Accurate Nomenclature for Forefoot Nerve Entrapment. A Historical Perspective

Abstract

Current medical nomenclature is often based on the early history of the condition, when the true etiology of the disease or condition was not known. Sadly, this incorrect terminology can become inextricably woven into the lexicon of mainstream medicine. More important, when this is the case, the terminology itself can become integrated into current clinical decision making and ultimately into surgical intervention for the condition. “Morton’s neuroma” is perhaps the most striking example of this nomenclature problem in foot and ankle surgery. We aimed to delineate the historical impetus for the terminology still being used today for this condition and to suggest appropriate terminology based on our current understanding of its pathogenesis. We concluded that this symptom complex should be given the diagnosis of nerve compression and be further distinguished by naming the involved nerve, such as compression of the interdigital nerve to the third web space or compression of the third common plantar digital nerve. Although the nomenclature becomes longer, the pathogenesis is correct, and treatment decisions can be made accordingly.

In many cases, the diagnostic name given to a patient’s symptoms is also included in the nomenclature of the surgical technique used to treat the disorder. Until recently, patients who had not been adequately helped by conservative treatment for “heel spur syndrome” often underwent resection of the bone spur or inferior calcaneal exostosis [1-3]. Further adding to the confusion is that the terms heel spur syndrome and plantar fasciitis are still being used interchangeably by providers. If the cause of the patient’s heel pain is believed to be plantar fasciitis, or more correctly, “plantar fasciosis” [4], the first approach would logically be nonoperative. Failure of conservative measures would be an indication for division of the plantar fascia, with a choice between classic and endoscopic approaches [5-12]. It has been suggested more recently that heel pain, especially when recalcitrant to traditional approaches, may be due solely to a nerve compression, or to nerve compression in combination with other etiologies. After this diagnosis is confirmed, surgical intervention should be aimed at the most significant elements of pathology, and may consist of decompressing the appropriate calcaneal nerve [13-17].

When this construct is applied to the names given to the treatment of pain problems related to the common plantar digital nerves, or interdigital nerves, critical treatment choices are also implied. In 1876, Thomas Morton [18] described what he believed to be a painful condition of the fourth metatarsophalangeal joint, which he treated by resecting that joint and the “adjacent soft parts,” including the common plantar digital nerve to the third/fourth web space. It was appropriate for Morton to consider this swollen portion of a nerve to be neuroma, ie, the pathologic result of a nerve injury. It was reasonable historically for surgical treatment to be directed at resection of the injured nerve. Aided by light and electron microscopy, historical perspective has enabled us to consider that this metatarsalgia may be due to chronic nerve compression [19-21]. If the patient’s symptoms of pain related to the perception of a small, round object between the third and fourth metatarsal heads were termed chronic nerve compression of the common plantar digital nerve, then the appropriate surgical treatment might be to decompress this nerve rather than to resect it [22-25]. If one resects Morton’s “neuroma” and it recurs, then the surgeon will be treating a neural mass in the third/fourth web space that is truly a painful neuroma [26,27]. The indicated treatment is then to resect that neuroma and implant the proximal end into muscle in the arch of the foot [27,28].

The purpose of this article is to focus attention on the appropriate terms to be used for clinically painful conditions of the digital nerves to the toes in areas other than the third/fourth web space. Joplin’s name has been connected to a painful condition of the medial digital nerve to the hallux [29], Heuter’s name to a similar condition of the first/second web space [30], Hauser’s name to a similar condition of the second/ third web space [31], and finally, Iselin’s name to a similar condition of the fourth/fifth web space (Fig. 1) [32]. What did these authors actually describe, and what would the pathology of these conditions be considered to be today?

Historical Considerations

The painful condition of the foot related to the fourth metatarsophalangeal joint, which is commonly called Morton’s neuroma, is now being attributed to Civinini [33]. Civinini, a professor of anatomy at the University of Pisa, did describe something in 1835, written in “old Italian.” What he actually described are the gross findings in one cadaver. He described a fusiform (gangliare) swelling (rigonfiamento) in the common plantar digital nerve to the third interspace. There was, therefore, no clinical description or treatment involved in this report.

Durlacher [34], in 1845, in his treatise on corns, bunions, and diseases of the nails, discussed the management of this painful condition, but he did not give it a specific name. Lewis Durlacher was a surgeon chiropodist to the Queen of England, and his patient was King George IV.

