What is the best course of action for an adult experiencing painful swollen toes?

Painful Swollen Toes: Clinical Management

For an adult with painful swollen toes, immediately assess for infection (purulent drainage, significant erythema, cellulitis) and determine if the patient has diabetes, as these factors fundamentally alter management priorities and urgency. 1, 2

Immediate Assessment

Critical Red Flags to Identify

• Purulent drainage, spreading erythema, or cellulitis requiring immediate antibiotic coverage for Staphylococcus aureus 2
• Diabetes status - diabetic patients require urgent specialized foot care as toe pathology can rapidly progress to ulceration with significant morbidity and mortality 1, 2
• Vascular compromise - absent pedal pulses (dorsalis pedis or posterior tibial) indicate need for ankle-brachial index measurement 1, 3
• Acute onset of red, hot, swollen foot/ankle in diabetic patients - must rule out Charcot neuroarthropathy 1

Specific Physical Examination Elements

• Palpate dorsalis pedis and posterior tibial pulses bilaterally 1, 3
• Inspect for pre-ulcerative signs: hyperkeratosis (callus), erythema, warmth, blistering, or skin breakdown 1, 3
• Examine for ingrown toenail: nail edge penetrating nail fold, granulation tissue, or purulent drainage 2
• Assess for toe deformities: hammertoes, bunions, or bony prominences that increase pressure 1
• Test for loss of protective sensation using 10-g monofilament if diabetic 1

Differential Diagnosis Based on Presentation

If Ingrown Toenail Identified

• Initiate antiseptic soaks with dilute vinegar (50:50 dilution) or 2% povidone-iodine for 10-15 minutes twice daily 2
• Apply mid- to high-potency topical corticosteroid ointment to the nail fold twice daily to reduce inflammation 2
• If infection present, start empiric oral antibiotics targeting S. aureus and streptococci 1, 2
• Refer to podiatrist if recurrent or if diabetic patient 2

If Pre-Ulcerative Lesion or Callus Present

• Perform immediate sharp debridement of all hyperkeratotic tissue using scalpel, scissors, or tissue nippers - this is the most definitive and controllable method 3
• Debridement reduces pressure, removes colonizing bacteria, and permits full tissue examination 3
• Repeat debridement sessions as often as needed if nonviable tissue continues to form 3

If Trauma or Acute Injury Suspected

• Obtain plain radiographs to rule out fracture or dislocation 4
• If radiographs normal but high clinical suspicion, obtain MRI to evaluate capsuloligamentous complex and assess for chondral/osteochondral lesions 5
• Apply RICE protocol (rest, ice, compression, elevation) 5

Pain Management

First-Line Analgesics

• Ibuprofen 400-800 mg every 8 hours (maximum 2400 mg/24 hours) for inflammation and pain control 5, 6
• Monitor for GI side effects (epigastric pain, dyspepsia, melena) and discontinue if signs of ulceration or bleeding develop 6
• Alternative: Acetaminophen 1000 mg every 8 hours (maximum 3000 mg/24 hours) if NSAIDs contraindicated 7

Common Pitfall

Do not use NSAIDs in patients with aspirin-sensitive asthma, active GI ulceration, or severe renal impairment 6. The anti-inflammatory effect may also mask signs of infection, so monitor closely 6.

Footwear Modifications (Critical for All Patients)

Immediate Instructions

• Prohibit walking barefoot, in socks only, or in thin-soled slippers both indoors and outdoors 1
• Prescribe properly fitted footwear with toe box 1-2 cm longer than foot, width equal to metatarsal phalangeal joint width, and adequate height for toes 1
• If foot deformities present, prescribe extra-depth shoes, custom-made footwear, or custom-made insoles 1

Specific Footwear Characteristics

• Broad and square toe box 1
• Laces with three or four eyes per side 1
• Padded tongue and quality lightweight materials 1
• Rigid sole to restrict dorsiflexion if acute injury present 5

Special Management for Diabetic Patients

Urgent Actions Required

• Refer immediately to trained foot care specialist for any diabetic patient with toe pathology 1, 2
• Schedule integrated foot care every 1-3 months for moderate-to-high risk patients (IWGDF risk 2-3) 2
• Educate on daily foot inspection using mirror if loss of protective sensation present 1
• Assess vascular status: if ankle-brachial index <0.6, toe pressure <50 mmHg, or TcPO2 <30 mmHg, consider revascularization 1, 3

Prevention Education

• Wash feet daily with careful drying between toes 1, 2
• Apply emollients to moisturize dry skin 1, 2
• Cut toenails straight across, never rounded at corners, avoiding cutting too short 2
• Contact healthcare professional immediately if any new lesion, increased pain, or signs of infection develop 1, 2

When to Escalate Care

Refer to Specialist If:

• Diabetic patient with any toe pathology 1, 2
• Absent pedal pulses or ankle-brachial index <0.9 1
• No improvement after 6 weeks of conservative treatment 3
• Signs of deep infection (purulent drainage, cellulitis, systemic symptoms) 1
• Suspected Charcot neuroarthropathy 1
• Recurrent ingrown toenail requiring definitive surgical management 2

Consider Hospitalization If:

• Ulcer deeper than subcutaneous tissues 1
• Severe infection with systemic signs 1
• Critical limb ischemia requiring urgent revascularization 1, 3