What is the best course of action for managing toe pain that occurs at night?

Management of Nocturnal Toe Pain

The most critical first step is determining whether the patient has diabetes, as diabetic peripheral neuropathy (DPN) is the most common cause of nocturnal foot pain and has specific FDA-approved treatments that should be initiated promptly. 1

Diagnostic Evaluation

Essential History Elements

• Diabetes status must be elicited immediately, as DPN is the leading cause of nocturnal neuropathic foot pain and requires specific pharmacologic management 1
• Pain character distinguishes the etiology: burning, tingling, or shooting pain indicates neuropathy, while sudden painful muscle contractions suggest nocturnal leg cramps 1
• Timing specificity is diagnostic: pain occurring exclusively at night or worsening at night differentiates neuropathic pain from mechanical causes 1
• Associated symptoms such as numbness, weakness, or autonomic dysfunction support neuropathy 1
• Relief with barefoot walking is pathognomonic for Haglund's deformity or bursitis, not neuropathy 2

Physical Examination Priorities

• Bilateral comparative examination of the entire foot is essential, evaluating both unloaded and loaded conditions 3
• Precise pain localization determines the differential: forefoot (metatarsalgia, Morton's neuroma), hindfoot (plantar fasciitis, Achilles pathology), or diffuse (neuropathy) 3
• Palpation for tenderness medial and lateral to the Achilles tendon insertion suggests Haglund's deformity with bursitis 4
• Calcaneal squeeze test (medial-to-lateral compression) identifies stress fractures 2

Imaging Algorithm

• Plain radiographs (three views: AP, oblique, lateral) are the mandatory first imaging study for chronic foot pain of unknown etiology, with 80-100% sensitivity for structural causes 1
• MRI or bone scan should be reserved for cases where radiographs are negative but clinical suspicion remains high for stress fracture or occult pathology 1

Treatment Algorithm

If Diabetic Neuropathy is Confirmed or Suspected

First-line pharmacologic treatment is either pregabalin OR duloxetine, as both have FDA approval and high-quality evidence for painful DPN 1

Pregabalin Regimen

• Start at 75 mg twice daily 1
• Titrate to 150-300 mg twice daily based on response 1
• Eight high-quality studies support efficacy 1

Duloxetine Regimen

• Start with lower doses in older patients 1
• Titrate gradually 1
• Two high-quality studies support efficacy 1

Adjunctive Topical Therapy

• Lidocaine 5% patches may be specifically useful for nocturnal neuropathic foot pain, though they cannot be used for more than 12 hours in a 24-hour period 1
• Topical amitriptyline 1-2% compounded with 0.5% ketamine applied up to 3 times daily improved pain in 75% of patients with erythromelalgia in one case series 4
• If ineffective, increase ketamine concentration up to 5% 4

If Mechanical/Structural Cause is Identified

For Haglund's Deformity with Bursitis

• Open-backed shoes to eliminate pressure on the posterior-lateral prominence 2
• Orthotic devices and accommodative padding to redistribute pressure 2
• NSAIDs (oral or topical) for pain relief 2
• Activity modification by reducing aggravating activities 2

For Plantar Fasciitis

• Stretching of the plantar fascia and foot orthotics as first-line therapy 5
• Extracorporeal shockwave therapy, corticosteroid injection, or platelet-rich plasma injection if first-line fails 5

For Achilles Tendinopathy

• Eccentric strength training is the most effective treatment and should be started immediately 6
• Shoe orthotics to correct overpronation or pes planus 6
• Approximately 80% of patients fully recover within 3-6 months with conservative treatment 6

Critical Contraindications

• NEVER prescribe opioids for painful DPN due to lack of long-term efficacy evidence and documented harms including addiction, fractures, motor vehicle accidents, and mortality 1
• NEVER inject corticosteroids near the Achilles tendon insertion as this dramatically increases rupture risk 2, 6

Referral Indications

• Refer to podiatric foot and ankle surgeon if no improvement occurs within 6-8 weeks of appropriate conservative treatment 1, 2
• Additional referral indications include: need for advanced imaging, consideration of surgical intervention, suspected stress fracture, or neurologic symptoms requiring subspecialist evaluation 1

Common Pitfalls

• Missing diabetic neuropathy: always assess diabetes status and screen for DPN in any patient with nocturnal foot pain 1
• Prescribing opioids: strong evidence against their use in neuropathic pain 1
• Overlooking stress fractures in patients with increased walking activity or change to harder surfaces, even with negative initial radiographs 2
• Not reexamining patients 3-5 days post-injury if trauma is involved 2

Red Flags Requiring Urgent Evaluation

• Constant pain at rest without mechanical explanation 2
• Numbness, burning, or tingling suggesting nerve involvement 2
• Sudden appearance of bilateral, painful, purple lesions on the toes (purple toes syndrome in patients on warfarin) 7