In 1870, Heuter, in Germany, described pain associated with the common exostosis of the first metatarsophalangeal joint. He changed the name of this painful condition to hallux valgus, and he described a transfer of the abductor hallucis brevis muscle in its treatment. It is likely that pain associated with the common plantar digital nerve to the first web space, adjacent to the lateral sesamoid, was given this eponym. His work is cited in a book written by Vogel in 1877 [30].

Thomas Morton was an orthopedic surgeon practicing in Philadelphia, Pennsylvania. He worked at the Pennsylvania Hospital and the Philadelphia Orthopedic Hospital. In 1876 he described a series of 15 patients of his own and one of a colleague who all shared the same complaints, which he termed metatarsalgia and which he attributed to an injury to the fourth metatarsophalangeal joint [18]. He was a careful observer and recorded in detail the history of many of these patients. To illustrate the perspective of medicine at this time in history, it is worth noting that his manuscript is published between an article on a new version of the ophthalmoscope and a section on the treatment of syphilis with mercury. Morton’s first patient, for example, was seen in July of 1870, having injured her foot on a “pedestrian tour to the Valley of the Faulhorn Mountain, while descending a steep ravine.” The woman describes what happened:

I trod upon quite a large stone which rolled from under my foot, causing me to slip, throwing my entire weight upon the forward foot; though not falling, I found my right foot injured; the pain was intense and accompanied by fainting sensations. With considerable difficulty I reached the valley of the Grindenwald, where for hours I endured great suffering. After this I found it impossible to wear a shoe even for a few moments, the least pressure inducing an attack of severe pain. At no time did the foot or toe swell or present any evidence of having been injured. During the succeeding five years the foot was never entirely free from pain, often my suffering has been very severe, and coming on in paroxysms. I have been able only to wear a very large shoe, and only for a limited apace of time, invariably being obliged to remove it every half hour or so, to relieve the foot. Much of the time I have gone without any covering except a stocking, and even at night have suffered intensely; slight pressure of the finger on the tender spot causes the same sensations as wearing a shoe.

As Morton describes his sixth case, he introduces the term neuralgia to describe the patient’s complaints, eg, “the neuralgia was far more severe than in any of the other cases,” suggesting that he used this term descriptively, related to symptoms, rather than etiologically. This sixth patient, a Dr. Alison, from Hagerstown, Maryland, was seen in conjunction with two other physicians, Drs. William Hunt and Albert Fricke, who all concluded that

… the neuralgia was unquestionably located in and about the head and phalanx of the fourth toe; even the slightest pressure or handling could not be tolerated. The paroxysms of suffering which the doctor had, forcibly reminded me of those cases of severe facial neuralgia which I had several times seen in the second branch of the fifth pair of nerves.

Morton’s surgical treatment of this patient was described as follows:

After etherization, I made a longer incision than in the other operations, on the upper and outer side of the fourth metatarsal bone, the shaft of which was divided rather more than half an inch beyond the head of the bone; the base of the first phalanx was also removed; the toe was then found to be so isolated that at Dr. Hunt’s suggestion it was removed; the adjacent soft parts were dissected away to insure the excision of all the surrounding nerve branches, the wound was brought together with silver wire, and dressed with dry charpie. Dr. Alison was so well on the third day that he left for his home in Maryland.

For follow-up, at a time unspecified, Dr. Morton reports that “Dr. Alison writes; ‘Am happy to report all right; have not experienced any pain whatever, and am feeling better than I have for years, and feel assured that the operation will give me permanent relief.’” The pathologic examination, reported by Dr. Fricke, indicated that

… the nervous structures were all healthy, as proved by microscopic examination; the only abnormal condition I found was a small abrasion upon the articular surface of the fourth metatarsal with the phalanx, not sufficient it would seem, to account for the excruciating pain the doctor suffered.

Morton operated on three patients with chronic disease for whom “no other treatment except complete excision of the irritable metatarsophalangeal joint with the surrounding soft parts will be likely to prove permanently successful.” In the other two patients, the pathology showed normal nerves and joints. Of the other patients, one was too “infirm” to have surgery, whereas the others were treated with “vigorous local blood-letting, anodyne applications, with long-continued rest, until all sensitiveness of the joint has disappeared.”

