METATARSALGIA OR MORTON'S DISEASE. By ROBERT JONES, FRCS, AH TUBBY, MS (LOND ...

32 Pages·2006·2.93 MB·English

METATARSALGIA OR MORTON'S DISEASE.
By ROBERT JONES, F.R.C.S.,
OF LIVERPOOL,
HONORARY SURGEON, ROYAL SOUTHERN HOSPITAL,
AND
A. H. TUBBY, M.S. (LOND.), F.R.C.S. (ENG.),
OF LONDON,
ASSISTANT SURGEON TO AND IN CHARGE OF THE ORTHOPEDIC DEPARTMENT OF
WESTMINSTER HOSPITAL; SURGEON TO THE NATIONAL ORTHOP.EDIC
HOSPITAL AND TO THE EVELINA HOSPITAL FOR SICK CHILDREN.
THIS distressing affection is a neuralgia situated in the
front part of the foot. The pain is of varying character,
sometimes intense and sometimes dull. In the morning it
is frequently noticed that the foot is free from pain in the
less severe cases, but invariably after walking for a time the
pain comes on. The affection is known by many synonyms:.
some of these are the following:
" Metatarsal neuralgia," "plantar neuralgia," "a form of
painful toe," "a peculiar painful affection of fourth meta-
tarsal phalangeal articulation."
The affection was originally described by Dr. Thomas
G. Morton, of Philadelphia, in I876, under this latter title,
and from that time the whole literature of the subject up to
I895 is contained in a pamphlet, which he has kindly for-
warded to us, and this list and that of the literature up to
date we append to the end of this article.
Inasmuch as the cause of the pain is undoubtedly some
alteration in the relationships of the various parts of the bony
and ligamentous framework of the foot,it is advisable to de-
scribe these briefly. In text-books on anatomy the arches of
20 297
298 28ROBERTJONES AND A. H. TUBBY.
the foot are described as two,-the longitudinal and the
transverse; and the longitudinal is said to consist of two
parts, an inner and an outer. The inner part is composed of
the os calcis, astragalus, scaphoid, cuneiform, and three inner
metatarsal bones. The outer part is made up of the os calcis,
cuboid, and two outer metatarsal bones. The transverse
arch is spoken of as being formed only of the scaphoid,
cuboid, and cuneiform bones. But this is less than the truth.
The metatarsal bones form a transverse arch at their
bases, and to a less extent at their heads. Vhen the foot is
brought to the ground, considerable spreading takes place,
especially of the transverse arch, at the heads of the meta-
tarsal bones, and the foot is broadened at that spot about
half to one inch, and the arch springs back when the foot is
lifted. The degree to which the heads of the metatarsal
bones are brought in contact with the ground varies with the
tone of the structures binding them together. In some pain-
ful feet relaxation is more marked in the anterior than in the
posterior part, so that many cases of this disease do not ex-
hibit typical flat-foot or relaxed ligaments posteriorly. The
best conception of the foot is that of a semidome, as Ellis has
pointed out, and the two feet placed together make up a
single dome. The arches, therefore. cannot be regarded as
separate, but are portions of the whole, so that, given flat-
tening in any one part, the remainder of the semidome suf-
fers, and especially the relative position of the heads of the
metatarsal bones to one another.
Dr. A. J. Chalmers has kindly prepared for us a coronal
antero-posterior section of a frozen foot, and the relative
positions of the heads of the metatarsal bones are well shown
(Fig. i). The second is in front of the first by one-quarter
inch; the third is behind the second by one-quarter inch; the
fourth is behind the third by one-quarter inch; the fifth is
behind the fourth by three-eighths inch,-that is, the heads
of the fourth and fifth are considerably behind the preceding
toe. Now, if we examine the relationships of the plantar
digital nerves to the heads of the metatarsal bones, we find
METATARSALGCA. 299
that they issue from under cover of the plantar fascia near
the clefts between the toes, after passing between the heads
of the metatarsal bones, but not deeply. The internal plantar
nerve gives off four digital branches, the first for the inner
side of the great toe, and the other three bifurcating to sup-
ply the adjacent sides of the first and second, second and
third, third and fourth toes. The external plantar nerve
FIG. I.-Diagramoffrozen section,showing thatthere ismostspace
between themetatarsals offourthandfifthtoes.
