr Chirurgie, §, 697): “ The foot is brought up to a 
right angle or beyond by division of the tendo Achilles, as re- 
commended by Krause. In this dorsal flexed position the arch TREA TMENT OF FLA T-EOO T. 
3 
is forcibly deepened by manipulation, and a plaster bandage ap- 
plied. After several weeks the patient may walk about, wearing 
for many months a wooden bandage made in the shape of the 
corrected arch, laced in front so that it may be removed for mas- 
sage and exercise.” The criticisms which I would make on 
these methods of treatment are, first, when the foot is brought 
up to a right angle or beyond, it is and must be from the shape 
of the articulating surfaces of its joints abducted, adduction being 
to any extent in this position, impossible. Second, patients suf- 
fering from this affection are as a rule unable to allow themselves 
the prolonged rest required by Mr. Marsh, nor would they sub- 
mit to the wooden bandages used by Dr. Hoffa. 
The operation which I have recommended and performed in 
a large number of cases is forcible over-coryection of the deformity 
not primarily for the purpose of replacing dislocated bones, but 
to forcibly overstretch all contracted parts and to break up ad- 
hesions which resist and restrain the movement of extension and 
adduction, the essential movement for carrying out the normal 
step. 
To force a fpot into the extreme position of adduction it 
must be extended (plantar flexed). This may be easily demon- 
strated on one’s own foot. The operation then is as follows : 
The foot is forcibly moved in every direction to break up adhe- 
sions and is finally extended and twisted inward as far as possible. 
In this position contracted muscles, ligaments and fascia are 
stretched to their extreme limit, and weakened and lengthened 
tissues are relaxed. While'this is the primary object of the 
operation the misplaced bones are and must be as far as is pos- 
sible replaced in normal position, the os calcis is drawn down- 
ward and inward beneath the astragalus and the arch assumes its 
greatest depth. 
Forcible over-correction can usually be accomplished by 
the hands alone, but in more resistant cases it is well to place the 
patient on a low bed, allowing the legs to hang over the edge; 
the foot can then be seized between the knees, and the necessary 
force supplied by the thigh muscles. 
Although the reposition is often accompanied by a formid- 
able cracking of adhesions the after symptoms are invariably 
slight. A well-fitting plaster bandage is applied in the over- 4 
ROYAL WHITMAN. 
corrected position, and the patient allowed to walk about on 
canes or crutches. In one week the bandages are removed in 
order that casts of the feet may be taken for braces, the bandages 
are then re-applied in the same position. 
At the end of three weeks all inflammatory appearances 
have usually disappeared, the patient is able to walk about with 
the braces and the detention from work is as a rule less than one 
month. 
The essential movement of extension and adduction which 
has been attained by the forcible stretching, is assured by a daily 
inward twisting of the foot by, or under the supervision of the 
surgeon, until passive adduction and extension can be carried 
out without pain or resistance. 
Voluntary assumption of the position becomes possible 
when the adductor muscles regain their power. I must again 
insist that it is not enough that the arch of the foot is deepened 
and that the foot appears perfectly normal, the muscles must 
regain their normal balance, for as long as the abductors restrain 
the necessary adduction and extension, the patient is in danger 
of relapse. This voluntary and involuntary resistance often per- 
sists long after pain and discomfort have disappeared, and it can 
only be overcome I believe by the passive stretching which I 
have before described. (Vide N. Y Medical Journal, Feb. 27, 
1892.) The brace is constantly worn and the displacement never 
allowed to recur. A waukenphast shoe is to be used, the heel 
of which is raised if necessary on the inner border, so that the 
weight line may fall slightly to the outer side. The patient is then 
instructed in the manner of walking and supporting weight. This 
is essential to success; he must no longer evert the feet, a position 
which brings all the weight and strain upon the weakened arch 
and brace, but must point them straight ahead or parallel to one 
another, so that he walks over his toes or, in other words, raises 
the body and flexes the foot in the normal manner by muscular 
activity. Each step is thus an active exercise by which muscular 
strength is increased, and the correct position of the foot assured. 
Walking is to be encouraged in the place of long continued rest 
as advocated by others. If the patient is obliged to stand con- 
stantly, the feet are relieved by changing their position, raising 
the body at times slightly on the toes or again throwing the 1 REA TMENT OF FLA T-FOOT. 
5 
weight more on the outer border of the foot. The patient must 
be made to thoroughly understand and appreciate the fact that 
cure is not assured by a brace or by an operation, but by his own 
voluntary exertion. Although massage and technical exercises 
should be recommended, they may be discarded if we can suc- 
ceed in freeing the foot from restraint so that passive adduction 
and extension are possible, supply the patient with a proper 
brace and shoe and assure ourselves that he walks in the proper 
manner. This means permanent cure. 
