Functional emphasis predates WWI
By Emily Delzell
The observations and treatments made and used by military clinicians more than 100 years ago remain relevant in modern foot care, according to a recent review of flat foot care in the US Army through 1918 published in May in the Journal of Foot and Ankle Surgery.
Strengthening the foot’s intrinsic muscles, for example, explored as an up and coming area of research in the last issue of LER: Foot Health (see “Importance of intrinsic muscles for foot health,” June 2016, page 15) was used by US Army orthopedic surgeons as early as World War I (WWI). Practitioners in that war’s Special Training Battalions, or “flat foot camps,” also used real-time biomechanical correction during marching, a practice very like modern gait retraining.
“What I found is that much of what we think of as new isn’t new at all—they’re things that are proven to be helpful, but people forget and end up relearning important lessons,” said COL Michael T. Neary, DPM, MBA, review author and podiatry consultant at Keller Army Community Hospital in West Point, NY.
Neary detailed the late 19th century professionalization of orthopedic surgery as a general surgery subspecialty that quickly allowed it to become a major player in military medicine. This involved transitioning from a field that almost exclusively used splints, straps, and other devices to correct pediatric deformities to one focused on prevention and surgical correction of chronic and progressive defects in patients of all ages.
These changes, Neary noted, dovetailed with the move from a rural society to an urbanized one in which factory workers could stand for hours, often in ill-fitting shoes, and with a rise in foot complaints. A 1907 study, for example, found flat feet complaints accounted for 2.8% of all new concerns among patients in 1890, a figure that increased to 18% by 1906.
By 1908, the US Surgeon General had commissioned the Army Shoe Board to research soldiers’ foot health; a 1912 study found more than 80% of soldiers were unable to choose properly fitting footwear, and that 30% of those who had chosen their footwear reported disabling foot injuries after an 8-mile march. Boots fitted using objective measures resolved many injuries, and the Shoe Board introduced the first standardized US Army boot, with a last based on foot shape, volume, and function.
—COL Michael T. Neary, DPM, MBA
Although the US didn’t enter WWI until 1917, reports from Europe in 1914 indicated flat foot was a major military efficiency problem. A group of US surgeons began working with the US Army to establish flat foot camps to educate soldiers and officers on foot anatomy, proper shoe wear, and foot strengthening exercises.
The camps treated enlistees with flat fleet deemed weak or undeveloped at places like Fort Ethan Allen in Arlington, VA, as well as behind the French front lines for soldiers with defects that developed or worsened during active service. Men spent about four weeks in the camps. After being measured and issued properly fitting shoes adjusted to correct any defects, they began “active training,” which included simple exercises designed to strengthen the intrinsic foot muscles (see illustration). An orthopedic surgeon went along on marching drills, instructing the men to keep the toes pointed straight ahead and shift the knees outward to offload weight laterally.
Of the 822 men treated in the camps, 75% returned to their groups and 54% went back to full duty.
“The camps were remarkably successful,” Neary said.
His historical research has changed the way he treats flat foot, plantar fasciitis, and overly flexible feet.
“Instead of asking patients to wear a brace or insert indefinitely, I often try exercises in addition to a device,” Neary said.
The orthopedic surgeons of WWI, he said, “knew it wasn’t foot structure, but the function of the foot that matters.”
Biomechanist Karen Mickle, PhD, who reviewed Neary’s paper for LER: Foot Health, strongly agreed.
“Far more emphasis should be placed on the functioning of the foot, during the activities that need to be undertaken, rather than the height of the arches alone,” said Mickle, a research fellow at the College of Sport and Exercise Science at Victoria University in Footscray, Australia. “Unfortunately, most foot assessments, whether in the [military] or in clinical practice, typically rely on the static positioning of the foot, still today.”
In addition to flat feet, intrinsic muscle strengthening can be helpful for such conditions as plantar fasciitis, hallux valgus, and lesser toe deformities, she said.
Neary MT. Flat feet and the U.S. Army through 1918. J Foot Ankle Surg 2016;55(3):675-681.