Careful attention must also be directed to shoes in older children. A child must be given as much opport unity as possible to walk barefooted for the purpose of developing the muscles of the foot.
As soon as pronating deformities occur correction becomes neces sary. In sonic cases, and especially in those accompanied by genii valgum, the patient seeks to compensate the deformity by walking with toes turned inward. It would thus be very wrong to attempt to change this rather ungraceful but certainly not dangerous attitude of the foot. It would only increase the main trouble.
The treatment of genu valgum is identical with that of flat-foot. By establishing an oblique supinating base for the feet, as mentioned above, the knees are forced apart and the faulty attitude of the joints of the foot is corrected.
For this purpose the inner side of the shoe must be raised about 1.5 cm. The ideal way to change the shape of the foot is to employ indi vidually prepared celluloid supports (Lange) (Fig. 100).
A plaster cast of the unweighted foot is taken. The foot is held in pronated position with toes adducted during the application of the nega tive. The child is told to stand on the foot just before the plaster becomes firm or the foot is pressed against a board. Layers of celluloid mass, bandage of webbing and straps arc applied over the positive. The layers are stiffened with steel wire and, according to Lange's suggestion, supports are prepared which retain the foot in any desired position. This cast surrounds the heel and gradually raises the inner arch of the foot, and a high border on the outer side prevents the foot slipping from the raised inner side and prohibits any abduction in Chopart's joint.
By the introduction of small wedges between the sole of the shoe and the plaster supports on the inner side, the cast may be supinated to any degree.. The child is now placed with the cast on a hard table and the inner side raised until the deviation of the axis of the lower leg is not only corrected, but even overcorrected to a slight pes warns. Meas urements for shoes are taken over these supports. The shoes will not appear to be exceptionally large if the supports are trimmed in a reason able way. The moment the child walks with these shoes and supports,
the foot is forced at each step into supination and adduction. After several months the overcorrection may gradually be abandoned and the foot under this treatment may be brought back to its normal shape.
All other purchasable and mechanically contrived braces and sup porters do not answer the purpose at all, or at least not to this extent.
They may possibly — by the insertion of a pad of rubber, cork, or leather — prevent a further depression of the arch of a foot and alle viate the existing pains, but they certainly can never have as much influ ence upon a foot as a celluloid support in changing entirely the existing deformity. Correction or overcorrcction of the abduction of the heel and front part of the foot alone, in combination with a raising of the arch, may bring about a normal development in the growth of a diseased foot.
About the same measures are to be employed with older children. In weak ankles, weak feet and fiat-foot, individually prepared supporters must be used.
It is unimportant what material is chosen. Celluloid and steel wire are the lightest and firmest. This simple technic enables the physician and patient to be independent of bandage makers and shoemakers. It is quite incomprehensible that some authors still persist in advocating the purchase of arch supporters by number.
In addition, much care must be given to the strengthening of the muscles of the foot. Walking barefooted, especially walking on the front part of the foot, grasping motions with the toes, exercises with foot weights to increase supination tend to strengthen the muscles. Growth and increase in strength arc impeded by weakening the feet— wearing too narrow and pointed shoes and faulty and deficient use of the lower limbs.
The form of flat-foot (pes p]anus) which has been occasionally described in text-books, does not exist in reality except in small children when they make their first attempt at walking. In older children it is always combined with an outward deviation or pes valgus (Spitzy).