What is the appropriate management for bilateral big toe pain in a teenager?

Bilateral Big Toe Pain in a Teenager

The most likely diagnosis is Sever disease (calcaneal apophysitis), which is the most common cause of heel pain in adolescents and children, though if pain is truly isolated to the big toes themselves, consider sesamoiditis, turf toe, or hallux rigidus as primary differentials. 1

Initial Diagnostic Approach

Key History Elements to Elicit

• Activity level and recent changes: Progressive worsening pain following increased activity or change to harder walking surface suggests stress fracture or apophysitis 1
• Trauma history: Acute onset with hyperextension injury points toward turf toe or sesamoid fracture 2
• Pain pattern: Pain at the base of the toes versus the heel versus the toe tip helps narrow the differential 3
• Bilateral versus unilateral: Bilateral symptoms raise concern for systemic causes including arthritides, particularly juvenile idiopathic arthritis 4

Critical Physical Examination Findings

• Point tenderness location: Palpate the sesamoid bones, metatarsophalangeal joints, base of metatarsals, and calcaneus to localize pathology 1, 3
• Calcaneal compression test: Squeeze the calcaneus medially to laterally—positive test suggests calcaneal stress fracture or apophysitis 1
• Range of motion assessment: Limited dorsiflexion of the big toe suggests hallux rigidus 2, 5
• Inspection for deformity: Look for hammertoe deformity, callus formation, or nail changes 3

Rule Out Serious Pathology First

When to Obtain Imaging

• Apply Ottawa Ankle and Foot Rules: Obtain radiographs if unable to bear weight immediately after injury, point tenderness over specific bones, or inability to walk 4 steps 3
• Initial imaging: Weight-bearing radiographs of the foot should be the first imaging study 1
• Advanced imaging: If radiographs negative but pain persists >1 week, MRI without contrast or technetium bone scanning for suspected stress fracture 1

Red Flags Requiring Immediate Referral

• Neurologic symptoms: Burning, tingling, or numbness requires immediate subspecialist referral for electromyography, nerve conduction studies, and MRI 1, 6
• Signs of infection: Warmth, erythema, systemic symptoms 3
• Constant pain at rest: May indicate tumor or vascular compromise 1
• Bilateral symptoms with other joint involvement: Consider juvenile idiopathic arthritis, which can be polyarticular and associated with IgA deficiency 4

Conservative Management Protocol

First-Line Treatment (0-6 Weeks)

• PRICE protocol: Protection, rest, ice, compression, elevation 3
• NSAIDs for pain control: Naproxen 250-500 mg twice daily (adjust dose for adolescent weight) or ibuprofen, which reduces swelling and allows more rapid return to activity 3, 7
• Activity modification: Reduce high-impact activities temporarily 1
• Footwear assessment: Open-backed shoes for posterior heel pain, well-cushioned athletic shoes for forefoot pain 4, 1

Specific Interventions Based on Diagnosis

• For sesamoiditis/turf toe: Rigid-soled shoes or carbon fiber inserts to limit motion at the metatarsophalangeal joint 2
• For Sever disease (calcaneal apophysitis): Heel lifts, stretching exercises for Achilles tendon and plantar fascia, activity modification 1
• For hallux rigidus: Physical therapy focusing on range of motion exercises 5

Common Pitfalls to Avoid

• Do not delay reexamination: If initial exam is limited by swelling within 48 hours, reexamine at 3-5 days when physical findings become more reliable 3
• Avoid corticosteroid injections: Never inject near tendons or in the forefoot area due to risk of tendon rupture 3
• Do not assume isolated mechanical cause: Bilateral symptoms in a teenager warrant consideration of systemic causes including juvenile idiopathic arthritis, particularly if associated with other joint pain 4
• Consider diabetes screening: Although uncommon in teenagers without risk factors, if diabetic, annual comprehensive foot exams are indicated starting at puberty or age 10 years after 5 years of diabetes duration 4

When to Refer

Refer to podiatric foot and ankle surgeon if:

• No improvement after 6-8 weeks of appropriate conservative treatment 1, 3
• Need for advanced diagnostic testing beyond plain radiographs 1
• Suspected stress fracture with negative initial radiographs requiring bone scan 1
• Consideration of surgical intervention for structural deformities 2

Special Consideration for Diabetic Teenagers

If the patient has type 1 diabetes for >5 years and is post-pubertal or >10 years old, perform annual comprehensive foot examination including inspection, palpation of pulses, and assessment of proprioception, vibration, and monofilament sensation 4. Diabetic neuropathy prevalence is 7% in youth with type 1 diabetes and associates with cardiovascular risk factors 4.