What are the potential causes of left great toe pain in an adult that worsens with weight bearing and range of motion?

Differential Diagnosis of Left Great Toe Pain with Weight Bearing and Range of Motion

The most likely causes of left great toe pain worsening with weight bearing and ROM in an adult are hallux rigidus (first MTP joint osteoarthritis), turf toe (plantar plate injury), sesamoiditis, or fracture (including sesamoid fracture). 1

Primary Diagnostic Considerations

Hallux Rigidus (First MTP Joint Arthritis)

• This is the most common arthritic condition of the foot and presents with pain at the first metatarsophalangeal (MTP) joint that worsens with dorsiflexion and weight bearing. 1
• Pain increases with internal and external rotation of the joint, and patients typically have limited ROM, particularly dorsiflexion. 1
• Gentle range-of-motion exercises and strengthening have the most uniform positive effects on arthritis pain, and NSAIDs provide short-term pain relief. 2

Turf Toe (Plantar Plate Injury)

• This represents a hyperextension injury to the first MTP joint with plantar capsule disruption. 1
• Pain localizes to the plantar aspect of the great toe and worsens with push-off during gait and passive dorsiflexion. 1
• These injuries are highly problematic and can significantly impact function if not properly diagnosed and treated. 1

Sesamoiditis and Sesamoid Pathology

• Sesamoid injuries cause plantar great toe pain that worsens with weight bearing, particularly during push-off. 3, 1
• Differentiation between bipartite versus fractured sesamoid remains difficult on radiographs alone. 3
• Sesamoid avascular necrosis can also present with similar symptoms and requires careful evaluation. 1

Fractures

• Hallux and sesamoid fractures require a high index of suspicion and can result in long-term pain and disability if not properly diagnosed. 1
• Stress fractures may present with progressively worsening pain following increased activity, and symptoms often precede radiographic findings. 4

Diagnostic Algorithm

Initial Clinical Examination

• Palpate specific anatomical structures to localize pain: first MTP joint dorsally and plantarly, sesamoids on the plantar surface, and the interphalangeal joint. 5, 6
• Assess ROM of the first MTP joint, noting any limitation in dorsiflexion (hallux rigidus) or pain with passive motion. 5, 1
• Evaluate gait pattern, observing for antalgic gait or avoidance of push-off through the great toe. 5, 6
• Examine the foot in both weight-bearing and non-weight-bearing positions, as reproduction of the patient's symptoms is key to making a correct diagnosis. 5

Initial Imaging

• Weight-bearing radiographs of the foot (AP, oblique, and lateral views) should be the first imaging study performed. 3
• Radiographs are useful to assess sesamoid dislocation, osteoarthritis of the first MTP joint, and to distinguish between bipartite versus fractured sesamoid. 3
• Radiographs have sensitivities ranging from 12% to 56% for stress fractures, so negative films do not exclude fracture. 3

Advanced Imaging When Radiographs Are Negative or Equivocal

• MRI foot without IV contrast is the most appropriate next imaging study for persistent great toe pain with negative radiographs. 3, 1
• MRI allows optimal visualization of bone marrow within the sesamoids, assessment of the plantar plate, and detection of occult fractures. 3
• MRI has replaced bone scans in the evaluation of symptomatic accessory ossicles and sesamoid pathology. 3
• Ultrasound can identify increased blood supply in sesamoiditis using power Doppler and allows dynamic assessment, though MRI provides superior characterization. 3

Initial Treatment Approach

Conservative Management (First-Line)

• NSAIDs (oral or topical) for pain relief and reducing inflammation. 2
• Rest and activity modification to prevent ongoing damage, particularly avoiding activities that require push-off through the great toe. 2
• Orthotic devices with Morton's extension or dancer's pad to offload the first MTP joint and sesamoids. 2
• Gentle range-of-motion exercises and strengthening exercises for hallux rigidus. 2
• Proper footwear with adequate cushioning and a stiff sole to limit MTP joint motion. 2

When to Advance Treatment

• If no improvement occurs within 6-8 weeks of appropriate conservative treatment, referral to a podiatric foot and ankle surgeon is indicated. 2, 4
• Consider immobilization with a cast or fixed-ankle walker-type device for persistent symptoms. 2
• Advanced imaging (MRI or ultrasound) should be obtained to confirm diagnosis and rule out other conditions if not already performed. 2

Critical Pitfalls to Avoid

• Never assume a simple "toe sprain" without proper evaluation—hallux and sesamoid injuries can result in long-term pain and disability if not properly diagnosed and treated. 1
• Do not rely solely on initial radiographs to exclude fracture, as stress fractures and sesamoid injuries may not be radiographically visible initially. 3, 4
• Avoid corticosteroid injections near the plantar plate or sesamoids, as these can lead to rupture or further tissue damage. 2
• Complete immobilization should be avoided to prevent muscular atrophy and deconditioning—protected weight bearing is preferred. 2
• Consider systemic causes (inflammatory arthritis, gout, infection) when symptoms are bilateral, involve other joints, or present with systemic signs. 4, 7