Take Off Your Shoes and Walk
by Simon J. Wikler D.S.C.
[This is a fair-use extract of a wonderful, but long out-of-print book published in 1961 by Devin-Adair]
Introduction: A New Approach to Foot Health
Burying Our Heads in the Sand
People will believe most readily what they want to believe. If certain facts lead to conclusions which are unacceptable to the average individual, he is quite capable of ignoring those facts, or rationalizing them in such a way that they no longer pose a threat to his peace of mind. Nowhere can this human shortcoming be better illustrated than in the attitude most of us take toward the kind of shoes we wear.
With the exception of the "Munson Last" type of workman's shoe, practically all shoes worn daily by men and women in our Western civilization have little relation to the shape of the human foot. The reason is that the well dressed man and woman of today like a symmetrically shaped shoe - one which tapers nearly to a point to the middle toe. Our feet however, are far from symmetrically proportioned, being quite broad at the toes and considerably longer and thicker on the big-toe side than on the outer side of the foot.
People are generally unwilling, it seems, to face up to these facts. Perhaps they realize unconsciously that logic would then compel them to wear a shoe shaped like the human foot-and this would be thoroughly unacceptable to the average clothes-conscious man or woman in the United States.
What Do We Know About Foot Health Today?
Strangely enough, it is as unusual to find a doctor wearing a pair of properly shaped shoes as it is to find a businessman or any type of white collar worker in shoes conducive to foot health. What then can doctors advise their patients concerning the proper kind of footwear for their health and comfort? The answer is very little, for the medical profession, as a whole, knows very little about foot weakness, its causes, its cure, or its close relationship to the kind of shoes we wear. Why?
In most medical schools, and in the practice of medicine generally, foot disorders fall into the domain of the orthopedic surgeon. But the average orthopedic surgeon spends very little of his time with nonoperative foot disorders. Unless a foot is so distorted (by a bunion for instance, a hammer toe, an injury, or a congenital anomaly) that operative intervention is clearly indicated, the orthopedist is usually not too concerned with treating and following the case. His time is taken up with the other aspects of orthopedic surgery and he has little interest in running a foot clinic for curing weak and disabled feet.
In the field of foot weaknesses and disabilities, the only classes that most medical schools provide for their students are given by the department of orthopedics. The limited time devoted to this department in the curriculum is almost always utilized in teaching about the handling of fractures and the other more dramatic aspects of orthopedics. The editor of Clinical Orthopedics, Dr. Anthony S. DePalma, himself a professor of orthopedics in a medical school, stated that "Medical Schools fail almost completely in giving the student a sound grounding and a sane therapeutic concept of foot conditions."
By common consent of patients and the medical profession, non-operative foot problems are referred to chiropodists. Yet it seems that most chiropodists do not know a great deal more about the cause and prevention of "foot trouble" than do the members of the medical profession. Dr. William A. Rossi, a leading chiropodist and an editor of the Boot and Shoe Recorder, stated in the October 1958 issue of the Journal of the American Podiatry Association: "Absence of scientific standards are the missing links in fields of foot health and footwear. Physicians, orthopedists, chiropodists, shoe fitters, shoe manufacturers, all have individualized approaches to foot health, with the result that no one knows what is a 'normal foot,' a 'good shoe,' or how to evaluate a foot."
A Crusade for Healthier American Feet
From time to time voices have been raised protesting that the shape of the shoe is almost invariably the causative factor in producing weak and disabled feet. As early as 1905, Dr. Peter Hoffman, an orthopedic surgeon, contended that most foot trouble was caused by compressing the feet into poorly shaped shoes which did not conform to the shape of the foot. Major Edward Lyman Munson, Jr., in 1912, in his book The Soldier's Foot and The Military Shoe, succeeded in convincing the Army that shoes should be built on a last which would conform to the natural shape of the foot. Presently Dr. Alfred Rives Shaiids, Jr., author of the Handbook of Orthopedics, states that the overwhelming causes of foot disability in children are the shoes they wear. Many people who have agreed with these theories in principle however, have never put them into practice because of the psychological block resulting from aesthetic considerations of shoe styles.
Dr. Wikler is convinced, as am I, that foot trouble among children is almost always caused by shoes, and that most adults' foot trouble would either not exist or would be much less bothersome if properly-shaped shoes had been worn during childhood or, better yet, if those people had gone barefoot (or the equivalent). In this book, Dr. Wikler states his case with great cogency, and in a manner so simple and direct as to be convincing to the unprejudiced and the lay reader. If his book could be widely read, and the concepts outlined herein were accepted and followed by pediatricians, general practitioners and orthopedic surgeons, the next generation of children in this country would have an excellent chance of growing up with little or no foot trouble, and consequently far healthier than any generation that has preceded it for many, many years.
Thomas Hale, Jr., M.D. Director, Albany Hospital Albany, N.Y.
How Shoes Cripple Our Feet
1- Discovering the Cause of Foot Trouble
Difficulties in Treating Foot Troubles without Knowing the Cause-Thousands of Theories-Barefooted and Healthy-A Little Boy Supplies the Answer-The Major Cause of Foot Trouble
Most Americans have poor feet and are unaware of it. Because of poor feet, countless Americans have posture distortions, are easily fatigued and become prone to degenerative illnesses.
I have discovered that it is easy, instead, to have strong healthy feet. I am going to tell you how, so you and your family will have good feet.
Difficulties in Treating Foot Troubles without Knowing the Cause
In 1933 1 graduated from Temple University School of Chiropody, trained as a foot specialist. I had been taught to relieve those who suffered from foot trouble; to pare their corns, calluses and ingrown toenails, and to bandage and pad their feet if they complained of soreness. But such treatment never cured anyone. Foot specialists could not prevent foot trouble, because its causes were not known.
This sad situation dissatisfied me and drove me to pursue my studies further. I read more books on the subject; I attended scientific meetings; I talked to leaders in the medical profession, but still I gained very little that would bring more permanent relief to my patients.
From 1935 to 1943 I was a member of the Lancaster Pennsylvania General Hospital Staff. In the clinic and in my office, most of the people who visited me had fallen arches to some degree. Treating their arches through massage and bandaging brought temporary relief to some but could cure none. Then, as now, commercial companies found it lucrative to supply arch supports for fallen arches. Unfortunately these supports rarely worked satisfactorily. People hoping to cure their trouble with such devices would go to one shoe store and doctor after another and end with a number of arch supports in their bureau drawers, all useless.
