Flatfoot over the centuries: the background of current conservative and operative treatments

Abstract

Purpose: Although flatfoot is a widespread human condition, historical medical texts and ancient illustrations on this deformity are extremely rare. Nowadays, doubts regarding its management remain unsolved. This historical review aims to identify the presence of pes planus since the prehistoric era and examine the treatments proposed over the centuries up to the present.

Method: For this propose, we performed an extensive electronic search of the relevant literature, complemented by a manual search of additional sources from archaeological to artistic, literary, historical, and scientific accounts, describing flatfoot and its treatment in different eras.

Results: Flatfoot accompanied the evolutionary timeline of human species: from Lucy Australopithecus to Homo Sapiens. It was described among various diseases suffered by Tutankhamun (1343-1324 B.C.), while the first anatomical description dates to Emperor Trajan (53-117 A.D.) and the medical studies of Galen (129-201 A.D.). It was also represented in the anatomical drawings of Leonardo da Vinci (1452-1519) and Girolamo Fabrici d'Acquapendente (1533-1619). Historically, the conservative treatment by insoles was the only one proposed until the nineteenth century. Since then, the most popular surgical procedures performed for correction have been osteotomies, arthrodesis, arthrorisis, and tendon lengthening and transfer.

Conclusion: During the centuries, conservative therapeutic strategies have not radically changed in their substance, while operative ones have become the protagonists during the twentieth century up to the present. Nevertheless, after more than 2000 years of history, there is no consensus regarding the best indication for the flatfoot and if it really needs to be treated.

Keywords: Arthrodesis, Arthrorisis; Flatfoot; Foot deformities; Insoles; Osteotomies; Pes planus; Tendon lengthening; Tendon transfer.

Fig. 1

The evolution of foot in primates: a Lateral, not weightbearing, radiographic images of a human foot and b chimpanzee foot, modified from Donald Johanson, Blake Edgar, From Lucy to Language, s.l., Cassell & Co London, 2001; c and d anatomical images of the transverse arch in the monkey, from Theatrum totius animalis fabricae - De anatomia animalium, Rari 113, by Girolamo Fabrici d'Acquapendente, Marciana National Library in Venice

Fig. 2

“Lucy” partial skeleton found at the sites of Hadar in Ethiopia in 1974 by Donald Johanson. The skeleton is dated to about 3.2 million years ago, and it has a small skull, 1.07 m high, and probably weighed between 29 and 45 kg. This original fossil of Lucy is kept at the National Museum of Ethiopia in Addis-Ababa

Fig. 3

Pharaoh Tutankhamun (1343–1324 B.C.): a wooden statue of the Pharaoh Tutankhamun and his stick, Saatchi Gallery (London, UK), suggesting that the pharaoh may have used it to support himself; b walking sticks found in his tomb, Burton photograph, kept in the Griffith Institute Archive, University of Oxford

Fig. 4

Galen and Ephesus: a the imprint of the left foot in the ancient city of Ephesus; b portrait of Galen from The Botanical Garden Library, University of Padova

Fig. 5

Leonardo Da Vinci (1452-1519): a portrait of the Italian artist and anatomist, from The Botanical Garden Library, University of Padova; b drawing of the foot bones from Anatomic Manuscript A, from The Royal British Library

Fig. 6

a Italian representation of right foot from dorsal view, 1575–1625, paint by G. F. d’Acquapendente, from “Theatrum totius animalis fabricae – De anatomia ossium”. Rari 111.21; Marciana National Library in Venice; b inferior part (legs) and c complete anterior view (pars antica) of the Oplomochlion form Fabrici’s Operationes chirurgicae (1647); d anonymous, Portrait of Girolamo Fabrici d'Acquapendente (Insignia of the Order of St. Mark of the Republic of Venice)

Fig. 7

Early conservative treatments (nineteenth century): a anterior section of the Thomas heel; b isolated Thomas heel; c complete shoe with the Thomas heel; d) stylized representation of an early orthesis used for the varus/valgus correction

Fig. 8

Surgical approach described by Ogston in Bristol Med Chir J (1884): a skin incision; b Chopart’s joint