What is the treatment for a patient with toe injury, specifically after bending their toe back, presenting with erythema and limited mobility, but able to move their great toe?

Treatment of Acute Great Toe Injury with Erythema

For this patient with a great toe injury from hyperextension (bending back) who retains mobility but has erythema, treat as an acute soft tissue injury with controlled cooling (20 minutes maximum, 4 times daily), elevation, and close monitoring for 3-5 days to rule out more severe ligamentous injury or alternative diagnoses. 1, 2

Immediate Assessment Priorities

• Verify the patient can actively move the great toe through full range of motion, which suggests no complete tendon rupture or fracture 1
• Assess for excessive swelling, hematoma formation, or inability to bear weight, which would indicate grade III injury requiring imaging 1
• Palpate for point tenderness over bone to determine if radiography is needed per Ottawa rules 1
• Re-examine in 3-5 days as initial swelling and pain can mask the true severity of ligamentous injury 1

First-Line Treatment Protocol

Controlled Cooling (Critical Timing)

• Apply cold therapy for exactly 20 minutes per session, maximum 4 times daily 2, 3
• Use melting iced water through a wet towel rather than direct ice application 4
• Never allow ice water immersion or continuous cooling, which causes tissue damage and ulceration 2
• Twenty-minute applications provide optimal pain reduction and joint mobility while minimizing adverse effects like tingling, numbness, and burning that occur with 30-minute applications 3

Elevation and Rest

• Elevate the affected foot above heart level during symptomatic episodes 2
• Avoid weight-bearing for 24-48 hours if pain is significant 1
• Warn the patient that motor function may be impaired for 30 minutes post-cooling, increasing reinjury risk 4

Pain Management

• NSAIDs reduce swelling and pain while decreasing time to return to activities 1
• Consider topical lidocaine 4-5% patches if pain persists beyond initial injury phase 2

Red Flags Requiring Urgent Reassessment

The erythema in this case requires careful consideration of alternative diagnoses:

• If erythema spreads beyond 1.5 cm from injury site or worsens despite treatment, consider infection requiring antibiotics 1
• If the toe becomes increasingly red, hot, and painful with normal imaging, consider erythromelalgia (neurovascular disorder) rather than traumatic injury 2, 5
• If fever, tachycardia, or systemic symptoms develop, urgent evaluation for infection is mandatory 1
• If erythema persists with severe pain disproportionate to injury, obtain plain radiographs to exclude occult fracture or osteomyelitis 1

Common Pitfalls to Avoid

• Do not apply ice for longer than 20 minutes per session - this increases discomfort symptoms without additional benefit and risks tissue damage 2, 3
• Do not use continuous fan cooling - this causes windburn-equivalent injury 2
• Do not assume simple sprain if erythema is prominent - this may indicate infection, erythromelalgia, or other pathology requiring different management 1, 2, 5
• Do not skip the 3-5 day re-examination - initial assessment can miss significant ligamentous injuries 1

Functional Support After Acute Phase

• Once acute pain subsides (typically 48-72 hours), transition to semirigid or lace-up ankle support if ankle involvement exists 1
• Begin graded exercise with proprioceptive training to reduce risk of recurrent injury 1
• Well-fitted footwear that cushions and redistributes pressure is essential once weight-bearing resumes 1

When to Escalate Care

• Persistent or worsening erythema after 48 hours of appropriate treatment warrants consideration of infection or alternative diagnosis 1
• Inability to bear weight after 3-5 days requires imaging and possible specialist referral 1
• Development of systemic symptoms (fever, elevated inflammatory markers) necessitates immediate evaluation for deep infection 1