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Sunday, April 5, 2015

Big Toe Joint Pain: Email Advice

Hi Dr Blake,

I've been a reader of your blog for a while now, just wanted to
thank you for putting all of this info out there, it is extremely

So I'm hoping to get some feedback about a recent toe injury. About me:
I've been an avid tennis player for a few years (play 3-4 times a week)
and am currently 38.  

About 2 weeks ago, I noticed that after playing my left big toe felt a 
little tender, but the next day the tenderness was gone.  Then a few days 
later I played again and this time after playing this feeling came back 
but was worse, in addition to feeling tender now I noticed that there 
was some swelling/aching. When I pushed off on the left foot it was 
even a little painful. Not acute, just sort of a dull ache feeling.  Well 
this time the swelling didn't go away.  So I scheduled an appointment 
with my doctor (podiatrist) and he did some poking and prodding and 
said it seemed ok, that I should just rest. He even took some x-rays 
(from the top of the foot) and said nothing was broken, that the sesamoids 
were fine and the joint looked good, that I should just rest.

So for the past 1.5 weeks I haven't played tennis, I've just done swimming
and biking (biking I put the middle of my foot on the pedal so most of
the weight is near my arch).  I've also been icing 2-3 times a day and
really trying to immobilize the joint. The problem, is that the swelling /
tender feeling hasn't subsided. Not at all.  I especially notice an issue
when I put weight on the ball of my foot, it's not painful, but it feels
really tender.  It is even more obvious if I go up on my toes.  My toe
joint doesn't feel stiff, there is no bruising and I appear to have full
range of motion.  If I sit down and move the toe up and down without 
weight on it, no pain at all.

So given these symptoms, do you have any hunches about what the issue
might be?  Aside from continuing to ice and keep the joint immobile, is
there anything else I can do?  (I'm spica taping but that doesn't seem
to help much).


Dr Blake's comment:
     Thank you so very much for your email. X-rays are poor indicators of anything serious within the joint, but it was the most appropriate test to do at that stage. You did well to get in to see someone so early. I love the 3 day rule: If pain does not go away after 3 days, you have to do something to try to change the course of the injury. Remember icing only controls swelling, never really gets rid of it. I love 2 times a day of 10 minute ice pack, but at least one time a day of straight contrast bathing to flush the tissue. 

You have to assume that you have a stress fracture because of the potential of overuse playing hard tennis 3-4 times a week, and how quickly this went from no pain to a lot of pain. Definitely check your shoes and make sure they are not worn out. Check the inserts in the shoes and see if there are holes in the area of pain. See if you can design a "dancer's pad" to take pressure off the area, probably will need it on both sides for balance as you start to go back to tennis. 

At this point in the injury typically more x-rays will not help. An MRI is normally recommended if 2-3 weeks pass with little or no improvement. Of course, if you were a Golden State Warrior, you probably would have already had 2 MRIs. So, if you are anxious, you can request it now. You can also treat the injury as a stress fracture, typically requiring a minimum of 6 weeks in an Anklizer Removable boot  (can be purchased online) with an accommodation for the big toe joint. 

So, make sure you are getting the calcium and Vit D3 you need. Avoid NSAIDs and cortisone shots if possible, since they can slow down bone healing. If you do not have custom orthotics, you may want to consider them to off weight the big toe joint, although some OTC inserts can be customized to do the same thing. 

I sure hope this helps point you in the right direction. It is never bad while you wait on a diagnosis (which you do not have), to continue to create a pain free (0-2 level pain) environment for proper healing whatever it takes. You are doing the correct thing with the bike pedal adjustment. Sometimes, you only need the boot for work when you do not want to think about it, and tennis shoes with dancer's pads for after work. Good luck, Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.