I asked an older physician on the hospital staff what he thought could be done to cure foot trouble. "Foot troubles are chronic conditions people have had for a long time," he advised. "You'll waste your time trying to find their cause and cure. Be content just to give people all the relief you possibly can."
Thousands of Theories
I talked with patients on every occasion, asking what they had done about their foot troubles. They found no cures. In more than 3,000 conversations with my patients I heard them describe every usual and unusual means of treating feet. Some had even put copper plates in their heels to get rid of static electricity, or slept with their feet pointing towards the North Pole to draw out tension magnetically.
Foot pains were not the only things for which people sought a cure. Foot trouble seemed to bring about fatigue and pain throughout the body. I was told, as chiropodists are told over and over again by weary patients, "When your feet hurt you hurt all over."
In the 1870's Father Sebastian Kneipp, an Austrian priest, became famous for a method of relieving fatigue -and its accompanying aches and pains. His treatment was to have people take off their shoes and walk barefooted in the morning dew. He ascribed the success of his treatments to the healing qualities of water.
In the early 1930's, Americans by the tens of thousands made pilgrimages to Canada for the "miraculous" foot manipulations of Dr. Mahlon Locke. There was such an interest in foot manipulation as a cure for fatigue that Temple University gave a course in it. I took the course and tried to improve my knowledge of foot manipulation by exchanging ideas with others. I still use foot manipulation on my patients with good results, but I realized even then that it could not cure foot trouble-nor reveal the causes.
Dr. Ralph W. Dye of Sandy Lake, Pennsylvania, in the late 1930's, introduced a new method of correcting foot disabilities by continuous adhesive bandaging. His method of bandaging forced the patient to walk from heel to toe instead of rolling off the inner side of the foot as do people with fallen arches. With this treatment, cold bloodless feet received warmth through greater muscular activity; toe numbness disappeared; nerve reflexes that had been absent became restored. The beneficial changes were not limited to the feet. Posture improved. In some cases excessively large hips became smaller with less strained walking. I could no longer doubt that poor feet contributed to poor posture and associated illnesses. To know the cause and prevention of foot trouble would be important. Soon after, I came upon conclusive evidence about the cause of foot troubles.
Barefooted and Healthy
While visiting shipyards during the Second World War, I noticed that the newly recruited female construction workers wore the same loose-fitting high-topped shoes as the men-and they worked with more ease of movement than I had ever seen in American women. It seemed that their feet actually thrived without the support I had been taught they needed. I accumulated more evidence to reinforce this observation. In Puerto Rico, as I traveled about the interior of the island where many of the people are habitually barefooted, I was amazed to find that they all had straight, undeformed toes, unlike the shoe-confined toes I had seen and treated in the United States.
When I returned to my practice, I continued to use manipulation and bandaging methods in treating fallen arches, but there were decided disadvantages to this treatment.
For example, irritations resulted from using adhesive tape on sensitive skins for the many months required for effective treatment. I tried newly developed treatments such as molded shoes and balanced appliances, but people were frequently dissatisfied with the measure of relief they obtained-and they certainly were never cured. It became clear that seeking temporary relief from foot trouble was no way to solve the problem. What was needed was treatment or prevention based on knowledge of the causes. But what were the causes?
In medical libraries I read a number of studies which, together with what I had seen, proved to me that habitually barefooted people do not acquire our foot troubles. In the following years, I traveled through Mexico, Costa Rica, Jamaica, and Haiti. Besides having sturdy toes and muscular feet, the people who were constantly barefooted did not have fallen arches. They had uniformly excellent posture -- and none with whom I spoke ever experienced being chronically tired. It was evident to me that some feature of shoes was causing foot trouble. But what was it?
A Little Boy Supplies the Answer
I found the answer back in the United States, by working with a boy two-and-a-half years old. His toes were being forced together in narrow shoes and he walked with his feet pointed outward in the typical posture of a child with fallen arches. He tired easily, always wanted to be carried, and fell frequently when walking. I asked the boy's mother why she bought shoes which pushed the child's toes together in the shape of the toe of the shoe? This made his toes so weak he could hardly bend them. "You should buy shoes that are wide enough for him," I told her.
"I tried," she answered. "I took him to the best shoe store in town, and they gave him the widest pair of shoes in the store."
They were 6-EE. Although he did not have an extremely wide foot, the shoes pressed against the sides of the toes. The mother went back to the shoe store and asked for the widest pair of shoes that could be ordered -size 6-EEE.
These were just wide enough for the boy's feet to lie flat without being squeezed, but there was no room to spread the toes, and with foot growth the shoes would again jam the toes together. The heavy stiff leather and shoe shank did not allow the rest of the foot to move freely. Remembering the healthy feet and strong toes of the people who were constantly barefooted, I suggested the child wear no shoes for the rest of the summer.
I had ample opportunity to watch the boy's feet as he walked about that summer. I could not help wondering what, during his first two years of life, had ruined his feet, turned them outward, and caused him to walk with a fallen-arched gait. For months I watched every movement of his toes, each twist of his ankles, the way he lifted his feet, the manner in which his foot first made contact with the ground.
Then an amazing thing happened. He finally stopped leaning on his arches; he started to walk straighter and more normally. At last I began to understand the cause of fallen arches and the origin of foot trouble. With his toes continually pressed together in his shoes, his body had to improvise a brace-instead of leaning on his weakened, squeezed-together toes, the inner sides of his feet were turned outward for balance. I realized then why people persist in leaning on their strained inner arches, which were never meant to support continuous leaning, and why they have to push off painfully from their arches instead of their toes, at the end of each step.
Going barefoot had made this boy's toe area broader and stronger. When he stood, his stronger toes were now able to spread out, giving him a broad forward area on which to support his weight. Now he used his toes in standing and walking-he would even stand on his toes frequently while playing. His fallen arches were cured. With better foot balance, he rarely fell. He no longer begged to be carried, and he seemed tireless in his activities.
The Major Cause of Foot Trouble
That was ten years ago. I have since examined thousands of children's and adults' feet, both in the United States and in foreign countries, determined to learn to what extent shoes can disable naturally healthy feet. I have conducted numerous tests in accredited hospitals and published my observations in widely distributed medical journals, presenting my views for the scrutiny and criticism of other doctors. There is now no question in my mind but that THE MAJOR CAUSE OF FOOT TROUBLE IS THE TYPE OF SHOES WE WEAR.