It is of interest to read the letter of referral that Morton received from his seventh case. Her letter begins:

It has been in my left for thirty years, it is a painful condition. The pain is in and about the joint of the fourth toe, with occasional attacks of intense suffering, when the pain extends to the knee, and if my shoe is not instantly removed when that attack comes on, the pain reaches the hip. … It seems that the least pressure will produce the same result. … My eldest sister has been similarly affected still longer than myself, but in her right foot, same toe and joint. Two of my friends suffer in like manner at the present time. In one of the two cases, the pain is relieved by placing the foot on the ground with the shoe off, and thus spreading the toes.

Morton observed that of his 15 patients, 12 were female and that “it would appear the affection is not so uncommon, only that, as a distinct disease, it has not heretofore been noticed.” Eight of the patients had a “direct history of injury to the joint of the fourth toe. In three or four cases it originated from shoe-pressure; and in the remainder no cause for the pain was assigned.” Morton carried out cadaver dissections in male and female feet to attempt to understand the etiology of this problem. He concluded the following:

The peculiar position which the fourth metatarsophalangeal articulation bears to that of the fifth, the great mobility of the fifth metatarsal, which by lateral pressure is brought into contact with the fourth, and lastly, the proximity of the digital branches of the external plantar nerve, which are, under certain circumstances, liable to be bruised by, or pinched between the fourth and the fifth metatarsals, may be ascribed the neuralgia in this region.

Morton includes an anatomy drawing from Henle in which the medial plantar nerve contributes a branch to the lateral plantar nerve to form the common plantar nerve to the fourth (not the third) web space. Except for this reference to a medical illustrator, Morton’s manuscript has no references.

Iselin wrote in German in 1912, and his work has been cited in English in an article on pediatric orthopedic problems [35]. Iselin described a painful condition related to traction, which when exerted on the epiphysis of the growing child results in a painful condition he called apophysitis. It is possible that this caused pain in the common digital nerve in the fourth web space, leading Iselin’s name to be linked to “neuralgic” pain of this anatomical region.

Emil D. W. Hauser was an orthopedic surgeon from Winnetka, Illinois, who wrote a book entitled Diseases of the Foot in 1939; its second edition was published in 1950 [36]. In 1971, he described his series of patients with “interdigital neuroma.”31 He described the typical symptoms of the “metatarsalgia” to include

… persistent pain between two digits, the pain is worse with weight-bearing and characteristically, removal of the shoe gives some relief; at times, there is paresthesia or numbness in the toes; there is always tenderness with pressure over the lesion; and occasionally, a tumor is palpable.

He concluded that “the interdigital neuroma is a traumatic or inflammatory lesion, or both. It is the result of a mechanical disturbance of the foot and is usually associated with abnormalities of the foot.” Hauser described 116 “lesions” in 96 women and 4 men.

About 60 percent of the patients were between ages 40 and 60 years. The lesion occurred between the second and third toes in 52 percent of the patients and between the third and fourth toes in 44 percent of the patients. The other four percent occurred between the fourth and fifth toes. Eighteen patients had two lesions on the same foot, and in 14, there was a lesion in each foot.

The pathology demonstrated in his Figure 2, termed an interdigital neuroma, is correctly identified histologically as demonstrating “perineural fibrosis” and is not a true neuroma. Hauser’s operative technique is of interest:

A pneumatic cuff is placed around the thigh. A general anesthesia is used. … A small transverse incision is made of the involved interspace. The incision is elongated, proximally on the fibular side and distally on the tibial side. This permits a closure which will allow the skin to be lengthened. The tumor is readily exposed. The thickened branches of the digital nerves are carefully demonstrated. The branches are divided, and the tumor is dissected free. The thickened nerve is then traced between the metatarsal heads. To facilitate this, a special spreader is utilized, forcing the metatarsal heads apart for visualization of the thickened nerve. The nerve is divided proximal to the metatarsal heads. Frequently, the toes on either side of the neuroma are contracted. There is a dorsal extension at the metatarsal-phalangeal joint. After removal of the tumor, the contracted toes on each side of the interspace are corrected. … An incision is made through one-half of the tendon on one side and a second incision, dividing one-half of the tendon on the opposite side, is made 1 to 2 centimeters distally.

Hauser reported that all but five of the patients operated on were “relieved immediately. The patients who were not relieved had a localized endarteritis obliterans” in the nerve identified on pathologic examination. Those patients had

… symptoms and signs similar to those seen where there is a reflex irritation and stimulation of the sensory nerves. Treatment for this condition consisted of whirlpool baths, massage, repeated blocking of the superficial nerve with Novocain, and continuation of the use of corrective shoes. It took from six months to one year to obtain complete relief of the symptoms.

