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Toe pain

Dr. Srishti GuptaMBBS

April 13, 2021

April 13, 2021

Toe pain
Toe pain

Pain can arise in one or more toes of the feet with or without the involvement of other parts of the foot. Toes can be affected in isolation, like big toe pain or second toe pain, or with more widespread involvement of other digits. The most frequent causes of pain in the toes involve mechanical injury or age-related wear and tear, and subsequent inflammation of the skin, toenails, muscles, bones, joints, tendons and ligaments of the toe. Sometimes, the pain of the toes can be neuropathic (stemming from the breakdown, injury or other diseases of the nerves of the foot) and presents with tingling, burning, a feeling of pins and needles pricking the skin or loss of sensation. While mechanical injuries of the forefoot and toe are common, some systemic diseases (diseases affecting the whole body) also affect the toes in a telltale manner. For example, an acute attack of gout typically presents with a swollen painful big toe that often wakes the patient up in the middle of the night. Gouty arthritis of the big toe is called podagra. Another cause of toe pain can be infection of any of the components of the digit. Some orthopaedic conditions that affect the toes arise due to a similar pattern of injury in susceptible individuals (like athletes and dancers). Pain may arise with or without noticeable physical changes. Although pain can subside spontaneously, if severe or accompanied by other signs and symptoms, it is wise to seek medical care. 

One can approach their primary physician with their complaints and can then be referred to an orthopedician, rheumatologist or podiatrist as per the need of the situation. Overall, the medical practitioner begins by making an assessment of the patient by taking a thorough medical history, conducting an extensive physical examination, ordering laboratory investigations, and radiological imaging of the foot. After reaching an accurate diagnosis, treatment is carried out through lifestyle changes, medicines, physiotherapy, occupational therapy or even surgery when necessary.

Signs and symptoms of toe pain

While toe pain itself could be a symptom, others could accompany it depending on the underlying cause. Some you may notice are mentioned below:

  • A hard, swollen, or tender toe
  • Hot, swollen, tender and red joint
  • Fluid buildup in toe 
  • Soreness of the toe
  • Overgrowth of skin around the toenail 
  • Darkening of the skin on the toe particularly around the toenail 
  • In case of an infection, oozing yellow pus may be seen 
  • Bleeding 
  • Pain
  • Stiffness of the joint
  • Ecchymosis (discolouration of the skin due to rupturing of delicate blood capillaries)
  • Bruising 
  • Weakness or complete inability to flex the big toe (i.e. bend it down towards the floor)

Causes of toe pain

The following conditions are known to cause toe pain:

  • Dermatological causes of toe pain affecting the skin over the toe and toenail:
    • Ingrown toenails: Toenails that grow into the surrounding skin of the toe and cause pain and can become infected.
    • Paronychia: Infection of the toenail (typically bacterial but can also be fungal) that causes pain and can lead to more serious complications like bone infections (osteomyelitis).
    • Bunions: A deformity at the joint connecting the big toe to the foot (first metatarsophalangeal joint) that causes the big toe to bend inward the other toes and a sharp angle is created at the inner border of the foot at the big toe. The big toe is red and painful.
    • Corns or calluses: Due to repeated rubbing and frictional injuries, the skin of the foot thickens and corns and calluses are formed. The toes (especially the big toe and the fifth toe) are commonly affected by this painful condition.
  • Systemic disease causes of toe pain: 
  • Orthopaedic causes of toe pain involving the bones, ligaments, tendons and joint capsules:
    • Capsulitis: The capsule covering the joints of the toes can become inflamed causing pain, swelling and redness. 
    • Hammer toe: A deformity in which one of the small toes develops a bend at the joint between the first and second segments so that the tip of the toe turns downward, making it look like a hammer or claw. The second toe is affected most often. 
    • Turf toe: A deformity of the big toe that occurs due to an injury, causing the toe to bend upward toward the ceiling unnaturally. 
    • Sesamoiditis: Inflamed tendons of the foot
    • Fracture: Either due to acute trauma or injury or due to long-standing stress injuries, fractures can occur to the bones of the toe. These can be minor hairline fractures or complete avulsion fractures. 
    • Freiberg disease: Due to loss of blood supply to the bone of the second toe, avascular necrosis (death of the bone) occurs, producing pain.  
    • Some other deformities of the toes following typical injuries that produce pain include: 
      • Reverse turf toe
      • Soccer toe
      • Hallux rigidus
      • Hallux limituxs
  • Neurological causes of toe pain:
    • Morton’s neuroma: One of the nerves innervating the toes becomes thickened and tumour-like swelling develops in it. This produces a burning pain in the ball of the foot that usually extends to the toes (typically the third and fourth toe of the foot but other toes can be affected as well).