There is nothing astonishing about this theory. What is astonishing however, is that while the cause of foot trouble is so evident a child could understand it, few persons know about it. Most people continue to acquire permanently and unnecessarily deformed feet simply because of the evolution of a fashion which started a hundred years ago.
2 The History of Foot Trouble
High Heels and Pointed Toes in Court Society - Yearning for a Disabling Shoe - Fashionable Shoes Can Be Inexpensively Made - The New Sickness-Disabling a Population with Shoes - Saddle Shoes and the jitterbug -- "Flats" Start a Revolution - A Lesson to Be Learned
Foot trouble struck American and European urbanized populations about eighty years ago. It changed the patterns of all our lives-more radically than most of us realize. Suddenly we became a crippled race. How did it happen?
High Heels and Pointed Toes in Court Society
There is no record of foot troubles in Biblical times comparable to modern foot ills. In the Greek, Roman, and Egyptian civilizations it was practically unknown. Since people then wore the thong-type sandal, open at the toes, or often went barefoot, there was little chance for corns, calluses, ingrown toenails or fallen arches to develop. Where people continue to wear sandals today, as in the Far East and Central America, foot trouble is almost an unheard-of phenomenon. And even though Northern Europeans and North Americans, living in colder climates and needing to have their feet totally covered, have always worn closed shoes, foot trouble was uncommon among them also until the advent of the Industrial Revolution.
The seeds of foot trouble were first sown, however, in the Renaissance when the elevation of the heel-the first characteristic of modern deforming footwear came into use. Catherine de Medici, a queen of short stature, wanted to appear taller, and had chopines put on her shoes. The chopine itself was not deforming because, unlike our modern heel, it elevated the entire foot. The elevated heel that followed, however, left the fore part of the foot on the ground and raised the heel, forcing the foot into a completely unnatural position.
A few centuries later heels became commonplace in court society and were worn by men and women alike, even though perpetual wearing of high heels caused shortened calf muscles. However, with the introduction of gunpowder and infantry warfare, men found it necessary to discard their high heels, while women continued to wear them.
About the same time that the heel came into usage, pointed-toed shoes became stylish. Early pointed toes differed somewhat from those seen today, in that they became pointed much beyond the foot-so far beyond the foot, indeed, that the long ends had to be fastened to the ankles or below the knees.
The introduction of the elevated heel and the pointed toe marked the beginning of modern foot disabilities - although during the period described, the majority of the population did not use these styles and had no appreciable foot trouble. Only the nobility could afford such shoes, and in those days, with sufficient servants to attend to one's needs and with carriages for transportation, a deforming shoe offered no great handicap. A lady of wealth of the eighteenth century had to endure very little stress from disabled feet with a footman and maid at her disposal. If similar shoes had been worn by the maid and the footman, they would have been miserable, but the working people did not wear a fashionable, constricting shoe which kept the toes pressed together and weakened and deformed the foot. Why, then, did such disabling footwear persist? What were the events and developments that made it appear reasonable, even desirable, for whole populations to cripple themselves?
Before the French Revolution, nobility considered the broad, muscular, but competent, bare foot of the peasant working in the fields as common and ugly; especially since they themselves had no need for strong feet and legs. It was their esthetic ideal to have tiny feet and delicate lower limbs. A way to achieve this was to cultivate smaller feet in early childhood. Accordingly, children of the wealthier classes, from their earliest years, were forced to wear shoes designed to keep their feet small. Cinderellas had to be born among the wealthy.
Yearning for a Disabling Shoe
The "leisure class" was fated to disappear. The Revolution took place in France. In England the common man obtained more privileges, while in the United States democracy became a reality. Yet the average woman wanted to imitate the waning nobility. There could be no greater embodiment of her dreams of "being a lady" than to wear the tiny shoes of a woman of wealth. If people could have afforded to, they would all have bought small shoes for their children as the nobility had done. Here was the beginning of a great yearning for a deforming type of footgear.
In the early nineteenth century the makers of shoes knew only too well the people's desire for a tiny fashionable shoe. But it took two or three days for a well-paid craftsman to make a single pair of such shoes. The cotton gin and the steam engine were invented in this era of industrial progress, but the shoe still had to be laboriously made by hand. The easiest footgear to make was the boot, in which the upper leather needed only to be hand stitched to the sole. With the invention of the sewing machine, limited mass production was possible. The uppers now could be sewn by machine, and cobblers would then hand sew them onto the soles. The need, now, was for a machine that would attach the sole to the upper.
The growth of new industries and commerce created the wealthy middle classes in America and European cities. This class could afford hand-made shoes. Soon, their children's feet were being molded to resemble the tiny, delicate feet of aristocrats. For the bulk of the population however, feet remained large and healthy. For example, a typical boy of a working class or farm family in the United States during the Civil War days was accustomed to go barefoot from spring to fall. Before starting school, he was sent to a cobbler who would make his shoes by hand, according to the measurements of each foot-leaving extra room for growth (since shoes were such a luxury) so that the child's foot was kept free of deformity.
Boots were so expensive that when it snowed a child would often run to school barefoot, with his precious shoes tied around his neck. When he got to school, he would dry his feet and put his boots on again, none the worse for his experience. This was the last period when children in the United States could reach maturity with the prospect of sound, healthy feet.
Fashionable Shoes Can Be Inexpensively Made
In 1858, Lyman R. Blake invented shoe machinery that could attach soles to uppers (the Mckay process). Overnight the United States had a new industry - manufactured shoes. It will be easy to understand how rapidly factory shoes became distributed if we compare it to the distribution of television sets. During the first five years of television, practically everyone in the country began viewing television programs at regular intervals. Equally phenomenal was the growth of the shoe industry in the past century. Age long dreams of inexpensive shoes came true. Within five years, shoe manufacturing had developed to a point where everyone could afford to wear the shoes of an aristocrat.
Some fifty years after stylish shoes had become available to all, having a tiny foot and wearing the shoes of an aristocrat was still a strong passion for most Americans. Trying to explain to working girls that these new shoes were meant for leisure and not for standing behind counters and in front of kitchen sinks was like talking to someone in a delirium. To these women, what mattered corns, calluses, fallen arches, when they could don the dainty footwear of the wealthy? Overnight American women were trying to push their feet into Cinderella's tiny slippers. Not only the women, but the men, too, had to have the aristocratic pointed shoes.
