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Big toe pain

I am a runner and after a race I had a pain in the big toe on the bottom just above the bend (about even with the nail bed). It hurts to press in one spot. Had xrays and MRI neither showed fracture. Used exercise bike v/s running for 3 weeks and wore a carbon fiber insert to keep foot from bending (as pressure causes the pain. Switched to boot as no improvement was being noticed. Been in boot over 2 weeks and still point tender at the same spot. No improvement has occurred in over 6 weeks. Doctors say they aren't sure what it is. Any ideas? I have races coming up in 4 and 6 weeks and just want some answers. Is it a bone bruise? Stress reaction?



Well....without actually examining you I certainly have no idea what is actually causing your pain, but I will be happy to give you some thoughts on what it might be and then you can confer with your doctors, hopefully one of whom is a podiatrist.

Three potential things come to mind.

The first would be a flexor tendonitis which is an inflammation of the tendon that runs on the bottom of the big toe which allows the big toes to bend downward. The MRI may or may not have shown tendon effusion (swelling of the tendon) that would have been diagnostic of the tendon being inflamed.

If you pull your toe upwards, towards your nose, the flexor tendon should begin to hurt since you are essentially stretching it. As you pull the toe upwards and then press with your other finger on the bottom of the toe, that too should cause pain.

The other possibility and this is where a podiatrist comes in handy, is a possible cartilaginous growth that occurs in some people on the bottom of the toe at the level of the toe joint. Sometimes it is fully palpable and you may even be able to move it from side to side.

Because of where it is located it is subject to the daily pounding of walking and running could certainly exacerbate the problem.

Next on the list of possibilities is a problem that may be coming from the joint where the big toe attaches into the foot. This is known as the first metatarsal phalangeal joint.

I do not know how old you are but many people both athletic and non-athletic will start to develop arthritic changes in this joint. As the joint becomes more arthritic the big toe loses its ability to bend upward and so when you walk or run, the big toe essentially cannot move out of the way and you may start to get pain on the bottom of the big toe simply because it is continuously getting pounded into the ground. This too, would be a condition that a podiatrist would be most familiar with.

As I mentioned earlier, I have no idea what you actually have going on, but walking around in a boot apparently not doing it for you.

You really need to have an adequate biomechanical exam by a foot specialist to determine the exact cause of your pain, because if you do not properly identify the source, you stand very little chance of clearing up the problem.

Part of the problem could be the way you actually run, part of the problem could be coming from your running shoes. For example, if your running shoes are too flexible where they bend at the ball of the foot, then this would exacerbate the problem.

If the big toe joint is arthritic, causing limited range of motion, that too will have to be addressed.

I do not know if it has been offered to you, but a cortisone injection on the bottom of the toe could possibly be helpful for all the conditions I just mentioned. A fracture would be the only diagnosis where a cortisone injection would be contraindicated.

It sounds like you have rested the toe long enough and that you may require a more aggressive approach, but first you have to get a proper diagnosis.

Marc Mitnick DPM

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