Pain in the Big Toe!!!

The idea for this latest blog was sparked by a visit to our office by a local doctor yesterday. What started as a very pleasant self introduction, eventually lead to a discussion about his chronic and progressively worsening pain in his right hallux or big toe joint to be precise. The more he talked the more aware i became that this is such a frequently reported condition, syndrome….. problem, that it might be worth describing to you.

Typically these patients are in their mid 30s to early 50s, very active, healthy and of normal body weight. Most commonly their activities include field or court sports. With an increasing number involved in those sports with a very restricted surface area, for example squash, tennis, racket ball, basket ball, indoor soccer, and paddle tennis (if you have ever heard of it, i hadn’t). The pain is initially localised to the 1st metatarsal phalangeal joint, ( big toe joint ). Usually it presents after the sporting event is over or the next morning, and the episode may last a few days. Often in its initial format it is grudingly accepted as the price of remaining active in the face of approaching mid life.

Later the episodes last longer, become more intense, and are no longer responsive to oral anti-inflammatories. Dress shoes irritate the joint further, and even normal walking becomes increasing painful.  Eventually when the pain limits the ability to participate in recreational activities, finally it time has arrived for the warrior to seek help!!.

Generally what is happening here, is a case of deteriorating functional hallux limitus. In lay terms the chaps have a mild or moderate mechanical instability which causes their foot to roll in more than is ideal, and as the muscles loose mechanical advantage the big toe joint jams and the surfaces slam into each other. Slam isnt a bad discription when you consider the extreme forces delivered in the rapid changes of direction that take place in these sports.

Structuraly this increasing discomfort is as result of diminished articular cartilage and osteophytic lipping of the joint margins. which once again in lay terms the cartilage is wearing away and around the edge of the joint new bone is being layed down which ultimately reduces the range of movement of the joint. Regretably the images below follow the progressive deterioration of one individuals right hallux over only an eight year span. Dispite diagnosis he resisted treatment until his everyday life became overshadowed by the pain in his hallux. Fortunatly he is also a good friend who stubbornly admits to living his life non proactively. Incidently he originally presented to our office with a diagnosis of gout.

Unfortunatly once lost the cartilage cannot be replaced and likewise the new bone growths can be surgically remodeled but in all likelyhood will reform. There is no single better treatment in this situation than that of prevention.

Prevention comes in various forms. The first of which is the proper diagnosis of the underlying structural deformity that caused the mechanical instability. Once armed with this information, changes can be made in footwear habits and design. Funtional orthotic intervention is next and the actual prescription will largely be dictated by the structural origin and the degree of distruction and funtional limitation. Finally physical therapys,  possibly medications, injectable,orall and/or topical, and lastly surgical.

The last thing we want to do is limit or modify your activity. Its hard to find a physical outlet that you can passionately enguage in, so we would rather you present yourself to a chiropodist or podiatrist long before that end stage so you can work togeather to be pain free and fully functional.