Note on the Condition of Stiff Great Toe in Adolescence

? The condition, as discussed in several papers by various surgeons, was known by the following symptoms:?(a.) Apparent flexion of the first phalanx of the toe on its metatarsal bone, (b.) Inability to dorsiflex the toe, more or less complete, (c.) Pain felt in efforts to dorsiflex the toe, as, for instance, in the act of standing on tiptoe. This pain is usually felt over dorsal aspect of joint; at a later stage it may be most marked below the joint, or it may be absent throughout the whole course of the case. Mr Cotterill criticised the views expressed by many surgeons as to the causation of this disease. Amongst others the following causes have been given:?(1.) Injury followed by contraction (Davies-Colley). (2.) Improperly fitting boots (several surgeons.) (3.) Gout, rheumatism, or rheumatoid arthritis (various). (4.) The development of puberty (Howard Marsh). (5.) A defect in the development of the spinal cord (Nunn). (6.) Contractions of various muscles (Ellis). (7.) Contractions of certain ligaments (Anderson.) (8.) Flat-foot (Golding Bird). Mr Cotterill proceeded to demonstrate that, while some of the above causes might lead to stiffness in the joint and inability to dorsiflex the toe, that none of them satisfactorily accounted for the condition as above defined, in which the hallux lies at an altered angle to its metatarsal bone (1st symptom). His view of the case is that the condition which he has named " Hallux Rigidus " is brought about by a necessary combination of flat-foot and boot pressure. The various stages of hallux rigidus and the appropriate treatment for each were then discussed. The following is an abstract of a few of the chief propositions made by Mr Cotterill:?1. Hallux rigidus proper is due to the invariable combination of flat-foot and boot pressure. 2. That while no amount of flat-foot alone will cause hallux rigidus (c. /., as in the case of negroes, who, being frequently flatfooted, never suffer from it), a slight amount of flat-foot in combination with boot confinement is sufficient to bring it about. 3. That hallux rigidus, partly consisting as it does in a more or less complete limitation of dorsiflexion of the hallux to a right angle with its metatarsal bone (which is the normal range of dorsiflexion in the healthy adolescent), exists, to a certain extent, in almost all cases of flat-foot occurring in persons wearing ordinary European boots. 4. That flat-foot occurring in barefooted nations, or in those who wear sabots or other such boots as provide for ample dorsiflexion of the great toe, does not cause hallux rigidus. 5. That the connexion between flat-foot and hallux rigidus has been frequently denied or overlooked owing to the imperfect y 278 THE STIFF GREAT TOE IN ADOLESCENTS, means of testing flat-foot,?and that while an inspection of the foot, or of the footprint, are apt to mislead, the most reliable test is an inspection of the boots which have been worn. 6. That hallux rigidus is frequently one of the earliest manifestations of flat-foot in booted nations. 7. That while it is commonest in young boys, it occurs frequently in girls. (This has been denied.) 8. That in the early stages hallux rigidus may be cured by attention to the flat-foot, and by giving room for dorsiflexion of the hallux in the boot. In the later stages excision of the proximal end of the first phalanx is probably the only means of cure, though palliative treatment by fixation of the joint may give relief to pain in walking. Surgeon-Major Black remarked that the subject of deformities of the foot was of much interest to army surgeons engaged in the recruiting service, and that the diagrams of the different shapes of plantar sole on the floor would be of value to that department. Mr Cotterill's observations on the form and relations of the ball of the great toe seemed to support the practice of ladies in using a highheeled boot, and to be somewhat at variance with professional objections to it, as impairing the maintenance of the arch and proper planting of the foot. Dr Scott Lang mentioned that this subject was brought forward three months ago by Mr Lucy and Mr Pavies-Colley simultaneously, but independently of each other. Mr Lucy wrote that he would be thankful to receive any suggestions as to treatment, etc.; and he (Dr Scott Lang) had written to him direct, pointing out that he had overlooked the tendency to flat-foot which was almost invariably present, and that he should support the in-step. He had no wish to differ from Mr Cotterill, and was quite alive to the potency of the other factor (viz., the boot). Still, it seemed rather unsafe to assert that the condition was absolutely impossible in barefooted races, for a case might yet turn up. But, letting