Static Foot Deformities
Hallux Valgus with Inflamed Bunion.—Scudamore in his “Treatise on Gout” observes that “the bursal disease over the first joint of the great toe, which is familiarly known as bunion, is a very common complaint with gouty persons.” In view of the fact that no reference is made in the context to the absence or presence in such cases of a condition of hallux valgus, one is led to believe that Scudamore overlooked the deformity and regarded the local bursitis as the outcome of a gouty inflammation of this structure.
Bradford and Lovatt, discussing hallux valgus, observe: “There may be pain and irritability in the great toe joint, and in severe cases extreme pain and difficulty in walking, which is usually attributed by the patient to gout.” We would only qualify this statement by the fact that the local heat, redness, and swelling that in this condition so often follow slight injuries or excessive walking is not only so interpreted by the patient, but far too frequently also by his medical attendant.
Routine examination of the bare foot will minimise the chance of such a fallacy, though of course it must be borne in mind that a gouty subject may present this deformity. But when we recollect that hallux valgus of slight degree “is almost universally present after middle childhood,” we see that, given the presence of this static foot deformity, any inflammatory process in the superjacent structures is infinitely more likely to be due to an inflammatory bursitis than to a gouty arthritis.
Given an inflamed bursa with cellulitis spreading over the dorsum of the foot, confusion with acute sthenic gout is all too easy. But in our experience, mirabile dictu, the ordinary more or less chronic circumscribed redness over the bunion is but too commonly misinterpreted as gout, this particularly in women, despite the rarity with which gout attacks their toe and the frequency with which their footgear is precisely adapted to produce hallux valgus. Given therefore the presence of this static foot deformity, we should in the absence of objective stigmata of gout, viz., tophi, suspend our diagnosis pending observation of the results obtained by local treatment of the displaced toe.
Hallux Rigidus.—This deformity is but too often overlooked, and if marked by pain and more or less rigidity of the first metatarso-phalangeal joint, it may, in lack of adequate examination, be flippantly dismissed as “gout,” this more particularly in its later stages, when, in addition to pain and stiffness therein, the joint is swollen, tender to the touch, and the bony ends actually enlarged. Here again local examination, if carefully carried out, will suffice to obviate such errors, while the quick response to rest and appropriate applications, with correction of the frequently associated sunken arch, will sufficiently attest its true nature.
Metatarsalgia.—As pointed out in our previous work on Fibrositis, “this painful condition is more often than not confused with rheumatism or gout.” We have known subjects wander to nearly every spa on the Continent under such a misconception. Not to mention the financial expense, the dietetic penances imposed, the consequences of such faulty diagnosis, are by no means trivial, for the intensity of the suffering may reduce the walking capacity to a minimum.
The neuralgic pain radiates into the toes and often upwards into the leg, usually comes on while walking, and is relieved by the removal of the boot. For its detection any altered relationship in the position of the third, fourth, and fifth metatarsals, especially their displacement to a lower level than normal, should be noted, and any limitation of the power of dorsal flexion of the foot likewise estimated. The presence of callosities under the heads of the metatarsals is very suggestive of this painful condition.