Leonardo's Foot

by Carol Ann Rinzler

  There is even a kids’ version of a crime-fighting flatfoot: Flatfoot Fox, “the smartest detective in the whole world.” The canny Fox, hero of five books by Clifford Eth, the pseudonym of Eth Clifford Rosenberg, a well-regarded children’s author and the biographer of Yiddish actress Molly Picon. Today, fifty-seven boxes of her papers, including the copy-edited proofs of some of the Flatfoot Fox books, are stored at the University of Minnesota Libraries Children’s Literature Research Collections. Rosenberg’s Fox solved cases in the animal world with the help of a friendly Secretary Bird, which in real life is a fairly scary animal, a raptor with long legs, wings, and tail, named for a crest of long feathers atop its head that look like old-fashioned quill pens.

  Back on the mean streets of the Big City, one early twentieth century member of a profession definitely not meant for children was also nicknamed “flatfoot,” courtesy of jazz instrumentalist and composer Bulee “Slim” Gaillard (1916–1991). Gaillard, who spoke eight languages and invented one of his own, a dialect he called Vout, published “Flatfoot Floogie with a Floy Floy” in 1938. The song was originally titled “Flatfoot Floozie”—from “Flossie,” early slang for a promiscuous girl–but the name was changed to avoid the radio censors’ blue pencil. The term Floy Floy slid by under their radar, un-noted except by those who knew quite well that it was slang for a venereal disease, probably syphilis whose third-stage symptoms include tabes dorsalis, the degeneration of nerve tissue that leads to loss of muscle and tendon reflexes in affected limbs, causing a lurching gait that seems to be referenced in a line from the last verse of the song: “If you go on stumblin’ with the gang!”

  Coded language and all, “Flatfoot Floogie” was recorded by such household names as Louis Armstrong, The Mills Brothers, Benny Goodman, Django Reinhardt, Count Basie, Fats Waller, and the luminous Nat King Cole. Not one of them publicly batted an eye as hep cats of all ages jitterbugged to a tune about a prostitute with late-stage syphilis, just as thirty years later their hippie children and grandchildren embraced “Puff, The Magic Dragon” and “Lucy in the Sky with Diamonds” that everyone—except the BBC, which banned “Lucy”—agreed were definitely, absolutely not code for marijuana or lysergic acid/LSD. The hep cats and the hippies also had this in common: According to the Online Etymology Dictionary, both sobriquets come from hep, first used as a synonym for “up to date” in a 1908 edition of The Saturday Evening Post. Hep itself is variously described as being either underworld slang, or as some etymologists suggest, a semantic descendent of hipi, a word in Wolof, the language spoken by as many as seven million people in West Africa, that means to see or to open your eyes or a person with open eyes.

  “Flatfoot Floogie” was Number One on the Hit Parade for eight weeks. Another Gaillard song, “Cement Mixer, Putti, Putti” (1946) made the Hit Parade, but “Flatfoot Floogie” was the true winner, so popular that a copy was included in a time capsule buried at the site of the 1939 New York World’s Fair to be opened in 5,000 years.

  Gaillard told friends he intended to be around for the occasion.

  Fixing or not fixing the no-problem problem

  Despite the social, religious, and military obsession with flatfeet, the good news is that people born with the flexible version rarely experience serious discomfort. The so-so news is that there has been very little serious investigation into what causes flatfeet, who is most likely to have them, and what if anything to do about the supposed problem.

  Like clubfoot and gout, the tendency to flexible flatfeet and high arches sometimes runs in families. Unlike clubfoot, however, there is no known link to a specific gene, and unlike gout, flatfeet are not linked to any metabolic disorder. In fact, when pressed, some experts suggest that any problem with flattened arches may be mostly in the mind of the observer not in the flatfooted person’s feet.

  In 1989, when the Army Institute of Environmental Medicine (Natick, Mass.) ran a study of more than 300 Army infantry trainees at Fort Benning, Georgia, they came to three fascinating and totally non-alarming conclusions.

