The history behind the diagnosis of Morton's neuroma
This is the first of a four-part series of blog posts dedicated to a better understanding of Morton's neuroma. I'd like to take a conversational approach with the topic and share some of my experiences as a podiatrist with 30 years of practice. Although the medical literature is helpful in understanding Morton's neuroma from a scholarly standpoint, I think the medical literature sometimes leaves out some of the subtleties that need to be shared regarding the diagnosis and treatment of Morton's neuroma. This first of four posts will focus on the history of Morton's neuroma. The second blog post will explore the diagnosis of Morton's neuroma. The third post will discuss conservative treatment of Morton's neuroma. And the fourth and final blog post will discuss surgical correction of Morton's neuroma.
Background of Morton's neuroma
Morton's neuroma goes by many names including Morton neuroma, Morton's metatarsalgia, Morton's toe, Morton's neuralgia, plantar neuroma, intermetatarsal neuroma, interdigital neuroma, and perineural fibroma. Despite the suffix, 'oma' which usually refers in Latin to a tumor, Morton's neuroma is a focal swelling of the interdigital nerve caused by an entrapment of the nerve against the transverse intermetatarsal ligament. Morton's neuroma is most commonly found in the forefoot with symptoms between the third and fourth toes. Pain is limited to the plantar (bottom) forefoot.
History of Morton's neuroma
The term neuroma was originally coined by Queen Victoria's surgical chiropodist Lewis Durlacher, in his 1845 book, A treatise on corns, bunions, diseases of nails and the general management of feet. (1) Durlacher described the condition as "a form of neuralgic affection". Morton's neuroma was first documented in the medical literature in 1876 by Philadelphia physician and surgeon Thomas G. Morton, professor of orthopedics surgery at the Philadelphia Polyclinic.(2) Dr. Morton is described as faculty of the Clinic and surgeon to the Pennsylvania Hospital and to the Orthopedic Hospital and Infirmary for Nervous Diseases. (3) Although Morton accurately described the symptoms of this condition, he concluded incorrectly that the condition was due to capsulitis of the 4th metatarsal phalangeal joint. Interestingly, T. G. Morton was also a pioneer in the diagnosis and surgical care of acute appendicitis. Although their relationship is unknown but presumed to be the son of T.G Morton, Thomas K. Morton also described the condition in 1890. T.K. Morton was professor of clinical surgery, surgeon to the out-patient department of the Pennsylvania Hospital, assistant surgeon to the orthopedic hospital and consulting surgeon to the Philadelphia dispensary. (3) In 1883 Hoadley was the first surgeon to intentionally excise a Morton's neuroma of the foot. (4) And in 1940, L.O. Betts confirmed in the literature that the symptoms of Morton's neuroma were indeed nerve pain and not capsular pain. (5)
It's interesting to note that most medical conditions will evolve over time, based upon new methods of treatment or new understanding of the condition. In the case of Morton's neuroma, once the condition was described and basic treatment methods applied, the ways in which we treated Morton's neuroma didn't change appreciably between 1845 and 1990. The chiropody literature is incomplete and doesn't describe a history of treating Morton's neuroma with conservative measures such as padding or shoe modification. The orthopedic literature leans upon Betts's description of surgical excision. Like the old surgeons used to say, "when in doubt, cut it out." As such, the treatment of Morton's neuroma remained unchanged for a century before newer, more recent methods of care evolved. More on that in my upcoming blog on the surgical treatment of Morton's neuroma.
Related blog posts:
1. Durlacher, L. A treatise on corns, bunions, the diseases of nails and the general management of feet: Marshal and Co., 1845.
2. Morton TG. The Classic. A peculiar and painful affection of the fourth metatarsal-phalangeal articulation. Thomas G. Morton, MD. Clinical orthopedics and related research 1979:4-9.
3. The Philadelphia Polyclinic Vol. 4. 1895
4. Hoadley AE. Six cases of metatarsalgiaChicago Med Rec 1893;5:32.
5. Betts L O. Morton's metatarsalgia. Med J August 1940;514-5.