If metatarsalgia is present, the anterior arch has given way. In Morton's disease the patient usually complains of a "live nerve" in the sole of the foot, which causes intense pain on pressure. This is due to a true traumatic neuritis, which follows bruising of a digital nerve, either between the metatarsal head and the ground or between the heads of two adjacent metatarsals. The pain is intolerable and life is a misery. The obvious treatment is to shield the nerve from the injury until the effects of the trauma have subsided. This can best be done by shaping a felt pad, which is to fit accurately behind the arch of the metatarsal heads. It is held in place by a band of 2 1/2-inch elastic shaped round the foot and sufficiently "snug" to afford considerable lateral support to the arch. In mild cases a small pad may suffice, but in severe cases it may be necessary to carry it back to the heel so that the whole of the sole of the foot is supported up to the level of the metatarsal heads, which are thus allowed to hang free in the boot, supported so that they just fail to touch the leather sole at all. While these palliative measures are being taken, muscle training, as about to be described, must be instituted.

By far the most common cause of metatarsalgia is not, however, neuritis, but rather an arthritis, a periostitis, or both. The condition may be due to one of three conditions. First, general weakness, due to prolonged illness, may have led to a simple dropping of the arch, together with a thinning and general softening of the plantar skin and subcutaneous tissue. The three middle metatarsal heads thus lack their usual protection and, at the same time, are called upon to bear a portion of the weight to which they are unaccustomed. Second, the trouble sometimes arises from pure indiscretion, such as walking on a pebbly road in thin-soled shoes. This may lead to a traumatic arthritis, adhesions are formed, and the pain and disability persist indefinitely until appropriate treatment is administered. The third condition, which commonly leads to metatarsalgia, is that of pes cavus, and even a slight degree of this deformity is capable of causing the greatest trouble and disability.

The treatment outlined above as applicable to cases of Morton's disease suffices to remedy the first condition. Its somewhat common occurrence should serve as an indication for prophylactic measures; and no patient, convalescent from prolonged illness, should ever be allowed to use his feet for their weight-bearing function until the muscular strength of the intrinsic muscles of the feet and of the long muscles which help to support the arches has been restored.

The second condition is frequently amenable to manipulation under anaesthesia; and, as already noted, this is the type of case of so-called "flat-foot" that we hear of as being "miraculously cured" by the bone-setter (see Chapter XVII (Forced Movement - "Bone-Setting").).

The consideration of the third condition is a difficult matter. In mild cases the felt pad and elastic band may prove all that is needed, but in more severe cases this is not enough. As in cases of painful flat-foot, so here, too, restoration of mobility of all the joints in the foot should be our first aim. Free manipulation is called for, and especially of the first tarsometatarsal joint. Then every attempt should be made to secure relaxation by means of massage of any muscles that may have a tendency to spasmodic contraction. Massage should also be used for the sake of nutrition, and as an assistance to exercises, being "spaced" between them if necessary. General kneading of the foot undoubtedly helps in the somewhat mysterious process of "softening up" the foot, though the scientific description of what actually takes place is difficult. It is probable that the skin and subcutaneous tissues derive increased nutrition and elasticity therefrom, that the plantar fascia becomes more elastic, and that the short muscles not only regain their elasticity but also benefit by the revival of the power of spontaneous action, both as regards contraction and relaxation. Cupping the sole is often of great service.

In more severe cases the elastic support to the foot-pad is inadequate. A wooden sole-piece must be worn, on which the felt pad rests. Low wire loops are fitted between the toes, and through these a continuous tape is threaded to exert pressure on the dorsum of each proximal phalanx. Not only does this tend to pull the phalanges down while the pad tends to push the metatarsals up, but it also assists materially in drawing the digits into their correct alignment with their corresponding metatarsals. Even a considerable degree of hallux valgus can be remedied in this way. The apparatus does not make walking easy, and even when felt is nailed on to the edges of the wood to serve as an "upper," it is not elegant. But even if only worn about the house in the evenings, it can yet accomplish much. Capt. Patterson claims that "even tenotomy [of the extensor tendons for claw-foot] can usually be eliminated by [this] method of splinting," and adds that it "will not keep the patient incapacitated longer than would operative interference." "In cases of severe bunion deformities," he says, "operation may perhaps be advisable, but only for its cosmetic value. In all cases a physiological cure can be obtained and the toe straightened without operation, so that the only thing the surgeon need ever do is to remove the exostoses at the head of the bone." This may sound optimistic, but when actual measurement of the length of a foot taken without weight can be shown to have increased three-quarters of an inch, it is plain that much can be accomplished.