Left Great Toe Pain with Walking and Weight-Bearing
The most likely diagnosis is hallux rigidus (great toe osteoarthritis) or turf toe (first metatarsophalangeal joint sprain), and you should obtain weight-bearing foot radiographs immediately to differentiate between these conditions and rule out fracture or sesamoid pathology. 1
Primary Diagnostic Considerations
Hallux rigidus presents as pain at the first metatarsophalangeal (MTP) joint that worsens with weight-bearing and dorsiflexion of the great toe, caused by degenerative arthritis limiting joint motion. 1 This is the most common arthritic condition of the foot in adults and typically causes dorsal great toe pain with walking. 1
Turf toe (acute or chronic first MTP joint sprain) causes pain at the plantar or dorsal aspect of the great toe base, resulting from hyperextension injury or repetitive stress during push-off phase of gait. 1 This condition is particularly common in athletes but can occur with any repetitive weight-bearing activity. 1
Sesamoid disorders (sesamoiditis, fracture, or avascular necrosis) cause plantar great toe pain localized beneath the first metatarsal head that intensifies with weight-bearing and toe dorsiflexion. 1 Point tenderness directly over the sesamoid bones on the plantar surface distinguishes this from other conditions. 1
Diagnostic Algorithm
Palpate specifically for:
- Point tenderness over the dorsal first MTP joint (suggests hallux rigidus) 1
- Tenderness on the plantar surface beneath the first metatarsal head (suggests sesamoid pathology) 1
- Pain with passive dorsiflexion of the great toe at the MTP joint (positive in both hallux rigidus and turf toe) 1
- Assess active and passive range of motion compared to the contralateral side, as limitation suggests hallux rigidus 1
Obtain weight-bearing anteroposterior, lateral, and oblique radiographs of the foot as the initial imaging study. 2, 3 Weight-bearing views are essential because they reveal joint space narrowing and alignment abnormalities not visible on non-weight-bearing films. 4
If radiographs are negative but pain persists beyond 1 week, order MRI without contrast to detect:
- Occult sesamoid fractures or stress fractures (radiographs have only 12-56% sensitivity for stress fractures) 2, 3
- Soft tissue injuries including plantar plate tears or capsular injuries 2
- Avascular necrosis of sesamoids 1
Critical Pitfalls to Avoid
Do not rely solely on initial radiographs to exclude fractures, as sensitivity for detecting acute sesamoid or metatarsal stress fractures ranges from only 12-56%. 2, 3 If clinical suspicion remains high with negative radiographs, proceed directly to MRI or CT. 2, 3
Avoid corticosteroid injections into the first MTP joint or near the flexor hallucis longus tendon, as this significantly increases the risk of tendon rupture and can accelerate cartilage degeneration in hallux rigidus. 2, 3
Reexamine the patient 3-5 days post-initial evaluation if swelling limits your examination, as excessive edema can obscure point tenderness and range of motion findings. 2
Consider gout or seronegative spondyloarthropathy if the patient describes acute onset of severe pain with erythema and swelling, particularly if symptoms began suddenly rather than gradually with activity. 5 However, these typically present with more dramatic inflammatory signs than simple mechanical pain with walking. 5
Initial Management Approach
For hallux rigidus: Prescribe rigid-soled shoes or carbon fiber inserts to limit dorsiflexion at the first MTP joint during gait, which directly reduces pain by preventing motion at the arthritic joint. 1 Activity modification to avoid push-off activities and NSAIDs for 2-4 weeks constitute first-line treatment. 1
For turf toe or sesamoid pathology: Implement strict activity modification with avoidance of push-off activities, use of stiff-soled shoes to limit MTP joint motion, and consider a Morton's extension orthosis to offload the sesamoids. 1 These conditions require 4-6 weeks of conservative management before considering advanced imaging or interventions. 1