Wendesdays are not ordinary days. Not in the pediatric consultation area of the Medical and Surgical Research Center (CIMEQ). Not at doors number 9 or 13; the examination rooms for patients with “flat feet”.
“Do you like how they’ve turned out?” is heard once, twice, three times... and so on until the last child, after midday.
They respond, uninhibited... He insists. They talk. Smile. There is a certain mutual understanding you can appreciate, and this is repeated ... You definitely have to have a gift to work with little ones. Here this is not lacking.
For the past 16 years, maybe a little more, Colonel Roberto Balmaseda Manent has been, we could say, undertaking a crusade. He’s a doctor, second degree specialist in Orthopedics and Traumatology, DSc, professor, senior researcher, and member of the Academy of Sciences of Cuba; and I suspect that these lines will pique his modesty.
This man, who has no shortage of decorations, such as the Carlos J. Finlay Order, awarded since the 1980s in Cuba to recognize the most significant scientific contributions, has introduced a surgical technique that guarantees the correction of what is commonly known as “flat feet”, or childhood planovalgus. More than 1,000 children have had both their feet operated on, with excellent results.
Almost two decades ago, Dr. Balmaseda held a book in his hands. Perhaps then he could not imagine where its pages would lead him - although there are things that one can sense from within. Serving as his inspiration was Trattato di chirurgia del piede (Essay on Foot Surgery), by the Italian Giacomo Pisani.
Perhaps he never imagined meeting him, their future friendship, the lessons on how much can be done for improved, healthier feet... Operating, one foot at a time… Followed by research, perfecting the technique. Today, the results speak for themselves.
The specialist literature notes that a normal foot allows us to walk, run, or remain standing without experiencing symptoms such as pain, fatigue, or deformities.
What a responsibility evolution bequeathed us, by raising the human center of gravity, making us the most unstable living being. In parallel, the foot assumed the function of antigravity control, capable of transforming the force of gravity into a stability factor, as an efficient mechanism for the upright position and gait, which prevents gravitational forces from killing us.
Experts estimate that an average person walks about 150,000 miles throughout his/her life.
Described as delicate and vulnerable, the feet contain proprioceptive sensory organs (which inform the body of the position and movement of the muscles). As such, the foot has been referred to as the “mirror of health”.
Injured feet can affect concentration, make us irritable, and are often the cause of pain in the legs, knees, hips and lower back.
The foot is a complex structure of between 26 - 28 bones (one-quarter of all those making up the body), 57 articular surfaces, 33 joints, 112 ligaments, and 20 muscles. And yet, it tends to be the “Cinderella” of orthopedics. At times underestimated, at others ignored. Although there are some who spend most of their life on them.
Childhood flat foot is nothing more than the arch along the inside of the foot coming into complete or near-complete contact with the ground, as Dr. Balmaseda told Granma International.
This may be physiological, until around the age of five, correcting with growth, in which case it does not require treatment other than “natural” measures such as exposing the foot to varied terrain, i.e. walking barefoot, using soft shoes that sit below the ankle, without any orthopedic correction, including the misnamed “prophylactic shoes.”
This way, the interviewee insists, “This child’s foot - it is important to understand this is not a small adult foot - with its genetic heritage, and exposed to external force: atmosphere and gravity, can develop and go through its different stages of growth and become a strong, normal adult foot.”
“If we put boots, supports, orthopedic corrections on a healthy child, that foot will not develop properly, because it may have a normal genetic heritage, but we are excluding environmental stimulus. We can compare the lack of this stimulus with the example of a deaf child: the child cannot speak because he/she is deaf, his/her phonetic system has not acquired expressive capacity, as it does not possess the acoustic information,” he explains.
Dr. Balmaseda also notes that many authors have confirmed that some adults have flat feet precisely because they used orthopedic shoes when they were children, which excluded them from environmental stimulus, and prevented proper foot development.
If the flat foot does not correct itself, then it becomes pathological. “Pain begins to appear in the feet, usually at night. This is the case of children who do not want to walk, and fatigue, tiredness, and discomfort begin to appear,” says the specialist.
Experts view flat foot as a symptom rather than an entity in itself, as such the condition should indicate something else, ranging from the damage caused by a foot fracture as a child, to a metabolic disease, or as a sign of a neurological disorder, or an inflammatory disease, the expert explains. Therefore, not all cases are treated equally.
But, he insists, “The foot is integral, and must be seen as such.”
Flat feet are often the cause of hallux valgus or bunions, claw toes, a flat metatarsal, degenerative knee injuries, back problems, among other ailments.
Thus one realizes the error of many, when not taking their feet seriously.