  Estimates of the number of flatfooted soldiers in the cohort ranged from a low of 10 percent to a high of more than 50 percent, depending on which of the six doctors running the study did the evaluating. To no one’s surprise, different researchers had different ideas about exactly what a flatfoot looked like, so the authors took pictures of every single one of the 600 feet in the study and did dozens of complicated measurements to visualize the actual structure of the arch in each foot. Then, because most estimates put the percentage of flat footed people in the general population at two out of every 10 people, they simply called the 20 percent of the feet with the lowest arches “flat.”

  Having done this, they discovered that soldiers with feet that were obviously flat were less not more likely than those with normal feet to suffer an injury during basic training. And in a perfectly counterintuitive finding, it appeared that those with higher-than-normal arches and insteps were twice as likely to end up with sprains and stress fractures, possibly because a foot with a high arch is a less efficient shock-absorber.

  Having said that, it is my duty to report that in 1999, a longitudinal (long-term, with follow-up) survey of 449 Navy SEALS run at the Naval Health Research Center in San Diego, California, and the Naval Hospital at Camp Lejeune in North Carolina produced similar results: Over time, those with flatfeet were at higher risk of stress fracture and inflammation of the Achilles tendon, the tissue that ties the calf muscle to the back of the heel. Nonetheless, the author of the Fort Benning study told The New York Times in 1990 that “[m]uch of what we’ve believed about flatfeet is mythology. I’ve seen drill sergeants with arches as convex as the bottoms of rocking chairs, who are active and successful.” The same goes for professional athletes. “If I had a choice as a professional athlete to have a high arch or a flat foot, I’d take the flat foot,” said Michael Coughlin, then-president of the American Orthopedic Foot and Ankle Society..

  He was right. Since then, a large number of continuing studies still attest to flatfeet being a no-problem problem. For example, in 2006, Saudi Arabian investigators at the Al-Hada and Taif Armed Force Hospitals in Taif, about 500 miles from the capital city of Ryadh and more or less 6756.5 miles (10873.5 kilometers) as the Boeing 777-300 flies from Washington D.C., ran a similar study and produced similar results among 2,100 recruits aged eighteen to twenty one, and got similarly much-less-than-alarming results. Once again, there was some disagreement as to exactly what constituted a flatfoot but those men whose feet everyone agreed were definitely flat often had relatives with the same condition, and flexible flatfeet were “of little consequence as a cause of disability in adults.” The only surprise was that just 5 percent of the men in the study met the Saudi researchers’ standard for having flatfeet versus the usual 20 percent cited in the United States and around the rest of the world. Perhaps it was the result of there being more than the usual number of differing ideas of what a flatfoot looked like.

  As for children, in 2005, researchers at the University of New South Wales (Australia) tested the movements of fifty-four children, age nine to twelve, half with flatfeet. Each of the twenty-seven children with flatfeet was fitted with a device between foot and knee to monitor the movement of the child’s joints to be measured and interpreted by computer. In the end, the flat-footed kids had balance and motor skills equal to children with normal arches, but were able to jump 15 percent higher, although how they did it with all those devices strapped on is certainly a mystery. The only area in which the flatfooted lagged was what Dara Twomey calls “lateral hopping ability,” that is, hopping sideways over a piece of string. Like the children in the 2011 Aberdeen study of clubfoot, Twomey’s young subjects took their assumed disability in stride. “I play netball and quite a bit of sport and I don’t feel there’s a difference or anything,” one of them said. “Most of my friends haven’t got flatfeet and I’m just as good as them in practically everything.” And probably in shoes without the inserts of
ten prescribed for people with flatfeet, because they may not be much of a treatment after all.

  As always, the Greeks had a word for it: orthos meaning straight. But orthotic—a device to support a body part such as the arch in your foot—did not enter the English vocabulary until the 1950s (Concise Oxford English Dictionary), 1955 (Merriam-Webster), or 1960–1965 (Unabridged/Random House Dictionary), take your pick.

  The first effort to cushion a foot inside a shoe was most likely layers of wool or another soft material piled inside a Greek or Roman sandal to relieve an aching less-than-perfect Greek or Roman arch. More than two thousand years later, in 1865, Everett Dunbar of Bridgewater, one of Massachusetts’ many shoe manufacturers, took a giant step forward by sticking leather lifts between inner and outer sole of his shoes to support the arch.