For the purpose of comparison one hundred consecutive 
cases of flat-foot were taken from the records of the out-door 
department of the Hospital for Ruptured and Crippled. These 
patients all applied for treatment in the six-and-a-half months 
prior to November 1st of the present year. 
In twenty-four the deformity, pain and rigidity were so great 
that forcible over-correction was recommended as a preliminary 
measure. This is, I think, about the usual proportion as seen in 
dispensary practice. These latter cases have been tabulated 
according to age and duration of symptoms. It is interesting to 
note that the class in which the deformity is greatest is the most 
favorable for permanent cure, as the patients are very amenable 
to treatment, lending an enthusiastic cooperation to the efforts 
of the surgeon; an element often lacking in cases of less severity. 
Cases of Rigid Flat-foot. 
Age. 
Duration. 
Sex. 
Double or Single. 
I 
21 
3 mos. 
M. 
D. 
2 
17 
i month 
F. 
D. 
3 
22 
3 mos. 
M. 
D. 
4 
i7 
3 years 
M. 
D. 
5 
i7 
i year 
F. 
D. 
6 
i i 
i year 
M. 
D. 
7 
>5 
i year 
M. 
D. 
8 
*5 
i year 
F. 
D. 
9 
11 
2 mos. 
M. 
D. 
IO 
14 
4 mos. 
F. 
I). 
ii 
14 
. . 
M. 
D. 
12 
5° 
3 mos. 
M. 
D. 
*3 
14 
M. 
U. 
i4 
42 
M. 
S. 6 
ROYAL WHITMAN. 
Age. 
Duration. 
Sex. 
Double or Singl 
*5 
r5 
i year 
M. 
D. 
16 
21 
1 year 
F. 
D. 
i7 
14 
. • 
M. 
D. 
18 
r3 
1 year 
F. 
D. 
19 
38 
1 year 
F. 
D. 
20 
13 
F. 
D. 
21 
J7 
. . 
F. 
D. 
22 
T9 
1 year 
M. 
D. 
23 
18 
M. 
D. 
24 
22 
3 mos. 
M. 
D. 
In addition to these cases of simple flat-foot there were five, 
of so-called chronic sprain of the ankle in which as a result of 
injury, the foot was rigidly held in an abducted position although 
the arch was normal in appearance. I have elsewhere called 
attention to the affection and its treatment.1 
To illustrate common types of severe flat-foot and the effect 
of treatment, the following cases may be quoted : 
Case i, (No. 4 in tabulated list). A boy, 17 years of age, had 
worked for three years as a printer. Having finally reached a position 
by which he became self-supporting, the constantly increasing pain 
and deformity of his feet, obliged him to give up work. He was, 
when he applied for treatment, a cripple, unfit for his own or any 
other occupation. On September 19, the operation of forcible 
over-correction was performed. One month later he returned to his 
work, the feet in normal position, with entire relief of pain and 
every prospect of permanent cure. 
Case 2. A woman, aged 38, was brought to me for treatment on 
October 21, with the following history. Increasing pain and weak- 
ness of the feet for three years. She had been constantly treated for 
rheumatism by medicines, massage, baths, etc. The “lumps” on the 
inside of the feet had been blistered many times to reduce the 
swelling. She had been obliged to use crutches for three months, 
and “when in the house dragged herself about in a rocking-chair.” 
In this case, by preliminary rest in plaster bandages, it was possible 
to bring the feet into proper position without etherization. She is 
now, November 10, able to walk without discomfort, although the 
muscles are still weak. In this type, when patients are debilitated 
1“ Persistent abduction of the foot.” 
nth, 1890. 
New York Medical Journal, October TREA TMENT OF FLA T-FOOT. 
7 
from constant pain and loss of exercise, massage and tonics are of 
much importance. Of all tonics, however, the most effectual is the 
assurance of speedy and permanent relief of an affection considered 
hopeless. 
Case j. This will serve to illustrate the effect of treatment 
in the rheumatic type of weakened arch. A young man, 19 years 
of age, applied to me on July 19, 1890. He had suffered from 
constant pain in the feet for three years. As he was a salesman in one 
of the large instrument shops in New York, he had had the benefit 
of advice and treatment from various physicians, and had exhausted 
the ingenuity of his associates in the application of various supports. 
He was obliged finally to discard them all, and when I saw him he 
told me that he “had suffered so much pain and was so discouraged 
that he wished he were dead.” The case to me seemed perfectly 
hopeless; the boy was emaciated and weak, both the knee and 
ankle-joints were swollen and infiltrated, the circumference of the 
ankle being greater then that of the calf. The toe-joints seemed 
ankvlosed. There was no apparent flat-foot or any appreciable 
spasm. When weight was borne there was well marked abduction of 
the feet. As the first indication was evidently the relief of pain and 
improvement of the nutrition, he was not allowed to walk, was given 
cod liver oil and syrup of the hypophosphites and forced feeding. In 
the meantime a course of vigorous massage with prolonged soaking of 
the feet in hot water, was faithfully carried out. In three weeks, 
braces were applied, and he was allowed to walk about. I then lost 
sight of the patient, and supposed that he had relapsed. Last 
summer he came to see me, and to my surprise said that he had 
continued free from pain, and “had not lost a day’s work in two 
years.” His feet were then almost perfectly normal in appearance 
and function. He continues to wear the braces, although it is prob- 
able that they are no longer necessary. 