The only reference included in Hauser’s paper was to his own book, but it was not a specific reference to any given statement in the book.

Robert J. Joplin wrote about his experience with the medial digital nerve to the big toe in his presidential address at the first annual meeting of the American Orthopedic Foot Society in Chicago in 1971 [29]. He described his experience with a condition related to a digital nerve in the foot that “could eventually lead to a burning pain similar to that associated with chronic nerve trauma in other areas, as in Morton’s Toe Syndrome. To date, I have removed 265 fibrosed proper digital nerves.” Joplin clearly depicts the chronic damage to this branch of the medial plantar nerve, which has become injured beneath the abnormal structures related to the hallux valgus deformity itself or to the surgery performed to correct the deformity. He depicts photographically and descriptively the hypertrophic length of this nerve in relation to the tibial sesamoid and its treatment by resection of the nerve to a level, although not specifically stated, that would seem to locate the proximal end of the resected nerve so that it lies deep to the abductor hallucis brevis muscle. He typically would observe the nerve to be “enlarged and bound down by scar tissue.” Histologic analysis demonstrated “thickened fibrosed walls” surrounding the nerve, but not a true neuroma. Joplin’s diagnosis was “perineural fibrosis of the proper digital nerve.” His comments on the overall approach to this problem are worth quoting:

After I had explained to the patient how simple it would be to excise this superficial sensory nerve under ankle block anesthesia, she said she would like to try it. The operation was just as easily performed as predicted, the convalescence uneventful, and the patient completely relieved.

Joplin concludes his description of this clinical entity by saying, “I warn you to watch out for [this], because it can cause total disability and much suffering, all of which can be relieved by its excision; and the patients never seem to miss it.” Joplin’s manuscript has no references.

Figure 1 depicts the nomenclature that has been given to these interdigital “neuromas.”

Discussion

The results of the treatment of a painful condition of the common plantar digital nerve must be considered in relation to whether the pain is due to a chronic nerve compression or a true neuroma. For example, a recent discussion of the results of cryoablation for the treatment of lower-extremity neuromas combined Morton’s neuromas and dorsal cutaneous neuromas and recurrent Morton’s neuromas, clearly a mixed group of etiologies [37]. In contrast, other articles on the treatment of lower-extremity neuromas describe the results of a true neuroma to a single nerve [38-40] or to a group of nerves [41] so that the results can be judged without consideration of whether nerve compression examples are included.

The study by Levitsky et al. [42] provides considerable insight into the pathogenesis of compression of the common plantar digital nerves. They included in the title of their paper “interdigital neuroma,” but on dissection of 71 feet, they did not identify a true neuroma. Instead, they identified and measured swelling or thickening in the nerves, which they histologically demonstrated to be due to proliferative connective tissue and not to a true neuroma. They found that a communicating branch was present in just 19 of the specimens (26.8%). The common plantar digital nerve to the third web space originated completely from the medial plantar nerve in 51 of the 71 specimens. In 11 of the 71 specimens, the lateral plantar nerve contributed to the branch to the third web space. In 9 of the specimens, the medial plantar nerve contributed to the fourth web space common plantar digital nerve. Considering the word neuroma in the true Latin sense of a swollen nerve, they identified such swellings or neuromas in the second web space in 6 male and 20 female specimens and in the third web space in 12 male and 20 female specimens. The common plantar digital nerve was not thicker in feet with a contribution from the medial to the lateral plantar nerves and was not more common in feet with this communication. In contrast, they found that the intermetatarsal head distance and the ratio of this distance to the digital nerve diameter were significantly lower in the second and third web spaces than in the first and fourth web spaces. They credit Betts [43], writing in 1940 from Australia, with the hypothesis that “neuritis” of the third web space is due to the communication from the medial to the lateral plantar nerve in this web space, with the nerves curving around the flexor digitorum brevis muscle, anchoring these nerves proximally. This theory was successfully refuted by the data from the study by Levitsky et al [42].

