Big Toe Swelling: Email Advice

Dear Dr Blake, 

     My big toe on my right foot is very swollen. It is about twice the size of a regular big toe. The swollen part is very warm, and very painful if I touch it .I can't wear a shoe on my right foot, it is very painful to even try to put a sock on my right foot. My toe and foot have been this way for over 2 weeks now. I'm still unable to wear a shoe. I can wear one of my husband's big socks. I do try to walk on my foot during the day, but the pain on the bottom and left side of my right foot is sometimes too painful to even try. I haven't been to a doctor, yet.....just like other people in  the USA, it's a money problem. I'm not asking for a 'hand out' or anything, like that. I would just like to know what's going on with my foot. Thanking u in advance for any help I can get from u for the diagnosis of my toe.

Regards,
Mari (name changed)

Dear Mari, 

     Pain and swelling in the big toe area is infection or gout until proven otherwise. There are also other more rare causes like fractures and sprains, but you would have had to know you did something to cause that. Please email back with answers to these questions:

1. Do you see any sign of an ingrown toenail that got infected? Did you cut your nails 4-5 days before the onset of pain? 
2. Do you have any infections in your body at this time or at the time of onset? Respiratory, urinary tract, etc.
3. Can you send a photo of both big toes?
4. Do you have any systemic signs of infection like fever, malaise, chills, or painful areas above your foot?
5. If you read about what causes gout dietary wise, is your diet high in purines? (see my post on foods that increase the chance of gout)
6. Do you tend to stay hydrated or not?
7. Is there a family history of gout or another systemic disease?
8. Could you have been exposed cold somehow?
9. How is your overall circulation in your feet and extremities?
10. Did anything happen in the 3-4 days prior to the onset of swelling like dropping something on your toe or starting a new exercise program or changing shoes?
11. Send me a close up on the nail itself please. 
12. What medications are you on for some can cause gout?

Hope this information gets us moving in the right direction. Rich

Varus Wedging for Excellent Pronation Control

Big Toe (Hallux) Soreness: A Method of Padding and Taping

Below is a video describing padding and taping for a painful big toe under the joint closest to the toe. This joint can get over stressed for several reasons--especially related to limitation of big toe joint motion and the presence of an accessory ossicle or sesamoid. Recently, a patient emailed me regarding pain in this area. I wanted to do this video for her especially, but I have many patients with this problem. 

Big Toe Pain: Inter-Phalangeal Joint---Email Advice

Hi Dr. Blake! 

     I am a 32 year old female whom recently started getting sharp stabbing pain under my big toe (not the large joint but the one in the first bend of the toe).

     I was diagnosed with an elevated first ray in my left foot and slight elevation in my right. I have some Hallux Limitus in the left so far, along with Hallux Valgus.
Dr Blake's comment: When the big toe joint has some limitation, then movement may be increased in the joint in front of (your painful area) or in back of (in the arch). 

Here are some of my questions:

1.  I am wondering what you would recommend for my particular condition?
Dr Blake's comment: You need to experiment with circumferential taping of the toe across the sore joint 24/7, padding either below (to bring the ground up), or to the side (classic dancer's pads), icing 2-3 times a day, figuring out if there are shoes that make it feel better (more padding, less flexibility, or more flexibility, etc), and cut out for the next several months activities that irritate it. I would at least get xrays to evaluate the area. 

2 Should I have surgery to avoid getting arthritis in the joint? (this has not happened yet)
Dr Blake's comment: I hear about preventive surgery, but I personally think that is mainly an oxymoron.

3. What brands of shoe would you recommend? 
Dr Blake's comment: You really have to play with this one. You have 5 parameters to deal with in a shoe, and some combinations will be the best. Set no preconceived notions. The 5 parameters are: padding, flexibility, width, toe box space and length. 

4.Can I still wear sandals so long as they have a back strap? 
Dr Blake's comment: Sandals, like any footwear, are fine if they do not increase the symptoms. Listen to your foot. 

5.I did stop trail running, as I don't want to end up crippled in my old age. I really appreciated coming across your site. No one seems to pay attention to this problem and it is terribly life-altering. I am devastated and having a hard time coping. I used to love running and being very active, so this is quite the blow, esp at such a young age. I appreciate any help you can offer. The doc hasn't told me how severe my condition could get. I do have my x-rays. Could I send those to you and get your opinion?
Dr Blake's comment: I would be happy to look at your films. Send to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. This problem does not tend to be that difficult to treat, so I guess I need more information from you. Try to send me 20 historical bullet points to review: How long, swelling, redness, duration after stop working out, etc, etc. Hope this helps some. Rich

Best,

Hallux Sesamoids: Email Advice

Thanks so much for this blog with many useful bits of info.

      I am 61 yr old active woman who noted a "callous" under my mid big toe with tenderness when in hiking boots for prolonged periods about 6 months ago. I was walking and doing pilates barefoot without pain.

     I saw a podiatrist last week  who did xray and showed a rare sesamoid under the  first joint (hallux inter phalangeal) in addition to the 2 sesamoids expected at the lower joint (big toe joint). Unfortunately it was fractured into 15 pieces by his count. He fitted me for orthotics which are due in 3 weeks. However, since then i have had a major flare up with pain and swelling not previously experienced. It is so bad that I cannot bear weight, and awake with throbbing pain in am. I suspect I aggravated something by squatting barefoot on counters while I painted kitchen cabs....

     My question is with this new onset sx should I be concerned about injury to tendons or joint now caused by the bony fragments? Since this sesamoid is rare, looking for info on what can go wrong and if treatment  is much different from other sesamoid fx. I read NSAIDs can interfere with bone healing, but wondered about a tendinitis as the culprit. Is the treatment of extra sesamoid fx pretty much the same as described in previous posts re non wt bearing? thanks.

Regards,

Dr Blake's response: 

     First of all, you have co-existed for 50+ years with these sesamoid flakes/fragments, without any problem so I think you will co-exist another 50 years or so (God willing!!) with them. When squatting you placed too much pressure on the area, and something (sesamoids, joint, tendons, nerves, ligaments)  got angry at you. Even though these sesamoid bones are there, who knows if they are the problem. Since it would be rare to have to remove these, they are probably not your problem. This is an educated guess, that any one has a right to change with my blessing at any time. 

     So, first thing you have to do is create a pain free environment to allow whatever to heal. If this takes crutches, shoes, orthotics, and/or removable boot, you have to start treating the pain. Then, you work on the inflammation with icing, contrasts, PT, oral meds (okay in this case), accupuncture, topical meds, etc. Once you get your orthotics, make sure they are modified to completely protect the area as you walk, even if you have to go to a shoe size bigger for a while. 

     In terms of diagnostic tests that I do, MRI and local anesthetic injection into the joint. The injection is easy, you place 1-2 ml of local anesthetic into the joint from the top and see if all your pain is gone. If so, you know that pain comes from inside the joint. If not, the pain is not coming from the sesamoids, but the external ligaments, tendon, or nerves. 

     MRIs are not perfect for toes, so I would only get if I needed more information because I did not have a game plan I was convinced of. The reason they are not great is the slices are 3.5 mm and you can miss the area of pain. Also, all parts of the soft tissue are near the skin, and the skin can allow in too much light (artifact). 

     So, for the next few weeks, create your pain free environment, use various forms of anti-inflammatory, create an orthotic base that protects the spot, and then gradually increase your activity. I sure hope this helps. Rich