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This freedom of action and pliability in the foot are interfered with by the stiffness of heavy shoes and the pressure of foot wear not made to fit the varying size and shape of the foot, but to the con- ventional shape elavil amitriptyline of a last. An examination of an adult, where shoes have been elavil for worn since infancy, shows usually many varia- tions from the normal standard. There is almost in- variably an impairment in the motion of the meta- tarsophalangeal joints, especially the first. There is * Read before the American Orthopaedic Association at its six- teenth annual meeting, held in Philadelphia, June 5, 6 and 7, 1902. usually also a loss or impairment of movement in the first metatarsocuneiform articulation, or a lim- itation of the power of voluntary spread and arch- ing of the foot. In addition to this there is a rela- tive muscular weakness of the muscles of the sole of the foot, including those attached to the first meta- tarsal (correspondingly to the volar muscles of the thumb), and in consequence of this often the de- velopment of a weak and flat foot and the lack of strength in the movement of the toes. ^lisplaced position of the heads of the metatarsals in relation to elavil 10mg the transverse axis of the front of the foot often result from boots that are thin in the waist and narrow in the shank. A distorted position of the smaller toes either con- fined to one toe or affecting many similarly, is not uncommon on the wearing of shoes which check the natural spread of the front of the foot. The first elavil for anxiety pha- lanx is flexed dorsally upon the metatarsus, while the second and third are contracted in a position of plantar flexion. .■\ loss or impairment of mobility in the metatar- sophalangeal articulation is caused by a stiffness of the sole of the boot which prevents the plantar flex- ion of elavil mg the toes bound down to the stiff soles by a strong and closely fitting upper, and by the upward -rock of the. front of the sole pressing the toes up- 662 BRADFORD: SHOE DEFORMITIES. [X. Y. Med. Jour., ward, holding them firmly in a position of slight dorsal flexion. This immobility of the toes causes in time elavil uses a loss elavil 50 of muscular strength in the flexor muscles of the phalanges, elavil 10 mg and under certain circumstances a loss of elasticity of the capsular ligaments of the toe joints, so that instead of a flexibility which should be Fig. II. — X-ray of hallux valgus, showing how the shoe causes a deformity. as great as that of the fingers, the arc of the motion at the metatarsophalangeal joints is limited to a few degrees. The amount of the damage to the strength and ease in walking inflicted in this way is greater than is sur>DOsed, and can only be estimated by a compari- son of the walking efficiency of shoeless and shoe- wearing races. The most conspicuous illustration of the superi- ority of the barefoot races in this respect was afford- ed in the campaign in Abyssinia. The elavil 25 mg marked su- periority in agility and fleetness of the barefooted Abyssinian was evident. This elavil buy has also been seen wherever the shoeless are matched in marching against shoe wearing people. Many of the United States officers have found moccasins and the train- ing necessary to wear moccasins with comfort a help in the pursuit of hill Indians.^ The plantar flexion of the toes is an action needed in the backward push of the front of elavil used for the foot, elavil 25mg at the end of the stride. The strength of this effort depends on the muscular strength of the muscles governing this motion as well as the freedom of this motion. Where, as is usually the case among shoe-wearing people, elavil 50 mg this action is not so strong as among the barefooted, a greater amount of work in the back- ward push of the foot comes at the ankle joint, the calf muscles becomes developed, and the muscles buy elavil online in the sole elavil 10 of the feet are small. It is commonly seen among elavil 50mg barefooted peoples not subjected to great de- mands in the way of climbing or hill work that their feet muscles are large and their calf muscles small, cheap elavil the reverse being true of shoe-wearing people. The normal condition is well seen in the Japanese jin- riksha runners, who have well muscled legs and feet. This disability, due to an impairment of the strength and freedom of motion of the metatarso- phalangeal articulation, is increased if the great toe is distorted from its normal position in the line of the axis of the foot and is turned outward, present- l-iG. III. — online elavil Crowding of the little toe, sandal strap. elavil 25

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