  The first stand-alone arch support, the Foot-Eazer™, was designed by William Mathias Scholl (1882–1968) in 1903, one year before he graduated from Chicago Medical School, now the Rosalind Franklin University of Medicine and Science named in honor of the British biophysicist whose radiographic images of DNA were indispensable to James D. Watson and Francis Crick’s discovery of the double helix. The following year, Scholl, the son of a German immigrant cobbler, was awarded U.S. Pat. No. 1575645 for his two-piece insert, leather on top of a rigid “silveroid” (a copper/nickel alloy also known as silverine, Alaska silver, or German silver) base, with a bump in the middle to support the arch. Scholl sold his insert himself, walking around to Chicago shoe stores toting along a foot from a human skeleton on which to demonstrate the insert, some of which survive to this day.1

  Just as Scholl was beginning to peddle his insert in Chicago, Royal Whitman (1857–1946), an orthopedist at New York’s Hospital for the Ruptured and Crippled, now the Hospital for Special Surgery, created his own arch supports, rigid, heavy metal devices called the Whitman Plates that were difficult to wear, but nonetheless widely prescribed by orthopedic surgeons. Whitman authored a now-classic paper, “Study of the Weak Foot, With Reference to Its Causes, Its Diagnosis, and Its Cure; with an Analysis of a Thousand Cases of So-Called Flat-Foot,” in the Journal of Bone & Joint Surgery in 1896. In his article, Whitman laid out the differences between congenital flatfoot and flatfoot acquired as an adult. The first, he wrote, was “hereditary and in some areas a race-linked condition.” The second was not true flatfoot, but “a minor element of weakness and a secondary element of the deformity; for the symptoms of flat-foot do not result because the foot is flat, but because it is becoming flat; they are the symptoms of strain up on the weak foot and of the injuries and changes accompanying a progressive dislocation.” Whitman took exception to the usually casual approach to flatfeet. Like doctors treating clubfoot, he proposed bracing, casting, and sometimes surgery for flatfeet and weak feet—plus his own arch support.

  Some of this was probably unnecessary.

  Flatfeet may be uncomfortable, but they are rarely crippling. In fact, so long as they are not yours, they can seem comical, like the big flat shoes worn by circus clowns. That may be one reason why the index for Harrison’s Principles of Internal Medicine, the text the Journal of the American Medical Association described in 2012 as “arguably the most recognized book in all of medicine,” includes flat warts and flat worms, but not flatfeet.2

  After the introduction of anesthesia and antiseptics made surgery safer, flatfeet, like clubfeet before them, became an inviting target for the newly empowered surgeons whose hands practically itched to realign ligaments, tendons, and bones in the attempt to improve a sagging arch. This kind of surgery may well benefit people with severely deformed flatfeet or feet made rigidly flat by abnormally fused bones, or flexible flatfeet that stiffen with age or adults with an acquired flatfoot (or flatfeet) due to a supporting tendon’s tearing or slipping and falling and taking the arch along with it, but asymptomatic flatfeet, even in adulthood, seem best left uncut.

  The other surgery for flexible flatfoot is sinus tarsi implant, a.k.a. subtalar arthroereisis, a procedure in which a small titanium device is inserted into a small hollow (sinus) in the foot between the heel bone (calcaneum) and the ankle bone (talus). It has not been greeted with enthusiastic applause. In 2009, the British National Institute for Health and Clinical Excellence (NICE), an independent, government-funded organization that advises the British National Health Service (NHS), assessed the effectiveness of arch implants. They found a high rate of postsurgical complications such as pain, a shift in the position of the implant that required it to be removed, or on rare occasion, the actual exit of the implant from the foot.

  Two years later, just as The Merck Manual, the continuing series of volumes offering orthodox American medicine diagnosis and treatment, chose to recommend surgery for some flatfeet, an article in AAOS Now, the journal of the American Academy of Orthopedic Surgeons, reported that although surgery might make sense for some cases of rigid flatfoot, flexible flatfoot is normal in babies and in about one out of four adults. Slipping an implant into one of these feet, the author decided, was a complication, not a solution; major insurance companies will not pay for the surgery as a treatment for either congenital or adult-acquired flatfoot because they contend it is an “experimental and investigational [procedure whose] … clinical value has not been established.”

