January, 1957. P H Y S I O T H E R A P Y Page Nine

METATARSALGIA: ETIOLOGY AND TREATMENT
B y : A . C. F IS H E R  O.B.E., M.D., E.R.C.S.

C hief M edical Officer, Roan Antelope Copper M ine Hospital, Luanshya, N . Rhodesia.

MA N Y  chronic foot ailments are due to the use o f shoes. T he A frican villager, who has so far escaped this 
“blessing,” is singularly free from  painful feet. However 
odd their shape, such feet are supple and toe movem ents 
free. O ur civilised man gets much of his painful feet from  
joint rigidity and functionless toes.

M orton’s M etatarsalgia has been attributed to  the 
collapse o f the anterior transverse arch o f the foot which 
is supposed to  lead to  compression of the digital nerves. 
However, many Surgeons believe th at the anterior transverse 
arch o f the foot is an anatom ical fiction and it certainly is 
not to  be seen in the bare-footed walker. T h at is why 
methods o f treatm ent aimed at reconstituing this arch give 
uniformly poor results.

? For more than a decade the w riter has based treatm ent 
on the following considerations:—

(1) The foot at the line of the heads o f the metatarsals 
is flat in transection.

(2) All the toes are capable o f strong p lantar flexion so 
th at the knuckles stand o u t prom inently. This is 
most marked in the hallux, but is only slightly less 
so in the second, third and fourth toes.

(3) In  walking the foot does no t passively roll forw ard 
on the m etatarsal pad, but, as the body passes the 
vertical, the toes flex strongly, takihg much o f the 
weight off the m etatarsals so th a t the area which 
bears the thrust o f the stride includes the pads o f all 
the toes, particularly the first, second and third, as 
well as the m etatarsal pad.

(4) A study o f the tracks o f a barefooted w alker in 
soft ground shows by the deep impression o f the 
toes how strongly they engage in the act o f thrusting 
the body forwaird.

In every case of m etatarsalgia th a t I have examined, 
plantar flexion o f the toes is absent or greatly diminished. 
W hen the condition is unilateral the power o f flexion on the 
sound side is always m arkedly greater th a n  on the affected 
side. W hen a step is taken off the aiffected foot the whole 
th ru st o f the stride is borne by the m etatarsal heads and the 
overlying pad. I t is n o t surprising th a t the nerves suffer 
from  pressure, particularly as the weighted fo o t rolls forw ard 
on th e m etatarsal heads, contributing a grinding action 
to the weight effect. As in all foot deform ities, the tolerance 
of the individual to  an abnorm al state differs widely, so 
th at m etatarsalgia appears in one individual when the 
condition is only slightly developed, while another will 
tolerate a much greater degree o f deformity.
Treatment:

F ro m  w hat has already been said it will be clear th at 
the treatm ent o f m etatarsalgia should be directed tow ards 
recovering the power o f flexion in the toes and tow ards 
re-education in the proper use o f the toes in walking. (1) 
T he patient should be directed to  plantar-flex his toe 
repeatedly at the m etatarsal heads in such a m anner that 
the heads are lifted clear o f the ground; this simple exercise 
can and should be done at any odd m om ent such as when 
standing w aiting for a bus. (2) H e should be instructed to 
kick off with his toes at each stride and n o t let the toes 
bend up passively; this has to be done consciously a t first, 
but becomes a h ab it later. T he m etatarsal b ar is co n tra­
indicated because it leaves the toes m ore helpless than ever, 
and other pads and straps have a sim ilar adverse effect. 
F ortunately, it is possible for the toes to  recover their 
m obility after a great many years, and I have had successes 
in cases o f 10 and' 15 years’ standing where the patient was 
intelligent and persistent.

N o do u b t the foregoing argum ent represents an over­
simplification o f the problem  o f M etatarsalgia. N everthe­
less the m ethods advocated above can be relied upon to 
give good results in a large p roportion o f cases.

Fig. 1.: Incorrect thrust not using toe-flexors. Fig. 2.: Correct use of toe-flexors.

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