There is another reason to determine the appropriate name for chronic compression of the common plantar digital nerves: in the literature of the future, compression of a nerve in the second/third web space should not erroneously be called Morton’s neuroma or Morton’s neuroma of the second/third web space. The most recent review of this subject, by Kay and Bennett [44] in the August 2003 issue of Foot and Ankle Clinics, agrees with this suggestion. However, they advocate using the name suggested by Weinfeld and Myerson [45] in 1996, interdigital neuritis. Such a name further clouds the treatment issue because it does not incorporate the accepted pathogenesis of the problem, chronic compression. Therefore, the simplest appropriate name is compression of the second (or third) interdigital nerve. It may require a subcommittee of the American Podiatric Medical Association or of the Journal’s editorial board to make this decision. It may be most appropriate to call the patient’s painful condition compression of the common plantar digital nerve to the … web space. A shorter name would be compression of the interdigital nerve to the third web space, and it could be noted that this particular site of compression used to be called Morton’s neuroma. This is descriptive but would permit treatment to be made appropriately and, of course, billing to be done with an International Classification of Diseases, Ninth Revision, code for compression or a nerve injury and for the surgical procedure to be coded either as neurolysis of a nerve or a neuroma resection, with or without muscle implantation. The appropriate codes for this are suggested in

Table 1. Linkage of ICD-9 and CPT Codes for Interdigital Nerves.

Clinical Diagnosis	ICD-9 Code	Surgical Procedure	CPT Code
Interdigital nerve compression	355.6	Neurolysis, foot, open	64704
		Endoscopic	64704-22
Interdigital neuroma	355.6	Neuroma resection	64784 or 28080
		With muscle implantation	Add 64787
Recurrent neuroma	355.6	Neuroma resection	64784
		With muscle implantation	Add 64787

Abbreviations: ICD-9, International Classification of Diseases, Ninth Revision; CPT, Current Procedural Terminology.

. Yet another reason for deciding on a name for this condition related to pathology is the suggestion from Italy that the “condition” be renamed “Civinini-Morton metatarsalgia” [46]. An article in support of relating the surgical treatment to the pathology of the interdigital nerve has been provided by Volpe et al. [47], who suggest neurolysis when the degree of nerve involvement is compression and resection when the pathology is related to the disruption of neural components.

Some final historical notes must be mentioned. R.K. Sandel, DSC, of Columbus, Ohio, in 1958, in a sixparagraph letter to the editor of the Journal of the American Podiatry Association, was the first, to our knowledge, to use the exact phrase Morton’s neuroma [48]. He described this condition in the second web space of one patient, and he went on to relate the anecdotes of Ramon D. Jacobs, DSC, of Detroit, Michigan, who stated,

… the frequency with which these problems occur in various locations is greatest between the 3rd and 4th digits, next, between the 4th and 5th digits, occasionally between the 1st and 2nd (especially in hallux valgus with displaced lateral sesamoid bone), and least commonly between the 2nd and 3rd digits. This is not just my own personal experience but is a composite opinion of most of the people with whom I have discussed this.

[48]

The article by Dewberry et al. [49] contains data from their own clinical series and from the study by Kite [50], which is similar to this and appears in

Table 2. Web Space Frequency of Interdigital Nerve Compression.

	Patients (%)
	Kite [50], 1996	Hauser [31], 1971	Dewberry et al. [49], 1973
Web Space	(n = 105)	(n = 116)	(n = 35)
Second	11	52	7.2
Third	89	44	88.0
Fourth	0	4	4.8

, which documents the frequency of compression of the interdigital nerves. Another article that shows the problem related to use of the word neuroma is the case report in 1972 by Levi et al. [51], in Hebrew, which shows a fracture of the fifth metacarpal on radiographs. However, the patient had symptoms in the web space between the third and fourth toes and had the interdigital nerve of that web space resected and reported as Morton’s neuroma. Finally, it seems that Hoadley [52], in 1893, was the first to resect the interdigital nerve to the third web space and call it a neuroma. His work has been quoted by Bickel and Dockerty [53] in 1947 as follows:

In 1893 Hoadley reported data on 6 cases of metatarsalgia. In one of his cases (II), in which the condition failed to respond to conservative treatment, he performed operation. His findings were significant. Unfortunately for patients suffering from this condition these findings were not generally known for nearly 5 decades. In the case in question Hoadley exposed the digital branches of the lateral plantar nerve to the fourth toe and found a small neuroma. He then resected the nerve. “A prompt and perfect cure” was obtained. He expressed the opinion that if operation was advisable, excision of the nerve was simpler and recovery prompter than excision of the metatarsophalangeal joint as advised by Morton.

A complete chronology of terms used for interdigital nerve compression appears in

Table 3. Chronology of Terms for Interdigital Nerve Compression.