In those years following the Civil War, shoes were not sold for their utilitarian value. Style, fashion, and exquisiteness of design were the characteristics emphasized - and that sold shoes. The French heel and the dainty line of the opera pump became standard equipment for the American female in all her activities. For the male, nothing less than the cut of the dancing slipper of the English nobility would do-and these shoes were worn for business. To sell shoes, manufacturers competed with each other in making shoes ever more "stylish." The toe of the shoe was shaped in a sharp point. When it was fitted over the normally squat toes, the toes were cramped into a space only one third or less their normal breadth. Never in the history of mankind had a population so willfully and so innocently disfigured a vital part of their body.
Other forces contributed to the mania. Peddlers who formerly toured the countryside selling ready-made clothes now sold ready-made shoes. These shoes were more fashionable than the local cobbler could supply. Department stores, because of the success of ready-made clothing and footwear, started to flourish. They soon could afford to spend large sums of money for advertising, and so further increase the desire for and the distribution of the new fashionable shoes.
The New Sickness
In the 1880's Dr. George M. Beard published two books in which he described a new sickness--exhaustive chronic fatigue-which was afflicting portions of American and Western European populations. The appearance of this illness, coincided with the advent of the newly manufactured shoe.
Dr. S. Wier Mitchell, in the 1900's, became famous for his treatment of this physical exhaustion (described in his book. which is still obtainable, Fat and Blood). Dr. Mitchell noted how healthy European immigrants would come to our shores only to be afflicted with the new illness. The exact causes of this chronic fatigue were unknown, but Dr. Mitchell and other scientists stated that shoes and other disabling types of clothing, such as corsets, were a cause.
Although books were written, sermons given, and crusades inaugurated to end the evil practice of wearing corsets which twisted the female into ridiculous shapes and crushed her ribs, lungs and abdominal organs, the accompanying crippling of the very foundation of the human structure received much less notice and very little was written or said about it.
Disabling a Population with Shoes
Wherever the newly manufactured shoes were worn, crippled feet followed. As a practicing chiropodist for over twenty years, I have seen the feet of scores of men and women who, in the latter part of the nineteenth and early part of the twentieth century, had worn the early products of the shoe industry. In a great many cases, the toes were crumpled together so badly that one toe lay upon another.
The owner of such feet was often a woman - physically incompetent and so helpless that the least strain would cause her to faint. Doors had to be opened for her, chairs put under her when she sat down, and care taken not to disturb her delicate sensibilities and constitution.
Disabled feet were more a phenomenon of this country than of Europe. I recall as a child that boys who had come as immigrants from Europe were more sturdy and vigorous than my shoe-wearing playmates born here in the United States. Adults who had spent their childhood in Europe were frequently perplexed about the relative weakness of American-born children. As a child I heard my father ask, "Why are American-born children so physically inferior to European born?"
My father was born in a rural district in the Austro-Hungarian Empire. It was not until he was fifteen that he owned a pair of shoes. During the warm weather he went barefoot, and in the winter he wrapped a kind of burlap around each toe and over the foot; after that he put on a felt-type boot. Never in those years were his feet damaged. My father today, at seventy-five, has more physical vigor in his limbs and gets less tired than many shoe-crippled youngsters fifty years his junior.
Shoes were at their crippling worst in the United States at the turn of the century when the needle-pointed toe shapes were popular. Fortunately, that era did not last long. About 1915 a wave of reform began to take place, and the physical-culture shoe with its broad toe was introduced. The shoe did not have a great vogue, but it was fashionable enough so that shoe factories began to make the toes of their shoes a little less pointed. From 1915 to 1935, people had only to squeeze their toes into a space about one half the proper breadth. While this was an improvement, it was not great enough to prevent deformation of the feet. It was rare to find a little toe without a corn or a big toe without at least a modest bunion. With toes so constricted, everyone had trouble with fallen arches to some degree.
Saddle Shoes and the Jitterbug
But shoes had taken a course toward non-crippling footwear. Young girls in the late 1930's had lost their reverence for queens and duchesses. They began to admire the athletic-type woman-the champion tennis player or Channel swimmer. To these adolescent products of the depression, the axiom that tiny feet made a lady was a fairy tale. The popular form of footgear was the two-toned oxford, or saddle shoe, which was sloppy and roomy-it became the style for high-school girls. For the first time in forty years a girl did not have to put on two-inch-high heels when she got to be fourteen or fifteen years old, as a badge of maturity.
The advent of jitterbug dancing also had an effect on the shoe styles of the day, since this dance required a good deal of acrobatics and could be performed best in a flat shoe. But doctors, shoe clerks, grandmothers, and even preachers-all opposed the new style of shoes for adolescents. A flat, broad-toed shoe, they said, was bad for the arches, and they predicted doom for these girls' feet. However, it was in this generation of women that I saw an approximation of normal feet for the first time in many decades. Grandmothers with gnarled toes would scold their grandchildren and insist no one could possibly walk without support in their shoes. Yet, those who disregarded that advice are the ones who have the better feet today.
"Flats" Start a Revolution
By the early 1940's the saddle-shoe wearers had grown to maturity. When a few manufacturers put out flat shoes as a novelty, these young women bought them all up and wanted more. The shoe industry predicted that the vogue for "flats" was a fad and would not last. They were wrong. A shoe merchant went over his records with me. In 1953 he sold sixty per cent "flats" of all shoes sold, and his was a high-fashion shoe store. In 1940 only five per cent of his total sales had been in "flats." In cheaper shoe stores the percentages were much higher. A revolution was taking place in women's footwear. The old-line manufacturers who could not change with the tide were swept out of business. Within a scant decade, women ceased being near-cripples and were on the way to normal feet once again.
Today, women's shoe styles are becoming more functional. The modern young woman does not wear pointed, high-heeled shoes constantly, as her grandmother did. She wears broad-toed casuals to neighborhood stores, perhaps thong sandals in the summer, and even slipper socks around the house in the winter.
A Lesson to Be Learned
How different it was when I first began my chiropody practice in 1933. Husbands used to bring their wives to my office complaining that the women were crippling their feet. The wives would explain that they could not go out in the street in flat-heeled shoes because it was unstylish-they would rather suffer pain than be comfortable. Whenever the subject of women's styles in footwear came up, people would throw up their hands in horror and say, "That's one subject you can't talk about reasonably with a woman." In the 1960's the situation is almost reversed. Wives now bring their husbands into my office and,, complain, "If only my husband would wear lighter shoes with broader toes, he would have less foot trouble."