gives off two digital branches, one for the outer side of the
little toe and one which bifurcates to supply the adjacent
sides of the fourth and fifth toes. Now this latter branch
receives a communication from the fourth branch of the in-
ternal plantar nerve. The position of this communication is
of great importance in explaining the position of the pain in
metatarsalgia. (Fig. 2.) The communicating branch passes
300 ROBERTJONES AND A. H. TUBBY.
beneath the head of the fourth metatarsal bone. If a trans-
verse section of the foot be made across the heads of the
netatarsal bones, it will be seen that the first and the fourth
(Fig. 3) bear the most pressure. It therefore seems that the
neuralgia is a pressure neuralgia, and our explanation of
most of the cases differs from that of Morton, which is as
follows:
Morton says that the fourth metatarso-phalangeal joint
is generally but not invariably affected. HIe states that the
metatarso-phalangeal joints of the first, second, and third
FIG. 2.-Diagram showing the' F1G. 3.-Transverse section ofthe foot
nervesgenerallytroddenupon across the heads of the metatarsal
inplantarneuralgia. bones.
toes are almost in a direct line to one another, while the head
of the fourth metatarsal is from one-eighth to one-quarter
inch behind the head of the third, and the fifth is from three-
eighths to one-half inch behind the head of the fourth. The
fifth metatarsal joint is therefore so much posterior to the
fourth that the base of the first phalanx of the little toe is
opposite the head and neck of the fourth metatarsal. He
also adds that the fourth has greater mobility than the first
three metatarsal bones, and the fifth still more than the
MAETATARSALGZA. 30I
fourth. If pressure be 1nade upon the foot across the heads
of the metatarsal bones, the head of the fifth metatarsal bone
and base of the phalanx are brought into direct contact with
the head and neck of the fourth metatarsal bone, and to some
extent the extremity of the fifth metatarsal rolls over or
under the fourth metatarsal. The branches of the external
plantar nerves are distributed not only to the skin, but there
are numerous small offsets of these nerves deeply lodged in
the soft tissues between the fourth and fifth toes, so that if
compression of the foot occurred they are likely to be
irritated.
We have pointed out above the importance of the posi-
tion of the communication between the external and internal
plantar nerves as throwing light upon the cause of the pain,
and this may be advanced as a reason for our venturing to
differ from the explanation given by Morton. We shall also
adduce clinical and therapeutic evidence in support of our
contention that in many cases the communicating branch is
compressed between the head of the fourth metatarsal bone
and the ground. There are, however, cases in which the
pain is not localized about the head of the fourth metatarsal
but elsewhere in the transverse arch of the foot, and it may
well be that the small offsets of the digital nerves passing
deeply between the heads of the bones become compressed,
and so give rise to pain.
For the sake of convenience in describing the affection
clinically we will divide it into three degrees.
The first or slighter degree comprises those cases where
pain, often shooting in character, is occasionally felt along
the metatarso-phalangeal joints during certain acts, such as
dancing, prolonged pressure of the feet in the stirrups,
skating with straps tightly laced across the toes. But the
pain quickly passes away on desisting from such acts.
In the second degree may be placed those cases where
characteristic symptoms quickly follow either early attempts
at walking after an injury, the wearing of an unduly tight
pair of boots, or a sudden and unexpected movement.
302 ROBERTJONES AND A. H. TUBBY.
Causes such as these appear to give rise to sudden yielding
of the metatarsal arch at one spot and nerve-compression.
It is in this class of cases that, on careful questioning, one
finds that the pain is frequently relieved with a sudden click
between the toes, and we venture to think the explanation of
the click is that the head of one of the metatarsal bones is
partially displaced downward from its fellows, and then either
by flexing the toes or by swaying the foot about the sub-
luxation is reduced and pressure on the nerves relieved. The
following cases will illustrate this degree:
CASE I.-A young lady, aged twenty-four years, of weak.
ligament type, while patting a horse after a ride was trodden
upon by its forefoot. Her foot became considerably swollen,
not very painful, and no lesion worse than pressure-bruising
could be observed. She was laid up for a week and then walked
about in house-boots or slippers. In less than three weeks she
complained of considerable pain behind the fourth and fifth toes,
and frequently had no rest. The pain, however, went almost
immediately on abstaining fromn walking or standing. This pain
lasted two months, and only left her when appropriate mechani-
cal treatment, to be described later, was employed.
CASE II. Dr. G. H., aged forty years, having read an ac-
count by one of the writers of this paper on the affection, kindly
sent the following letter: "I have been suffering from this affec-
tion for about six months. I first felt it in playing cricket. While
fielding at 'point,' I turned round sharply to stop a hard ball
and a sudden pain in the right foot nearly brought me down.