Date	Author	Terminology Used	Pathology	Treatment
1835	Civinini [33]	Gangliare rigonfiamento	Nerve swelling	None
1845	Durlacher [34]	NA	NA	NA
1870	Heuter [30]	“Exostosis of first metatarsophalangeal joint” changed to “hallux valgus”	Bone	Osteotomy
1876	Morton [18]	Metatarsalgia of fourth toe	Bone	Excise joint (amputate toe)
1891	Bradford [54]	Metatarsal neuralgia, Morton’s affection of the foot	Bone	NA
1893	Morton [55]	Metatarsalgia, Morton’s affection of the foot	Bone	Excise joint (amputate toe)
1893	Hoadley [52]	Metatarsalgia	Nerve	Neurectomy
1912	Iselin [32]	Traction apophysitis, fifth toe	Bone	None
1940	Betts [43]	Morton’s metatarsalgia	Neuritis	Neurectomy (plantar)
1943	McElvenny [56]	Metatarsalgia	Neuritis	Neurectomy (dorsal)
1946	King [19]	Morton’s metatarsalgia	Sclerosing neuritis	Neurectomy
1950	Hauser [36]	Morton’s disease	Bone or nerve compression	None given
1951	Mulder [57]	Morton’s metatarsalgia	Metatarsal bursa	Neurectomy
1958	Sandel [48]	Morton’s neuroma of second toe	Nerve lesion	Neurectomy
1962	Bateman [58]	Morton’s neuroma	Nerve lesion	Neurectomy
1966	Kite [50]	Morton’s toe neuroma	Nerve lesion	Neurectomy
1971	Hauser [31]	Interdigital neuroma, second web	Nerve lesion	Neurectomy
1971	Joplin [29]	Proper digital nerve, first toe	Perineural fibrosis	Neurectomy
1972	Levi et al. [51]	Morton’s neuroma	Neuroma	Neurectomy
1973	Reed and Bliss [59]	Morton’s neuroma	Elastofibroma	Neurectomy
1973	Dewberry et al. [49]	Morton’s neuroma	Nerve injury	Neurectomy
1979	Gautier [22]	Thomas Morton’s disease	Nerve compression	Neurolysis
1982	Jahss [60]	Morton’s neuroma	Nerve lesion	Neurectomy
1983	Mann and Reynolds [61]	Interdigital neuroma	Neuroma	Neurectomy
1987	Miller [62]	Morton’s neuroma	Nerve lesion	Neurectomy
1991	Friscia et al. [63]	Primary interdigital neuroma	Neuroma	Neurectomy
1992	Dellon [23]	Morton’s neuroma	Nerve compression	Neurolysis
1996	Weinfeld and Myerson [45]	Interdigital neuritis	Nerve compression	Neurolysis
2003	Kay and Bennett [44]	Morton’s neuroma	Perineural fibrosis	Neurectomy or neurolysis
2005	Larson et al. (present article)	Compression of interdigital nerve	Nerve compression	Neurolysis

Abbreviation: NA, not available.

.

Conclusion

Review of the historical writings demonstrates that Morton did not describe a painful condition related to a common plantar digital nerve of any web space but rather a painful condition related to the fourth metatarsophalangeal joint. He treated this painful condition by resection of the joint and the nerves, probably on both sides of that joint. He also amputated one toe. Eponyms related to Heuter and Iselin are also related to joint or osseous pathology. No description of pain related to the interdigital nerve was ever due to a histopathologically proven neuroma; instead, those painful conditions were related to chronic nerve compression that is not related to interconnections of the medial and lateral plantar nerves to the common digital nerve of the third web space. Current understanding of the pathogenesis of pain arising from a common plantar nerve, the interdigital nerve, in any web space is due to chronic nerve compression, and it is appropriate to have the initial surgical approach be one of neurolysis rather than resection. Joplin described a painful condition arising from the medial digital nerve to the medial side of the hallux, which, owing to the extent of the pathology along the nerve and its structural adherence to bone from previous surgery, most likely should be treated surgically by resection, with the proximal end being placed deep to or within muscle. Recurrent pain after neurolysis of an interdigital plantar nerve or after resection of this nerve (which produced a true neuroma) is appropriately treated by resection of that nerve at a proximal level in the foot and implantation of the proximal stump into muscle in a nonweightbearing location, such as the arch of the foot.