Diagnosis of toe pain

Toe pain can occur due to many causes and assessing accompanying symptoms can aid in diagnosis. One major cause can be gout, which carries the following risk factors:

  • Alcoholism or excessive daily alcohol consumption
  • Diet consisting of foods rich in fats, red meats and seafood
  • Use of thiazides diuretic medicines (for high blood pressure treatment) like bendroflumethiazide
  • Family history of gout
  • Other lifestyle disease like hypertension, diabetes or hypercholesterolaemia (raised blood lipids)

Depending on the clinical assessment, some of the following tests may be ordered:

  • Joint synovial fluid aspiration: The diagnosis of gout is made upon the demonstration of monosodium urate (MSU) crystals in the joint synovial fluid.
  • Radio imaging with X-rays of the foot can be done to rule out some causes of toe pain. A foot X-ray will demonstrate a tear in the ligament, fascia, or capsule along with a possible joint dislocation at the big toe.
  • A sample of pus material may be taken from the toe for culture and sensitivity studies in order to prescribe the most effective antibiotic to clear an infection up.
  • Serum uric acid test: A few weeks after the attack of gouty arthritis resolves, the uric acid level is checked to start long term therapy. However, the test is not of any use during an attack.
  • Orthopaedic examination: Special tests are conducted to assess the range of motion and stability of the big toe and the affected joint.

After the diagnosis has been made the treatment consists of medications and supportive therapy.

(Read more: Home remedies for corns)

Treatment of toe pain

Depending on the underlying cause, medical treatment of toe pain may include:

  • Pain relief: Mild over-the-counter analgesics like ibuprofen or paracetamol are usually sufficient. If the pain is not relieved the doctor may prescribe stronger medicines.
  • Topical antibiotics: Polymyxin and neomycin (components of Neosporin) may be applied over the toe to prevent infection. Steroid ointments prescribed by the doctor can also help prevent infection.
  • Antibiotics: In case of an infection of the toe, oral broad spectrum antibiotics may need to be started and, on the arrival of pus culture and sensitivity reports, upgraded to the appropriate sensitive antibiotic. The use of oral antibiotics depends on the severity of the infection and may be foregone in milder cases.
  • Corticosteroid injections: An inflamed joint not responding to oral therapy may require an intra articular (into the joint) injection of corticosteroid for pain relief.
  • NSAIDs: Aspirin, acetaminophen or ibuprofen can control the pain and other inflammatory symptoms of a gout attack till it resolves.
  • Colchicine: Another drug that is used for acute symptom relief is colchicine. It is better suited for people who cannot tolerate NSAIDs such as those who suffer from peptic ulcers, gastritis or asthma.

Surgical treatment: Surgical treatment like a matrixectomy (procedure to partially or completely remove toenail) may be needed if conservative treatment fails and if the injury is extensive. After the operation, analgesics, antibiotics and bandaging are mandatory. Daily salt water foot soaks and open-toe shoes are recommended. Toenails grow back in a few months following a partial removal but can take up to a year or more after a complete toenail removal.

Physical rehabilitation: After an injury, the big toe is taped in place, after being bent slightly downward toward the floor (plantar flexion) to prevent its dislocation. Three to 5 days after the injury, moderate-intensity passive bending of the big toe should be started, making way for more intensive strengthening exercises. The aim is to restore the range of motion of the big toe joint. Pulsed ultrasound therapy, if available, can be used to hasten healing in some cases.

Supportive treatment: Depending on the cause, some of the following measures may be recommended to hasten healing and prevent complications.

  • Soaking feet in warm water for 15 to 20 minutes at a time 3 to 4 times per day helps in healing and pain relief.
  • Feet should be kept clean and dry.
  • Ideally, footwear that is open at the toes should be worn.
  • Alcohol consumption should be reduced.
  • Avoiding smoking may help.
  • Limiting unhealthy foods like red meat and seafood may prove to be useful.
  • Patients should increase activity and follow a healthy diet.
  • Resting, icing, compressing and elevating the foot (or affected limb) should be done.

(Read more: Home remedies for gout)

Complications of toe pain

Mild toe pain that doesn’t have a serious underlying cause may not result in any severe complications. But as toe pain can be caused by a variety of conditions, if severe cases are not treated on time, they could result in the following:

  • Toenail infection
  • Infection of the bones of the toe (osteomyelitis)
  • Foot ulcers
  • Open sores
  • Chronic pain
  • Loss of blood flow to the infected area
  • Loss of toe
  • Permanent nerve damage

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