The boot was a comparatively new one and had had spikes on
the sole, but all of these had come out except one placed under-
neath the head of the fourth metatarsal bone. In the place of the
spikes I had had nails put in, but these did not project from the
sole as far as the solitary spike. As the ground was very hard,
the chief pressure of the foot came upon the spike, and so an
elevation of the sole was caused at that spot which pressed upon
thefourth metatarsal bone. This, with a sudden twist, caused the
pain which has continued with certain boots ever since. There
is no corn nor any flat-foot, but if I get very tired the pain comes
on severely and I find considerable relief by pressing on the toes
ALETATARSALGIA. 303
and separating the heads of the fourth and fifth metatarsal
bones."
CASE III.-Mrs. P., aged thirty-four years, the wife of a
medical man, stated that for two years past she had suffered
agonizing pain in the left foot. She had tried all manner of boots
and had failed to get relief. The pain was situated about the
head of the fourth metatarsal bone. It was so severe as to render
her life entirely miserable. As a rule, there was no pain in the
morning but only a dull ache, but this increased whenever she
attempted to walk, so that she was obliged to remove her boot at
any cost. When the pain was very severe she would, so to speak,
throw the foot about, when, after a time, a distinct click was felt
and heard, and the relief was immediate. She was advised to
have a boot made with some thickening on the sole just behind
the head ofthe fourth metatarsal bone, and from this she obtained
relief.
CASE IV.-Miss M. A., aged thirty-one years, was treated
for severe bunion of the left foot. The head of the first meta-
tarsal bone was excised and for a time all went well. After re-
covering from this, and on walking about in a pair of somewhat
tight boots, she began to complain of a burning, darting pain in
the fourth interdigital space. Relief from this could only be ob-
tained by rapidlv flexing the toes, and after a distinct sort of click
had been felt. This patient was somewhat flat-footed, and before
the operation for the bunion it was noticed that the sole of the
foot was concave instead of convex across the heads of the meta-
tarsal bones, and that the head of the fourth metatarsal bone was
prominent with thickened skin over it. There can be no doubt
that the removal of the head of the first metatarsal bone so
weakened the anterior transverse arch as to make it the imme-
diate cause of the metatarsalgia.
CASE V..-Mr. C., aged thirty-nine years, a bank cashier,
and standing most of the dav, complained of pain on the outer
side of the foot which became so bad as to necessitate his
giving up his position at his desk in the latter part of the day.
His father had suffered from gout, but he himself had not at
any timne had an acute attack. On examination of the right foot
there was noticed at once a peculiar inward twist of the front
part of the foot, and the base of the fifth metatarsal bone was
prominent, very painful, and with a false bursa over it. He com-
304 3ROBERTJOAES AND A. H. TUBBY.
plained also of dull aching pain about the head of the third meta-
tarsal, but it had never been paroxysmal. The arch of the foot
was somewhat lowered, and, on examining the sole, a corn was
found beneaththeheadof thethird metatarsalbone,whichseemed
to have dropped away from the others. The boots he had been
wearing were narrow in the tread and very pointed. He was
advised to rest the foot entirely for a fortnight, and meanwhile
a pair of low-heeled boots were made, with a valgus pad beneath
the instep, and so arranged as to fit tightly across that part, and
to leave ample room across the heads of the metatarsal bones in
treading. It seemed to be highly probable that the displacement
of the head of the third metatarsal bone arose from the pressure
of narrow boots on that part of the transverse arch. To relieve
the pain over the base of the fifth metatarsal bone it was sug-
gested that the leather of the boot should be blocked out over
the spot. A month afterwards he expressed himself as much
relieved.
CASE VI.-Mr. N., aged thirty-two years, suffered paroxys-
mal pain in the front part of the right foot, which became so
severe at times as to entirely prevent him moving about. He
played much cricket, and had frequently been struck with the
ball on the dorsum of the foot. The boots he was wearing were
fashionable, and no doubt contributed to the perpetuation of the
pain. The latter was always worse in the evening, and occa-
sionally became agonizing in awarm room, and was accompanied
by considerable redness and extreme tenderness in the first inter-
space. Relief was temporarily obtained by removing the boot.
On examination it was noted that the arch of the foot had given
way, the base of the fifth metatarsal bone was prominent, and
anterior part of the foot twisted inward, and there were depres-
sion and enlargement of the head of the second metatarsal bone.
