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. GOUT IN THE INSTEP Next to the metatarso-phalangeal joints, the _tarsal_ articulations are the most frequent site of _initial_ attacks of gout. Here again we would insist on the necessity of excluding _infections_ of the _tarsal joints_ or _shafts_ and even more important, _static foot deformities_. _Gonococcal Arthritis._—In a table compiled by Garrod from those of Foucart, Brandes, Rollet, and Fournier, the relative frequency of the implication of individual joints in gonorrhœal arthritis shows that out of a total of 119 the _tarsus_ and _metatarsus_ were attacked in five instances. In the more acute cases the periarticular swelling, local heat, and pink blush may be confused with _acute gout_. The resemblance is enhanced in that, as in gout, the overlying _tendon sheaths_ are liable to become inflamed and distended with fluid. _Tuberculous and Syphilitic Disease of the Tarsal Joints or the Related Joints._—In cases of obscure pain and inflammatory trouble in the instep the possibility of arthritic and bony lesions of this nature should not be overlooked, especially if there be suggestive lesions elsewhere, or if the history afford evidence of the possibility of such contingencies. _Pes Planus._—In all cases of pain and swelling, with or without redness, in the instep, it is well to recollect that, though flatfoot may for a long time exist without giving rise to symptoms, it frequently happens that, in sequence to some unusual strain on the plantar arch, the static disturbance in the foot enters quite _abruptly_ on a _painful_ phase. Congestion and swelling of the foot is common, and actual teno-synovitis of the tibial and peroneal muscles is not infrequent. Tenderness, too, at points of ligamentary strain is almost always present, and more or less constant pain.[40] The frequency with which the _local_ and _referred_ pains of _flatfoot_ are misinterpreted as “gout” and dietetic restrictions and other useless and uncalled-for methods of therapy enjoined is well exemplified by a case which has just left our consulting room.