What is the best course of treatment for a 63-year-old male with chronic toe pain who is currently undergoing physiotherapy?

Management of Chronic Toe Pain in a 63-Year-Old Male

For a 63-year-old male with chronic toe pain who is currently undergoing physiotherapy, the recommended approach is to continue physiotherapy with appropriate imaging and pharmacological management, beginning with radiography of the foot as the initial diagnostic step.

Diagnostic Approach

• Radiography (X-ray) of the foot is the recommended first imaging study for evaluating chronic toe pain, with a standard three-view study (anteroposterior, oblique, and lateral) 1, 2
• If radiographs are negative or equivocal but clinical suspicion remains high, advanced imaging such as MRI without IV contrast should be considered, particularly if soft tissue pathology is suspected 1
• Evaluate for point tenderness, swelling, deformity, or skin changes in the affected toe, and assess weight-bearing ability and gait pattern 2

Treatment Algorithm

First-line Treatment

• Continue physiotherapy with focus on stretching exercises and strengthening of intrinsic foot muscles 2
• NSAIDs for pain management and reducing inflammation - naproxen 500 mg twice daily is recommended, with the lowest effective dose for the shortest duration 3
• Appropriate footwear with adequate width to reduce pressure on the affected toe 2
• Consider orthotic devices to redistribute pressure and reduce pain 2, 4

Second-line Treatment

• If pain persists after 6-8 weeks of conservative treatment, consider:
  • MRI foot without IV contrast to evaluate for occult fractures, soft tissue pathology, or neuromas 1
  • Ultrasound may be useful for detecting Morton's neuroma, intermetatarsal bursitis, or plantar plate tears 1, 5
  • Referral to a foot and ankle specialist 2, 4

For Specific Conditions

• For Morton's neuroma (if diagnosed): Consider interdigital corticosteroid injection in addition to orthotics and activity modification 5
• For metatarsalgia: Focus on metatarsal padding and appropriate footwear 6
• For hallux rigidus or other great toe pathologies: Consider stiff-soled shoes and rocker-bottom modifications 7
• For neuropathic pain: Consider gabapentin starting at 300 mg at bedtime (up to 2400 mg daily divided into 3 doses) or pregabalin 75-300 mg every 12 hours 1

Common Pitfalls and Caveats

• Overlooking small avulsion fractures on radiographs, which may require weight-bearing views 2
• Underestimating the impact of proper footwear on symptom management 2
• Failing to consider systemic causes of toe pain, such as inflammatory arthropathies or neuropathies 8
• Corticosteroid injections should be used judiciously, especially near tendons 4

When to Refer

• No improvement after 6-8 weeks of appropriate conservative treatment 2, 4
• Need for advanced imaging or diagnostic testing 1
• Suspicion of systemic disease causing toe pain 8
• Consideration of surgical intervention for structural abnormalities 6, 7

Special Considerations

• For elderly patients, consider a lower dose of NSAIDs due to increased risk of adverse effects 3
• For patients with neuropathic pain components, consider specialized treatments such as Scrambler therapy if conventional treatments fail 9
• For patients with renal or hepatic impairment, adjust medication dosages accordingly 3