If a lesson about foot trouble can be learned from history, it is that we are at the mercy of the latest shoe styles. We should take warning from it, for now, just when we have returned to more sane footwear, high fashion has dictated a return to the pointed-toed shoes of fifty years ago. Style conscious women have demanded these shoes for themselves and, more important, are now demanding this style for their children as well. As a result, the bunions and compressed toes of our grandparents are again being formed in children's feet.
3 - The Shoe Industry and Foot Health
"Corrective Shoe" Stores - . . . . .
Every child who wears present-day shoes has his feet distorted to some degree. Sensing this, parents are confused about shoes, and pediatricians tell me that they are asked as many questions about children's feet as they are about food. However, awareness of the causes of foot distortion can prevent trouble not only from the usual children's shoe but also from another serious source which I am going to discuss.
"Corrective Shoe" Stores
A professional looking and positive sounding shoe clerk says that your child has fallen arches and needs a corrective shoe. How are you to know this is true?
Most shoe merchants do their sincerest best for their customers considering our limited knowledge of foot health - others heartlessly use our lack of knowledge solely for profit. Characteristically they "find" something wrong with every child's foot . . . which then "needs" the merchants shoes. Increasing numbers of doctors are wary of these merchants. Some practitioners, who have no definite knowledge of shoes, may send a worried mother to them in good faith.
A typical case is that of Susie R. As a toddler, she had a normal low arch and walked slightly flat footed as all toddlers do. Heavy corrective shoes were put on her feet. After wearing the stiff supportive shoes for several months her feet became weak. Then when she wanted to go barefoot her feet were so tender and the muscle so weak that it was painful. She was still able to walk with the supportive shoe, however, since the walking was done without any flexible foot action whatever. Her mother was certain Susie's feet were bad in the first place, so now Susie continues to go to the same merchant and buy the same expensive shoes. Susie will be a foot cripple as long as she lives. A child's foot can never grow properly with an unrelenting rearrangement of its complex mechanisms.
However, Susie's mother is satisfied that she did right in going to this merchant. She recommends him to other parents and thus increases the volume of business in corrective shoes. This type of shoe merchandising has become so profitable that there are few large communities in the United States that do not have them. You can easily identify them because no child is ever fitted in these stores without having at least some "correction" in their shoes.
I spent a day in such a shoe store observing the operation. "How can you sell these corrective shoes," I asked the owner. "You insist on the necessity of 'arch cookies,' 'cuboids,' 'metatarsal supports,' and so on-yet from the continuous complaints of customers, you know that these supports are of no help to the feet. How do you justify this?"
"It's a wonderful living," the owner commented. "Besides, I always instruct them to do certain exercises. They never do them. When they complain too much about their feet, I say, 'Well, did you do the exercises?' That usually shuts them up."
Doctors use shoe stores to carry out their instructions regarding additions to shoes - should clerks, on their own initiative, recommend radical changes in a child's shoe which will have lasting effects on the yet unformed foot? A "corrective line," besides carrying the usual supportive devices, includes shoes which hold the foot rigid or force the foot to grow sharply inward or outward permanently.
Merchants who do not believe in these types of shoes have been forced to carry them in stock to be competitive with other stores. Manufacturers, against their wishes, have had to incorporate "corrective lines" in order not to lose retail accounts. This has ended in wide distribution of these types of children's shoes. As far as I can ascertain, corrective lines are never designed under adequate medical supervision and cause foot disability among millions of Americans. This is particularly,, unfortunate because it is established that babies' feet left to grow naturally will be normal.
Dr. Lee Bivings, a pediatrician from Atlanta, estimates 99% of new born babies have perfectly normal feet - and in his clinic more than 6o% of these same, shoe-wearing babies have acquired foot disabilities at six years of age. An ideal physiological shoe, the equivalent of barefootedness, would keep babies' feet normal until. six years of age!
To develop a physiological shoe and have it widely distributed is not easy, as I found out by personal experience.
. . . . . . . . .
5 Preventing Children's Foot Trouble
Preventing Foot Trouble of the Pre-walking Infant - No Pre-walking Shoes - Crawling for Exercise - Infants' Booties - Babies' Socks - First Shoes - Necessity for a Flexible Shoe - Shape of the Toe - Avoid Arch-support Features - Heels on Infants' Shoes - Choosing the Right Length - Choosing the Right Width - Going Barefoot Is a "Must" for Young Children - Then Compare . . . - Children's Shoes, Ages Five to Twelve - Are Loose Shoes Too Large? - How Long Should Shoes Last? -Dress Shoes for Children - Should Older Children Go Barefoot? - . . . . . .
In a paper published in the August 1959 issue of Journal of Military Medicine, Dr. Thomas Hale Jr. and I quote fifty of our leading authorities on foot disease, all of whom have different, and often opposing, ideas as to cause and prevention of foot trouble. Authorities acknowledge that causes are not established, and yet physicians, pediatricians, and foot specialists must refer to these authorities. If what to do about foot disease is confusing for a doctor, how much more confusing it must be for a nonprofessional Nevertheless, there is one thing which is certain about our commonplace foot trouble-it is one hundred per cent preventable. We will show you how to go about it with sensible, practical, and conservative techniques that will be supported by your doctor.
Preventing Foot Troubles of the Pre-walking Infant
You who are parents have probably noticed your child constantly spreading, bending, stretching his fingers and toes from the first weeks of life. You would not think of keeping your baby from moving his hands and wiggling his fingers. You would not swaddle his hands and fingers. Why, then, swaddle his feet and toes?
Tight blankets which keep feet and toes motionless serve only to weaken them. Place the blanket over the baby's feet loosely. Raised supports at the foot of the crib can be used so the blanket can be elevated over the feet, allowing plenty of room for movement. Toes which are not given opportunity for exercise in the very early years are likely never to develop properly - nor can any later treatment ever fully restore their proper functioning. Unfortunately, most American parents damage their infants' toes and feet in the first weeks of life by depriving the child of the chance to move his feet freely. By keeping anything tight or constricting off your baby's feet, you will have already started him on the way to foot health.
No Pre-walking Shoes
Do not buy pre-walking shoes for your baby. They may look pretty and soft, but they can seriously impede the natural movements of the infant's foot. Whenever you see a bronzed pair of baby shoes, know that it is a symbol of damage to some baby's foot. In warm weather, the baby should play barefooted in a play pen. When he starts to creep and crawl on the carpeted floors, he should be allowed to crawl barefooted.