Relief was obtained by boots constructed on the same plan
as in the previous case. He was also advised to soak the feet
in hot water containing a drachm of bicarbonate of soda to the
pint, and citrate of potassium was given internally. After some
'weeks the pain lessened and disappeared.
CASE VII.-Mr. J. D., aged twenty-five years, experienced
pain and difficulty in walking. He could only hobble on account
of the pain, and had tried all sorts of boots. The history of gout
was wvell marked in the family. Pain conmplained of in both feet,
METAT7ARSALGSA. 305
about the head of the third metatarsal bones, and over the base
of the fifth metatarsals. In the soles of both feet the head of the
third metatarsal was very prominent with a large corn on it, and
in the right foot smaller ones were present over the heads of the
second and fourth. The arch of the foot was much increased,
and the toes of both feet were hyperextended. At times acute
attacks of pain, lasting on and off for a fortnight, occurred, and
completely laid him up. The inward twist of the front part of the
perfect foot was well marked. So extreme was the displacement
of the head of the third metatarsal bone on the right side that its
removal was advised. As he objected to this and was anxious
to try other treatment, bathing in hot water every night and
boots closely fitting over the instep and very broad in the tread
were tried, and considerable improvement resulted.
CASE VIII.-Mrs. S., aged twenty-four years, had been con-
fined six months previously, and the first time afterwards that
slhe went out for any exercise she felt a sudden pain in the right
foot, and noticed a distinct "crick-crack" when the pain came on.
Now she can walk for about a mile in comfort, then the pain
commences and becomes throbbing and finally burning, and then
the feet get so swollen that she must get the boots off as soon as
possible. There is no gout in her family. The right foot is flat
and the anterior arch is spread. The pain is situated about the
head of the fourth metatarsal bone, and is increased by tightly
grasping the heads and diminishing by pressure at the bases.
There is a sinall corn beneath the fourth metatarsal head. She
had been wearing badly shaped boots for a considerable time.
She was advised to wear a bandage around the bases of the meta-
tarsal bones and to have a special thickening in the sole just
behind the painful spot. Unfortunately, she did not again pre-
sent herself, and so the final condition of the case cannot be
noted.
The thiird or severe degree is characterized by pain of so
persistent, agonizing a nature as to entirely cripple the
patient.
CASE IX.-In I894 a lady of about forty-five years was sent
by Dr. Willoughby Gardner, of Shrewsbury. She had consulted
a number of our profession, but the ailment was ascribed to rheu-
matisIml, gout, or lhysteria; and although Dr. Gardner had exer-
306 ROBERTJONES AND A. H. TUBBY.
cised considerable ingenuity in trying to relieve the painful area
from pressure by mechanical means, nothing seemed to give her
any relief. On examining the foot there was some reddening of
the third and fourth toes, and the nail was altered from maltutri-
tion. There was no swelling. The patient seemed very hopeless
and distressed, and had quite given up walking, which was im-
possible to her. There was distinct pain over the fourth meta-
tarso-phalangeal joint. There were no callosities nor corns.
The foot was flat, both arches having yielded. Appended is her
brief description., which somewhat inefficiently describes her
plight:
"It was in the early part of the year I893 that I first began
to be troubled with a pain in the third toe of my right foot when-
ever I wore boots: in loose slippers I felt nothing of it. As time
went on the pain increased terribly, and my toe became swollen
and discolored and the nail almost disappeared, drawn in by in-
tense pain. I consulted several doctors, but they were unable
to give me any permanent relief, and for more than two years
my life was entirely spoilt by the pain in my foot, which I can
only describe as sickening, like treading on something very hot.
Since the operation, last July, I have had no recurrence of the
old pain, and lately I have been walking several miles almost
daily."
The operation will be referred to later.
CASE X was that of Mrs. S., aged twenty-four years. Her
life, which was an active one, was rendered utterly miserable, as
she could neither walk, hunt, nor dance. Her right foot was flat,
with a yielding of the anterior arch. There was no swelling, nor
any history ofrheumatism or gout. Pressure on the first, second,
third, and fifth metatarso-phalangeal joints was painless, but the
moment the fourth was squeezed there was considerable pain.
She complained of a subluxation, and certainly the joint appeared
to be abnormally lax, but it could not, by manipulation, be dis-
located. There was no redness nor sign of malnutrition. She
describes her case as follows:
"The first complaint I had to make of my foot was in
January, I893, when, on walking any distance, a sort of cramp
up my instep occurred, which, on continuing to walk, increased