What is the best course of treatment for pain and swelling in the base of the 2nd and 3rd toe?

Pain and Swelling at Base of 2nd and 3rd Toes

Begin with conservative treatment including rest, ice, NSAIDs, and proper footwear, while ruling out fracture using the Ottawa Ankle and Foot Rules if there is inability to bear weight or point tenderness over the metatarsal bones.

Initial Assessment and Diagnosis

The location of pain at the base of the 2nd and 3rd toes suggests several possible diagnoses that require differentiation:

Key Physical Examination Findings

• Palpate for point tenderness at the base of the 2nd and 3rd metatarsal bones, the metatarsophalangeal (MTP) joints, and surrounding soft tissues 1
• Assess for swelling location: Rapid onset of swelling suggests acute ligamentous injury or fracture 1
• Perform calcaneal compression test by squeezing the foot from medial to lateral to evaluate for stress fracture 1
• Evaluate for pre-ulcerative lesions including blisters, fissures, callus, or hemorrhage, particularly in patients with diabetes 2
• Check for deformity: Look for hammertoe deformity with nail changes or callus on the apex of the toes 2

Rule Out Fracture First

Apply the Ottawa Ankle and Foot Rules to determine if radiographs are needed 2:

• Obtain radiographs if there is inability to bear weight immediately after injury 1
• Obtain radiographs if there is point tenderness at the base of the 5th metatarsal bone or navicular bone 2
• Obtain radiographs if there is inability to walk at least 4 steps 2

Critical timing consideration: If initial examination is limited by excessive swelling and pain within 48 hours of injury, reexamine the patient 3-5 days post-injury when physical findings become more reliable for distinguishing partial tears from complete ligament ruptures 2, 1

Conservative Treatment Protocol

Immediate Management (First 72 Hours)

Implement the PRICE protocol 2:

• Protection: Use compressive device or buddy taping to adjacent toe
• Rest: Limit weight-bearing activities for up to 72 hours 2
• Ice: Apply cryotherapy for 10-minute periods through a wet towel to reduce pain and swelling 2, 3
• Compression: Apply compressive wrapping
• Elevation: Elevate the foot above heart level

Pharmacologic Management

• NSAIDs (ibuprofen, naproxen, or celecoxib) provide pain control, reduce swelling, and allow more rapid return to activity 2, 3
• Controlled trials demonstrate that NSAIDs are superior to placebo for improved pain control, decreased swelling, and faster return to function 2

Footwear Modifications

• Wide toe-box shoes to reduce pressure on the affected toes 4
• Soft uppers to minimize irritation 4
• Padding of bony prominences if present 4
• Consider metatarsal pads to redistribute pressure away from the metatarsal heads 4

When Conservative Treatment Fails

If symptoms persist beyond 6-8 weeks of appropriate conservative treatment, refer to a podiatric foot and ankle surgeon 3

Advanced Diagnostic Imaging

• If radiographs are negative but pain persists >1 week, obtain MRI without contrast or CT without contrast as equivalent alternatives 1
• For suspected stress fracture with negative initial radiographs, obtain technetium bone scanning, as symptoms often precede radiographically visible fractures 1, 5

Surgical Considerations

For patients with non-rigid hammertoe deformity with nail changes, excess callus, or pre-ulcerative lesions on the apex of the 2nd or 3rd toe:

• Consider digital flexor tendon tenotomy to help prevent ulceration and reduce deformity 2
• This procedure is performed as an outpatient with no need for subsequent immobilization 2
• Alternative: Toe silicone or semi-rigid orthotic devices to reduce excess callus 2

Common Pitfalls to Avoid

• Do not delay reexamination: Always reexamine 3-5 days post-injury, as excessive swelling within the first 48 hours can obscure true injury severity 2, 1
• Avoid corticosteroid injections near tendons or in the forefoot area, as they increase risk of tendon rupture 3, 5
• Do not overlook stress fractures: Patients often report increased walking activity before symptom onset, and radiographs may initially be negative 1
• Avoid complete immobilization unless fracture is confirmed, as this leads to muscular atrophy and deconditioning 3

Red Flags Requiring Immediate Referral

• Neurologic symptoms including burning, tingling, or numbness suggesting nerve involvement 5
• Constant pain at rest or progressive worsening despite treatment 3
• Signs of infection: Increasing redness, warmth, or systemic symptoms 3
• Suspected vascular compromise 1