Crawling for Exercise
Crawling is a necessary developmental exercise for your baby. Give him every chance to do so. (Infants are often forced to sit too long in devices which keep them from underfoot while mother does her work. Pressure upon the thighs caused by such apparatuses is likely to strain the muscles and cut off the blood supply.) The child should be allowed to crawl in the playpen whenever possible, rather than being kept inactive.
Do not try to hasten a baby's first steps. He will walk when his feet and legs are ready.
During the first year of life, wool booties are the best type of footwear. However, they should be bought large enough so they cannot in any way constrict the feet or toes. When the baby begins to toddle about on the cool floor, these booties or soft slippers, which yield to the pressure of the baby's toe movements, are the most suitable.
Infants' feet do not have to be protected from the cold nearly as much as some adults think. Babies need no more protection for their feet when crawling on a cold floor than they do for their hands. The reason most adults are concerned about exposing their babies' feet is because they are used to having their own feet always covered and protected, and are not accustomed to a little bit of exposure. Babies actually thrive on it.
When your child begins to wear socks, you must take the same care in fitting them as with shoes. A sock is not made in the shape of the foot. It is made more like a tube that tapers to a point at the end of the foot. For this reason stretch socks can be particularly harmful they cause constant pressure on the toes. If a sock is pulled tight over the child's toes, his toes will tend to take the shape of the pointed sock.
Buy socks at least one inch longer than the toes. Pull them out so the extra length is free of the toes - the extra length of sock will fit into the unused portion of the toe of the shoe.
When your child has started to walk by himself at home, he will shortly be walking on pavement and you need protection for the bottom of his feet. You would now be ready to get the first pair of shoes for your infant. Shoes that are flexible, roomy, and simply made are best. Remember, children's toes and feet must be allowed to grow naturally without restrictions and pressures.
Necessity for a Flexible Shoe
Some shoes look better, and have better leather and more durable construction, but too often they are so firmly made that they rob the infant of the free use of his foot.
To test flexibility, grasp the heel of the shoe in one hand, the toe in the other, then bend the heel and toe toward each other. If the shoe bends at the ball (the part of the sole directly behind the toes), and not through the center of the shoe, it means that the shoe has steel stiffening through the arch. A toddler wearing such shoes must walk stiff-footed because the shoe will prevent him from bending his feet. Such a shoe must not be purchased for any child.
Shoe stores which sell an arch-support line of children's shoes often do not carry a flexible infant's shoe. A clerk in such a shop may use the most persuasive arguments to convince you that his supportive shoes are best. Be firm, and find a store where the shoe in your child's size is flexible through the arch. Having found a flexible arch, make certain that the sole itself is not so thick that the shoe becomes hard to bend. An infant will outgrow a pair of shoes before he outwears it, so an unnecessarily thick sole has no value and should be avoided.
Do not resole younger children's shoes, for resoling them makes them smaller.
Shape of the Toe
The next thing to look for is the shape of the toe of the shoe. Shapes of children's shoes have undergone much improvement in the past decade. Occasionally one finds the old-style cowboy-boot-type shoes with their pointed toes. Do not under any circumstances purchase these.
Learn to identify pointed-type infant shoes by noting the differences between the generally tapered toes of adult shoes and the common broad-toed infants' shoes. The few minutes it will take to learn the difference will be worth while. Knowing the difference, and continuing with broader-toed shoes as the child gets older and the choice of shoe styles increases, will provide for added years of more normal growth until the inevitable adults' pointed-toed shoes must be worn.
Avoid Arch-support Features
Look inside the shoe. If the salesman says it is an "arch" shoe, or if it is so labelled, that does not necessarily mean it is supportive. Some manufacturers falsely use the words "arch support" in their shoes to sell more of them. Run your fingers over the inner sole of the shoe. If there are added elevations on the inner sole, beware. Shoes that have raises inside them are also likely to have other arch support features, all of them deforming. More about this later, but for the present, any shoes with arch support features are to be avoided.
Heels on Infants' Shoes
For infants, shoes without raised heels are the most desirable, though often unobtainable. Very likely, you will have to settle for a so-called "spring heel" in which there is a leather elevation under the sole at the heel.
Choosing the Right Length
When you have selected the best type of shoe for your child, you are ready to choose the correct length. Shoe clerks generally use a measuring device to measure the approximate size, then bring out a few pairs of shoes to be tried on. Check the clerk's assurance as to proper length. Have the child stand up with his weight resting evenly on both feet. Use your fingers to feel exactly where the child's toes lie in the shoe. Do not be afraid of spoiling the shoe by pressing your finger into the stiff leather toe in order to find where the big toe ends. Remember, a "good fit" is not what you are after in your child's shoe. If a pair of children's shoes fits "just right," when it is bought, it will certainly be too small in no time. There should be at least one adult thumb width or three-fourths of one inch of space between the end of the child's toes and the end of the shoe.
Choosing the Right Width
When buying your child's shoes, get the widest size possible. To test the width, feel alongside both sides of the foot at the ball, making sure there is free space between the sides of the foot and the sides of the shoe.
Be sure to feel both sides at the same time, so as to avoid pushing the foot to one side of the shoe when feeling for the proper width. A guide to getting the widest possible shoe for your baby is to leave enough space between the rows of eyelets to be able to tighten the laces. Mothers must be prepared to have uninformed shoe clerks protest vigorously at their insisting on wider shoes. Most people are not aware that the usual infant's shoe fit will deform the toes.
Severest deformities from shoe pressures occur before four years of age when bones are softest.
Going Barefoot Is a "Must" for Young Children
It is not enough that children's feet be free from deforming shoes-foot health also depends upon going barefoot in order to develop agility and strength in the feet. . . . For toddlers, shoes should be worn outdoors only during inclement weather and indoors only for infrequent dress-up occasions.
Fortunately, children can go barefoot most frequently in life during the first five years, while they do not yet attend school. These years are the most important in foot development. Children under five who go barefoot, if watched closely by their parents, are unlikely to walk where they will cut their feet or do themselves harm. Moreover, if they go barefoot frequently, they will soon develop tough, protective skin on the bottom of their feet. Skin thus developed is soft and has no callus but will give much protection. You have read accounts in the newspapers of international track stars winning races over cinder tracks barefooted - a normal capability of the human foot, though a constantly shoe-wearing "tenderfoot" is unable to understand it..