  So thanks to Scholl and Whitman—but mostly Scholl, who eventually built a multi-million dollar business on top of his Foot-Eazer™—orthotics remain the treatment of choice. A worldwide industry now thrives based on Dr. Scholl’s store-to-store sales strategy. Lighter materials, better fit, more comfortable support, and claims of fewer injuries among athletes, support sales of inexpensive over-the-counter inserts to special customized ones costing several hundred dollars a pair.

  The inserts are supposed to compensate for an irregularity in the structure of the foot, most commonly, a low arch, but neither orthopedists, nor podiatrists, nor neurologists, nor fitness experts, nor scientists specializing in biomechanics (the force exerted by muscles and gravity on our bones and joints) can tell you exactly how orthotics inside your shoes influence your movements or affect the stress you put on joints and muscles when you walk, run, skip, jump, hop, or do any one of the things you do while standing up.

  Orthotics enthusiasts will tell you most studies suggest that people do feel better with inserts in their shoes, although which inserts produce what effect is definitely open to dispute. When Benno M. Nigg, professor of biomechanics and co-director of the Human Performance Lab at the University of Calgary in Alberta, asked one distance runner to test orthotics from five reputable manufacturers, each insert designed to correct his pronation in a different way, the runner voted for the two that seemed to enable him to run faster. But the two he chose had totally different structures. Which led Nigg to ask, do orthotics work? And if so, how? That pretty much depends on who’s wearing the insert. One person using the arch may end up walking on the outer edge of her foot and maybe even grabbing at the floor with her toes in an effort to hold her balance, a second might just continue along in the position his muscles and joints consider normal even with the insert in place, and a third just might be positioning his foot more normally with the arch than without it.

  What’s a flatfooted person to believe?

  The same Old Wives who prescribe chicken soup for a cold say that flatfeet are a sign of a bad temper. They also say that it’s bad luck to allow your “first footer” (an old-fashioned term for the first person to walk through your door after the stroke of midnight on New Year’s Eve) to be someone who has eyebrows that meet in the middle or cross-eyes, or, what else? a person with flatfeet.

  The chicken soup gained a certain legitimacy in 2000 when a team of pulmonary specialists at the University of Nebraska Medical Center found a wealth of honest-to-goodness anti-inflammatory compounds in chicken, onion, sweet potato, turnip, carrot, celery, and parsley in broth with no salt, but lots of matzoh balls. Their report, in the journal Chest, said that the soup helped reduce the m
ovement of neutrophils, anti-viral and anti-bacterial cells that multiply during an infection to behave like tiny vacuum cleaners, sucking up cellular debris. To validate their findings, the lung doctors also tested commercial chicken soups (some were more active than the homemade version), vegetable soup (minor effect), and plain tap water (no effect). Clearly, the star of the show was the chicken soup, with or without the matzoh balls.

  There’s no such proof of a connection between flatfeet and bad luck or a bad temper, but it would not be unreasonable to assume that a person with a physical characteristic other people consider other-ly might be a bit cranky from time to time. Or at least until he or she learns that flatfeet may well have played an important role in setting the rules by which we measure our world.

  Foot rules and rulers

  Sometimes our words have more than one meaning. For example, when the Greek sophist Protagoras (c. 490–420 BCE) said that “man is the measure of all things,” he meant that we, not our gods, determine our fate. But there is another way to interpret what he said, because man really is the measure of his world.

  Measurements, Secretary of State John Quincy Adams wrote in a report to Congress in 1817, “are among the necessities of life to every individual in society.” Length—the height of a man or the distance from here to there—is particularly important. From the beginning, every ancient society had a way to measure it and virtually all the values began with our anatomy: our fingers, our hands, and our feet. This link is so strong that in many Romance languages the word for inch and thumb are the same or come from the same root. In French, the word for both is pouce; in Italian, pollice; in Dutch, duim. In Spanish, an inch is pulgada, a thumb, pulgar; in Portuguese, it’s polgada and polegar.