Big toe. Big problems.


The big toe, or hallux, can have several pain generators. The pain can vary from annoying to debilitating. The first metatarsal phalangeal (MTP) joint is where the long bone (metatarsal) of the foot meets the big toe. This joint can have multiple issues. Some of the common ones are listed below.

Hallux Rigidus
Hallux rigidus is osteoarthritis of this first MTP joint. Osteoarthritis is the wearing down of cartilage. The degraded cartilage causes "bone-on-bone" movement. The joint becomes stiff and painful. It can also be red from time to time. The body responds to this with inflammation and pain. Over time, the body can lay down bone spurs, decreasing the motion and increasing the deformity of the joint. Treatments can range from orthotics, shoes with a rocker-bottom to limit the motion in the joint, NSAIDs, and cortisone injections. The definitive treatment is surgery. There are two surgical options: fusion of the joint and joint replacement.

Hallux Valgus
Hallux valgus, more commonly known as a bunion, is a mal-alignment of the first MTP joint. Ill-fitting shoes, injuries, joint laxity, and perhaps a touch of genetics can cause this. Bunions can be painful and can cause issues with shoes. Also, the big toe can “bully” the lesser toes, causing hammertoes as they move out of its way. Conservative management includes bunion splints, silicone sleeves, pads, and shoes with a wide toe box. These can alleviate the symptoms, but ultimately they do not fix the alignment issue. That can only be done with surgery. Surgery fixes the deformity by fixing the alignment.

Gout was once known as “the disease of kings” because it was associated with rich foods or foods high in purines such as liver, anchovies, and shellfish. It is also associated with beer, sugary drinks, and obesity. The increased uric acid levels in the blood form crystals that are deposited outside of joint. Although it can affect any joint in the body, it most commonly affects the great toe joint. The typical presentation of this is a red and very tender joint. It is so tender, in fact, that a bedsheet rubbing over it can cause significant pain and discomfort. It can be a chronic disease with flare-ups. The acute attacks can be treated with a medication called colchicine. The chronic disease is treated daily with allopurinol. Blood levels of uric acid can be monitored by primary care providers.