that pass, he still contended that of the two factors insisted on by Mr Cotterill, the tendency to flat-foot, or a modification of flat-foot, ought to be looked upon as the primary factor, and the other as accidental or secondary. Mr Cotterill had stated that the bootmaker was the savage here, but the bootmaker might reply that he made the boots of proper length until the tendency to flat-foot, with lengthening of inner edge of the foot, began to come on. The two factors mentioned could at any rate be considered separately, and he contended that, even upon Mr Cotterill's own showing, the lengthening of the inner edge of the foot was the primary factor. Confusion arose owing to there being no exact definition of what was meant by flat-foot; but he thought the complaint under consideration was in the main a modification of flat-foot, consisting of undue pressure upwards on the ball of the great toe. The metaBY MR J. M. COTTERILL. 279 tarsal bone was extended on the tarsus, and the phalanges and metatarsal bone came to occupy the same straight line, preventing the extensor proprius hallucis from acting. Mr Cotterill ascribed his success in the treatment of his cases to be mainly due to the recognition of a tendency to flat-foot, or a modification of it. Mr Catlicart pointed out that Surgeon-Major Black was mistaken in supposing that high heels prevented flat-foot, and showed that they actually tended to produce that deformity, by throwing a greater strain on the arch of the foot. He thought that Mr Cotterill had been too exclusive in associating the rigidity of the great toe invariably with flat-foot, and thought that it might be accounted for by the irritation caused by the wrinkle of the upper leather coming on to the great toe joint, perhaps combined with a too short boot. He felt that Mr Cotterill had demonstrated the necessary association of flat-foot with the wearing of boots, but thought that a similar result might be brought about by ill-fitting boots without the necessary accompaniment of flat-foot. Mr Macdonald Brown, in thanking Mr Cotterill for his able paper, said that the Society owed him a debt of gratitude for the lucid manner in which he had placed before it the various morbid conditions affecting the metatarso-phalangeal joint of the great toe. Up till the present time these had been confused and mistaken by different authors, and in his opinion Mr Cotterill had made out a good case for his " Hallux Kigidus." There was an anatomical point in connexion with the joint in question which, he was glad to notice, had been hinted at in the paper, viz., the condition of the so-called "glenoid," or plantar ligament. This, as was well known, was fibro-cartilaginous in nature, and any part which it played in the contracture (one of the most prominent features of the disease) must therefore be an extreme]y slight one. Mr Brown would venture to suggest an additional factor in the production of this contracture: the hallucine metatarso-phalangeal differed from the corresponding joints of the other toes not only in its greater size, but also in its cavity, consisting of a horizontal as well as a vertical part, the former being considerably the larger, and having in addition to ligaments, etc., sesamoid bones in its floor. In " hallux rigidus" this secondary synovial pouch must be crushed out of place as well as inflamed, and its cavity if not obliterated at least much altered. This, together with the subsequent contraction of the inflamed subserous tissue, would be capable of aiding in the production of the deformity. Dr Peel Ritchie, while agreeing generally with the explanation given by Mr Cotterill of the combined eS'ects of flat-sole and pressure, also thought that the form as well as the length of the boot contributed to produce the result. The pointed form of boot was objectionable, as it caused pressure on the joint. Dr Cotterill, in reply, reminded some of the speakers that he 280 THE STIFF GREAT TOE IN ADOLESCENTS. had specially guarded himself by saying that injury, gout, contractions of muscles, and other such causes, might undoubtedly cause stiffness in the joint of the great toe, but these causes could not possibly bring about the alteration of that angle of 30? of dorsitiexion which normally exists between the hallux and its metatarsal bone, and which is interfered with in all true cases of hallux rigidus as he had defined it to them, and as it had been described in the various papers on the subject. In reply to Mr Scott Lang, Mr Cotterill reminded the meeting that he had brought forward conclusive evidence to show that no amount of flat-foot, however extreme, could possibly cause hallux rigidus in the absence of boot confinement, and that therefore it could not be truly said that the condition was due to fiat-foot.