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Then Compare . . .
If you will have your child follow the directions just outlined, until he is five, you will find that he has perfectly functioning, almost entirely unimpaired feet. (The ends of the first, fourth and fifth toes may be curled in a little, no matter how great care is taken, because there are presently no shoes on the market which are entirely non-deforming). Compare your child's feet with those of his playmates the same age - with whom this care was not taken. Your child will have straighter, stronger toes and denser muscles on the bottom of his feet. You will be amazed to discover that other children's toes will be skinny and weak, even gnarled. When you see the ease with which your child moves about on his feet you will feel rewarded for the care you have taken of his feet.
Children's Shoes, Ages Five to Twelve
Shoes available for older children are not designed to be grown into - they taper more at the end of the toes and are worse in this respect than baby shoes. Your child will often outgrow his shoes a month after they have been bought. Therefore, you must make it your responsibility to examine his feet at least once a week. If there is one-half inch or less of free space beyond the big toe, the shoe has become too short. Discard that pair, no matter how much wear is left in them.
To understand why such a shoe must be discarded, look at the toe of your child's shoe. Notice how narrow it becomes in the last inch. The area in the toe of the shoe one-half inch from the end is sometimes reduced by half. Moreover, children's toes are deformed without their feeling the slightest pain. Consequently, parents can be unaware that their children's feet are being deformed daily. You must never depend on your child to complain that his shoes hurt him to insure that his shoes are not crippling his feet.
Are Loose Shoes Too Large?
Fitting the shoe large, as it should be, will provoke comments and advice from older people about a loose shoe being bad for the foot. Do not believe them. They think feet need shoe support because their own feet are so weak-a tight fitting shoe must serve as a brace for them to walk at all. Children whose feet are healthy do not need a shoe for support; they need a shoe only for protection.
How Long Should Shoes Last?
How often should you replace your child's shoes? Anywhere from one to nine months, generally, though he can outgrow shoes in about twelve weeks. It is always a race of the growing foot and the wear left in the shoe against the time when the narrowing end of the shoe will begin to pinch the toes together.
Dress Shoes for Children
The habit of buying dress shoes as well as everyday shoes for growing children is unfortunate. Most parents have the idea that when the everyday pair becomes shabby, the dress shoes can then be used for everyday wear. The temptation to get full wear out of both pairs is great, even though they may be too short. Buying single pairs more frequently would solve this problem for boys.
For girls, however, it is not as easy, since most little girls want a special dress shoe, such as a patent leather pump. If such shoes are worn, the parents can only reconcile themselves to the expensive but inescapable fact that a pair of dress shoes can only be worn for the twelve Sundays it takes to outgrow it.
Another popular style among younger girls is ballerina-type slippers. To stay on the foot, they must be fitted snugly at the toe. This is not as dangerous as it might seem, since the end of this shoe is flexible and the toes can mold the shoe to some extent. However, ballerina slippers which have stiff toes are quite deforming.
Should Older Children Go Barefoot?
Not so long ago, children in rural areas most always went barefoot in warm weather, as did many adults. It is only since shoes have been inexpensively made that we have taken to wearing them constantly.
Fortunately, customs are changing again. In California and Florida it has become popular for children in larger cities to go barefoot. It has always been popular in Hawaii. Children in the suburbs of Eastern cities are going barefoot in the summer.
Are you afraid your child will injure his feet playing if he goes barefoot? In Hawaii children and grownups play football in their bare feet. There are a great many such football teams, called the "Barefoot Leagues."
Are you afraid he will catch cold if he goes outdoors with his feet uncovered? In a children's institution in Eggenberg, Austria, some years ago, the director, unable to afford shoes, had the boys and girls go barefoot throughout the winter - sometimes in deep snows. They were none the worse for the experience, and they developed a much greater immunity to colds than children in the same village who wore shoes.
Are you concerned with what neighbors will think about your child going barefoot? One summer I examined the children's feet in an orphanage in Baltimore. The shoes which had been provided were so illfitting that I suggested to the woman in charge it would be better to let the children go barefoot. "I agree," she replied, "but visitors seeing orphan children barefooted will protest, 'The poor children are not even being given shoesl' " Surely your child need not be bound by such artificial notions of well-being.
Do you live in the city, where children do not ordinarily have the opportunity to go barefoot? Then you should make it a habit to have your child take his shoes off when coming in from the street. Let him put on slipper socks, thong sandals, or go barefoot.
If you had the occasion to examine as many feet as I have, you would instantly be able to detect those who have had the opportunity to go barefoot as children. The suppleness and strength in their feet makes their appearance distinctive. "You went barefooted often as a child!" I frequently tell people I have never seen before. They look at me surprised, but invariably they say, "Yes." I add, "You never tire easily, do you?" The answer is almost always, "No, never."
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6 - Care of Fallen Arches in Children
Flat Feet and Fallen Arches in Infants and Toddlers Are Normal - Leave the Arches of Flatfooted Infants and Toddlers Alone - . . . - Post-toddlers' Fallen Arches - Fallen Arches: Ages Three to Five . . . Four-fold Foot Care for Children's Arches
To prevent an infant from acquiring fallen arches, the single most important thing a parent can do is to leave shoes off their feet as much as possible during the first eighteen months. Consider the following analogy:
Imagine putting heavy leather mittens on an infant's hands from the first months of life, leather mittens which fit snugly, so that the child's fingers are pressed together so tightly he can hardly move them. The mittens are kept on his hands all day, and are taken off only for sleeping at night, for naps in the afternoon and baths once a day. When the child is in the crib we are careful to make sure his hands are tucked so tightly he cannot move his fingers freely. When he wakes in the morning, we immediately put cotton mittens on his hands and place the heavier leather mittens snugly over his fingers once again - day after day.
After two years, during which time the child has hardly ever had the chance to wiggle his fingers, we expect him to begin holding a spoon and cup. He is unable to do it, because all those complex muscles which should have been developing are undeveloped and unused.
Suppose we keep this system up until he is sixteen? It would be ridiculous to expect him to be able to play a violin, use a typewriter, or do anything well with his fingers for the rest of his life, for he would never have developed the muscles he should have during his formative years.
We do just that to babies' toes and feet. Is it any wonder so many of us do not have the strength to stand and walk straight?