Similar cases occasionally come under observation when as 
the result of general rheumatism the feet remain rigid and greatly 
deformed. In such cases I have not hesitated to recommend 
forcible correction of the deformity on the principle that whenever 
possible the normal relations of the foot as a weight bearer should 
be regained. 
Case 4.—A young lady twenty years of age, was seen in consulta- 
tion on March 3d, 1892, one and a half years before, the left ankle 
had been sprained. As the usual treatment failed to relieve the 
symptoms a specialist was consulted and a long course of daily treat- 8 
ROYAL WHITMAN. 
ment carried out, including local and general massage, and the use of 
a leg brace. This support protected the joint somewhat, but the 
weakness, pain and inability to walk for any distance continued so 
that the patient had become a semi-invalid. The only complete relief 
experienced during this time was when the ankle was held in a plaster 
bandage, and crutches used. It was during the treatment of one of 
the recurrent sprains that I saw the patient. The condition and 
cause of the weakness was apparent. Although the foot was normal 
in appearance, when weight was borne the arch flattened, the fore 
foot turned outwards opening and exposing the astragalo-scaphoid 
joint which was very sensitive to the slightest touch. As soon as the 
arch was properly supported the symptoms were completely relieved, 
and after a short course of local massage and exercises, the patient 
informed me that she had walked five miles without discomfort. When 
last seen a few weeks later, the only trace of the former trouble was a 
slight sensitiveness to deep pressure on the scaphoid bone. 
Case 5. A delicate girl, eleven years of age, was referred to me 
on Oct. 25th, 1891, for weakness and deformity of the feet. A 
specialist had previously been consulted, who had advised leg sup- 
ports, but the mother said the child was so sensitive that she con- 
sidered the physical deformity of less consequence than the probable 
moral effect of the remedy. The feet were so weak that the patient 
was unable to raise the body on the toes; the deformity was very 
marked, and the child was awkward and easily fatigued. There was 
no pain, spasm or limitation of motion. The arch was supported, the 
child supplied with proper shoes and a course of exercises recom- 
mended, which I believe were never carried out. One year later the 
feet were perfectly normal in appearance and function, and the child 
is able to walk long distances without fatigue. I have never thought 
it necessary or advisable to use leg supports in any case of flat foot, or 
so-called weak ankles. When the arch is protected by a proper brace 
and shoe, and the weight of the body brought into the normal relation 
to the foot, the muscles rapidly regain their ability to protect the 
ankle. 
I think it has been made clear that the method of treat- 
ment which aims at permanent cure by a reversal of the con- 
ditions under which the deformity has developed, differs essen- 
tially from efforts at relief of symptoms by applying braces 
without regard to the condition of the foot, and from those ope- 
rations which would substitute an ankylosis of an important joint 
for muscular strength and activity. TREA TMENT OF FLA T-FOO T. 
9 
More minute details of the treatment, the description of the 
brace used and the method of its manufacture may be found in 
the New York Medical Journal of February 27th, 1892. 
The ability to apply a proper brace under proper conditions 
is essential to success. No one who has witnessed the immediate 
relief of pain from the application could doubt for a moment its 
efficiency or necessity. An habitually misplaced foot remains 
weak for a long time and must be held in position while the 
muscles regain their strength. Once the surgeon is familiar with 
its application and appreciates its use the field of therapeutic effort 
broadens to include not only the treatment of acquired flat-foot, 
but its prevention, by a recognition of its predisposing causes and 
early symptoms. In children, the cases of weak ankles of “growing 
out joints,” those who are awkward and easily fatigued; in older 
subjects, the easily sprained ankle, the chronic sprains and the 
like, will be found very amenable to relief by treatment conducted 
on the principles laid down; that the weight of the body must 
fall normally on the foot, and that the muscles must be properly 
balanced and the walk carried out in the normal manner, what- 
ever may have been the cause of the original deformity. 
In conclusion I may take this opportunity of thanking the 
writers of the most recent articles on flat-foot, Drs. Wood,1 Dane2 
and Dauriac3for their kind references to my work on this subject. 
126 West Fifty-ninth Street, 
New York. 
1 Annals of Surgery, Nov. 1892. 
2 Boston Medical and Surgical Journal, Oct. 27th, Nov. 3d and 10th. 
3 Gazette des Hopitaux, Sept. 10th, 1892.