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What is causing my pain in the knuckle of the big toe, just below the toe nail?

by AmyC
(Saint Paul, MN)

At night I have a variety of pains in the top side of my big toe on the right foot. It starts with a feeling similar to a loose Band-Aid pulling loose when my foot is at rest. That's not painful, but annoying. As the night continues, the same spot starts to develop stabbing sessions of "electric" shocks that are painful and cause toe spasms and foot jerking. Later, the toe becomes really painful, mostly when pointed rather than when flexed (although that hurts, too). The pain has been increasing in pain steadily over the last week and disturbs my sleep. It's very localized to the area just below (but not under) the toe nail on the top of the toe.

The pain is distinctly NOT in the nail bed or the bottom of the foot/toe. I don't have any visible swelling nor have I ever had gout. I'm a mid-40s woman who has had heel bursitis recently. I've recently had my foot x-rayed and there is no break or fracture in the foot or toe.

I'd like to determine the cause and if there is anything I can do to relieve the pain. Thank you for any insights you can provide.


Hi Amy,

It appears that you are having a lot of different sensations in a very small area. The good news about that is since a small area is involved there is a small number of anatomical structures to consider.
You mention that the affected area is not red, hot or swollen and if that is the case then there is no inflammatory process going on. That would tell me that the joint (interphalangeal joint) is probably not affected, such as in the case of an arthritic flare up, as an example.
So making the assumption that the joint is not involved and the nail is not involved then we are really limited in what might be causing the problem.
The three main structures that would need to be considered would be the extensor tendon that travels along the top of the toe and attaches into the bone just behind the nail. That could be part of the problem but I doubt it for the simple reason you state your problem occurs at night and you make no mention of having the problem during the day.
That leaves us with the artery and nerve that travels into the toe. Unless your toe is changing color during these episodes, such as either very red or very pale, then I doubt it is an arterial problem. (I am making the assumption you are not a smoker).
That leaves us with nerve involvement. Descriptions such as "electric shocks" is very indicative of nerve irritation.
From someone looking at this from the other side of the internet, it sounds very much like a neuritis or irritation of the nerve that travels into the toe. There are actually more than one nerve, but it sees your problem is coming from the one that is on the top inside portion of the toe.
If this is the case, the problem may be stemming from one of three places. The first might be the lower back. You could have a radiculopathy which is an irritation of a nerve where it comes out of the spinal cord. Sleeping in a certain position could be straining the angle of the vertebrae and causing this type of sensation.
The other place and probably the more common place that the local nerve is being irritated is at the big toe joint. If you have any type of arthritis in the big toe joint (bunion) the nerve may be getting irritated particularly when your foot lies in a certain position and this too may set off the problem. Lastly, there is always the possibility that the nerve is being irritated at the exact point where it is bothering you.
Now, you mention you have had this problem for a short term. You may find that as quickly as it came, it disappears.
I would suggest you see a foot specialist in your area and ask about the possibility of a neuritis as the source of your problem. If the doctor concurs then there is treatment available. Just to be on the safe side, ask the doctor to check the circulation into the toe as sometimes a lack of circulation can cause similar problems and is potentially a more severe problem.

Marc Mitnick DPM

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