Flat Feet and Fallen Arches in Infants and Toddlers Are Normal
Babies appear to have flat feet because of the thick layer of baby fat present in every infant's arch, which is normal and necessary. From this fat, babies muscles and bones absorb nourishment as they grow. It starts disappearing late in the third year, but until then every baby normally has low arches.
Additionally, when baby first starts to walk, he stands with his feet pointed out in a fallen -arched manner in order to balance himself. For a toddler this is normal. When a few months later, he acquires strength (if his feet and toes have not been weakened and distorted by shoes), he will by himself abandon the fallen-arched gait and stance.
Leave the Arches of Flatfooted Infants and Toddlers Alone
Many parents inadvisedly buy corrective shoes for their infants "to correct their flat-footedness." After the child wears these shoes for a year or more his feet become distorted, and such measures seem to have been justified. Parents who have fears about their toddler's feet should wait until he begins to walk firmly and with assurance; only then can real arch defects of the foot be recognized and corrected. Do not make the harmful mistake of treating your infant's or toddler's "fallen arches" when his flat feet are normal to him and should be left alone.
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. . . . A fourth misconception is that it is not good for a child to have short, square feet, as he will surely have fallen arches. Actually, that is how undeformed feet should look, but since children's feet are so commonly deformed, even most doctors hardly ever see a normal pair and the myth continues. The recent influence of physicians and pediatricians to encourage young children to go barefoot is forcing shoe manufacturers to make older children's shoes in EE and EEE widths. Formerly they made mostly A's and B's. But these broad feet are not "spread" - they have just been allowed to grow as wide as they should naturally grow.
Post-toddlers' Fallen Arches
After your toddler has begun to walk firmly, if he really has fallen arches (you can easily tell by giving him the test explained in Chapter 11) you will be pleased to know that treatment for the young child is very simple, and can easily be carried out at home. Simply put aside all his shoes and stockings and allow him to walk barefooted. You can help by playing with his toes so he will wiggle them more, but in most cases it is not necessary, since the child of two will start using his toes by himself the moment the impediment is removed from them.
In a few weeks his toes will become fatter and stronger. Gradually the child will put his weight on his toes instead of his arches. Soon he will walk with his toes pointing straight ahead, and play about the house with more spring and agility on his feet. . . . .
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Fallen Arches: Ages Three to Five
Treatment for fallen arches of these children is also readily successful, but it takes a little longer. The recovery is often as rapid and spectacular as in the following severe case of a four-year-old girl.
A mother brought her into my office. The girl was wearing such stiff arch-support shoes that she could not possibly move her feet inside them. Being tiny, she could not bend the inflexible leather of the shoes with her feet. Upon taking off her shoes, I saw that her feet were mostly bones with very little flesh and muscle on them.
While still an infant, the mother, following one of the local advertisements had bought the child corrective arch shoes. The little girl had begun to cry at night because of pains in her legs. During the day she fell frequently while walking, and she whimpered constantly.
I advised the mother to discard her child's shoes and let her walk barefooted at all times. In a week the girl stopped crying. Her toes became perceptibly less scrawny. During the second week she was walking straighter. By the end of the sixth week, she stopped having pains in her legs at night. She slept soundly, ate better, grew three quarters of an inch, and her feet had become much more muscular and sturdy.
That little girl needed no professional treatment though her arches had been badly damaged. The same is true for most children under six who have fallen arches - walking barefooted appears to be all that is necessary for recovery. Moreover, their skin is sensitive to adhesive tape, and specialized treatment such as steel braces on shoes (Dennis-Browne night splints) can cause harm by restricting the exercise the child normally gets in thrashing his feet and legs about while in bed. There is no harm to await professional treatment -bandaging and exercise - until after the child is six. In any case let him go barefoot and nature will probably make professional care unnecessary.
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Four-fold Foot Care for Children's Arches
Helpful as professional care may be, more important is the care practiced by the parents at home. To restate, that care must be four-fold. First, be aware that shoes distort the feet. Do not buy them for the child before he really needs them; then fit them properly. Second, do not wait for the child to complain about foot pains before you see if his shoes are distorting his feet. Third, the child must be given the opportunity to go barefoot for a part of the day, preferably three hours a day. Fourth, you may additionally supervise and encourage the child in doing the foot-strengthening exercises just outlined.
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From chapter 7
- General Foot Care for Children
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An active child's feet are always in a sweat; sweat is nature's way of getting rid of bodily waste, and cooling the body at the same time by evaporation. But nature never intended us to keep our feet overheated, covered with stockings and heavy leather shoes all day so the sweat cannot evaporate.
Accumulated sweat is accumulated waste which decays on feet which are covered. The child who wears shoes all day would need to bathe and change his socks twice a day, in order to keep his feet fresh. The barefooted child whose feet are soiled with dirt from lawns or floors of the house, would in this sense have cleaner feet than a child who has worn a shoe and stocking all day.
In most cases sweating is either from too much and too heavy footwear, or from the strain of fallen arches. With fallen arches, the feet must work harder to walk; they therefore sweat more. The first thing that clears up in treating children's fallen arches is excessive sweating. If yours is the rare child whose feet over-sweat naturally and are tender, use a tablespoon of alum to a gallon of warm water. Have him soak his feet in this solution for fifteen minutes at night, for several nights, and the excessive sweating will be relieved long enough to allow skin macerations to heal up.
Part of Chapter 13 . . .
Findings from Examination of 441 Children's Feet
(The book provided detailed results from an extensive study performed between 1957 and 1960)
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(Many tables and results omitted)
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Barefooted Children Have Better Feet
Many mothers told us they objected to their children going barefoot because of the danger of catching colds, injuries, lack of support for the feet, dirtiness, feet growing large, etc.
|TABLE 10||- children's feet were:|
|Mothers who objected to their children going barefoot||
|Mothers who had no objection to their children going barefoot||
|E||- Excellent feet|
|G||- Good feet|
|F||- Fair feet|
|P||- Poor feet|
|VP||- Very poor feet|
(Each mother was asked, but only those with strong opinions for or against going barefoot were counted.)
As was evident from Table 7 (not shown here) , children who had the opportunity of going barefoot a great deal, had less deformed toes, greater flexor strength, more ability to spread the toes. They also had denser muscles on the bottom of the feet; greater agility than those who had never gone barefoot, with a wider range of hip circumduction and more flexibility of the gluteal and hamstring muscles, and therefore, more ability to touch the toes when the knees were held stiff.