As Dr. Balmaseda explains, 80% of the children aged between two and five years of age with flat feet who attend consultations are physiological cases, usually spontaneously evolving into normal or non-flat feet. Only approximately 3% present further symptoms and require orthopedic treatment.
This group is considered as having a growth disorder, Dr. Balmaseda explains, likening this to the anomalies of tooth formation that sometimes occur in children. In these cases, the dentist removes teeth where necessary, and aligns the teeth using metal braces or rubber bands, thus repositioning them to ensure their proper growth. Such treatment and its effectiveness are well known among our population.
Seeking increasingly effective treatments and conserving biological and human integrity are the present and future concerns of medicine, and the principles followed Dr. Balmaseda.
The established Cuban procedure, founded by Dr. Balmaseda - based on the “arthroereisis” technique outlined by Spanish surgeon Recaredo Álvarez in 1976 - replaces a titanium and polyethylene implant with a stainless steel screw between 15 and 20 millimeters long, similar to those used to treat fractures.
The advantages include a relatively simple surgical technique compared to others, a rapid recovery rate and resumption of walking, in addition to not requiring hospitalization.
The expert explained that the result is a mechanical contribution to achieve the correction of the excessive calcaneovalgus (flexible flatfoot in infants and young children), by raising the inner arch of the foot, and proprioceptive stimulation that increases muscle tone to maintain this correction. The treatment arranges the structures of the foot and restores normal physiology, by implanting a screw properly positioned in the middle of the tarsus (bone structure found at the outer edge of the foot in the articulation of the talus and the calcaneus bones).
This new technique surpasses the traditional and often abused treatment using orthopedic shoes, supports, and insoles; which have proven to be inefficient in almost 90% of cases, as they are unable to maintain the correction in the child's foot.
This has been demonstrated in comparative studies by Spanish orthopedic surgeon Antonio Viladot and Italian Giacomo Pisani, results which have been corroborated in Cuban medical practice.
On this matter, Dr. Balmaseda also states his disagreement with waiting for the customary orthopedic consultation at the age of two, as in his opinion the child should be assessed in the first months of life and before starting to walk. “At two years old, all children have a physiological flat foot which is normal and does not need support, orthopedic shoes or the misnamed prophylactic footwear. These children should be regularly checked by the specialist who can confirm the diagnosis of either pediatric flat foot or another type of flat feet.”
He offers the examples of neurological flat foot, congenital flat foot, flat foot caused by metabolic or other diseases that, although rare, do occur, and require a different type of treatment.
Dr. Balmaseda’s technique is an ideal outpatient surgical method in children, but can also be used to treat adults, where the condition is frequently seen.
“The technique had not been researched from the viewpoint of neurophysiology. We did so with Professor Lázaro Gómez Fernández of the International Center for Neurological Restoration. We studied the electromyography and neuroplasticity in the lower limbs of twenty children, before they underwent surgery, Balmaseda explains.
They then compared the operated limb with that which had not yet been operated on, and demonstrated that on fitting the screw, there was a stimulus of the foot muscles, which contracted to form a “bridge” as a result of the proprioceptive stimulus.
CIMEQ, which is also a teaching and research center, works to share this experience among the Cuban orthopedic community.
Children should be seen by an orthopedic surgeon from the first months of life and, if considered within normal limits, should be examined annually until they finish growing around the age of 16.
The proposed surgical treatment is indicated for children with calcaneovalgus foot, preferably aged between four and seven, who experience symptoms such as pain at night or when walking, fatigue, or deformities at other levels.
When children that fall within this age range have calcaneovalgus foot, but do not experience the symptoms described above, they are considered normal and their development is monitored until they stop growing, while they are encouraged to practice sports to strengthen their foot muscles.
“Today's child is tomorrow’s adult, and we must educate ourselves as to how to also guarantee a better quality of life. Educating the foot for a harmonious development is part of this,” the doctor states.
He adds that the population needs to be aware that flat foot is not unimportant. Greater prevention and awareness of how important foot deformities are to general health are required.
Dr. Balmaseda provides an example. The foot, he says, is the body part that externalizes pain. “You have a foot injury, and even after recovery, the pain may continue a bit longer because the information is stored in the cerebral cortex. The area of sensory cortical representation in the foot is larger than that of the hand, which is why the foot is considered a remarkable support tool. The opposite of hands where this ratio is reversed with a greater motor cortical representation than the foot. Hence the hand is described as a remarkable work tool, given its multiplicity of movement.”
Simpler still, incorrectly treated feet can lead to impairment.
“Do you like how they’ve turned out?” is heard.
The children do not lie, and they smile. Behind the screen, nurse Sandra Arias Avilé changes their bandages, removes stitches, offers advice...
Outside, the friendly mutual understanding is evident: “Hey doctor, sort out these flat feet!”
