What is the best course of treatment for a patient with bilateral foot pain and right big toe tenderness, who has been putting more pressure on their right foot while walking, with no signs of infection or inflammation, but reports pain to touch?

Initial Diagnostic Approach for Bilateral Foot Pain with Right Big Toe Tenderness

The most critical first step is to rule out peripheral artery disease (PAD), infection, and structural deformities through focused vascular and neurologic examination, followed by weight-bearing radiographs if trauma or structural pathology is suspected. 1, 2

Immediate Assessment Priorities

Vascular Evaluation (Critical First Step)

• Remove all footwear and garments to perform a thorough lower extremity examination 1
• Palpate bilateral pedal pulses (dorsalis pedis and posterior tibial arteries) 1
• Assess for signs of ischemia: asymmetric hair growth, nail bed changes, calf muscle atrophy, elevation pallor, or dependent rubor 1
• If pulses are diminished or absent, obtain ankle-brachial index testing immediately, as PAD combined with foot pain portends poor outcomes without prompt intervention 1

Rule Out Infection

• Examine for signs of soft tissue infection: non-purulent secretions, friable granulation tissue, wound undermining, foul odor, or erythema 3
• Check for pre-ulcerative lesions including blisters, fissures, callus, or hemorrhage, particularly if the patient has diabetes 4
• If infection is suspected with PAD, obtain urgent surgical AND vascular consultation within 24-48 hours, as this combination dramatically increases amputation risk 1

Structural and Neurologic Assessment

• Palpate for point tenderness at the first metatarsophalangeal joint, base of the great toe, and along the medial aspect of the foot 4
• Assess for deformity such as hallux rigidus, bunion, or hammertoe deformity 4
• Perform calcaneal compression test (squeeze calcaneus medial to lateral) to evaluate for stress fracture 2
• Check for loss of protective sensation using 10-g monofilament testing, as loss of protective sensation (LOPS) increases ulceration risk 1

Differential Diagnosis Based on Clinical Findings

For Right Big Toe Tenderness with Pain to Touch

• Hallux rigidus or first metatarsophalangeal joint arthritis: aching pain worsened by weight-bearing, improved when not bearing weight 1
• Sesamoid pathology (sesamoiditis, fracture, or bipartite sesamoid): localized tenderness at first metatarsal head region 3
• Gout or inflammatory arthropathy: consider especially with bilateral symptoms or pain in other joints 2
• Stress fracture: progressive worsening pain following increased activity or change to harder walking surface 2
• Digital nerve neuroma: localized tenderness with "electric" type pain 5

For Bilateral Foot Pain

• Plantar fasciitis: heel pain worse with first steps in morning 6
• Metatarsalgia: pain at ball of foot, common in runners and athletes 3
• Peripheral neuropathy: burning or tingling suggests neurologic cause 2
• PAD with claudication: bilateral leg discomfort with walking, relieved by rest within 10 minutes 1

Imaging Strategy

When to Order Radiographs

• Obtain weight-bearing radiographs of the foot as first-line imaging if trauma history exists, inability to bear weight, or point tenderness over bony structures 2, 3
• Apply Ottawa Foot Rules: order radiographs if unable to bear weight immediately after injury, point tenderness at base of 5th metatarsal or navicular, or inability to walk 4 steps 4
• Radiographs have 85% sensitivity and 95% specificity for plantar fasciitis and are useful to exclude fractures, sesamoid pathology, and arthritis 2, 3

Advanced Imaging Indications

• If radiographs are negative but pain persists >1 week, order MRI without contrast for suspected stress fracture, soft tissue pathology, or occult bone injury 2, 3
• Technetium bone scanning is useful for suspected stress fracture with negative radiographs, as symptoms precede radiographic findings by weeks 2, 3

Initial Treatment Algorithm

Conservative Management (First 6-8 Weeks)

• Implement PRICE protocol: protection, rest, ice, compression, elevation 4
• Prescribe NSAIDs (ibuprofen, naproxen, or celecoxib) for pain control and inflammation reduction 4
• Recommend well-fitted walking shoes or athletic shoes that cushion feet and redistribute pressure 1
• Modify activity: reduce pressure on right foot by using assistive device if needed 7
• Initiate stretching exercises for plantar fascia and Achilles tendon 6

Specific Interventions Based on Diagnosis

• For plantar fasciitis: add heel cushions, arch supports, or orthotics 2
• For sesamoid pathology: offload first metatarsal head with dancer's pad or orthotic 3
• For stress fracture: protect and immobilize the foot 2

Red Flags Requiring Urgent Referral

Obtain urgent surgical consultation if any of the following are present: 1

• Signs of systemic inflammatory response (fever, tachycardia, hypotension)
• Rapid progression of infection
• Extensive necrosis or gangrene
• Critical limb ischemia (absent pulses, rest pain, tissue loss)
• Unexplained persistent foot pain despite appropriate treatment
• Evidence of deep-space infection or abscess

When to Refer for Routine Consultation

• No improvement after 6-8 weeks of appropriate conservative treatment 2, 4
• Need for advanced diagnostic testing beyond plain radiographs 2
• Consideration of surgical intervention for structural deformity 1
• Neurologic symptoms requiring electromyography or nerve conduction studies 2

Critical Pitfalls to Avoid

• Never inject corticosteroids near the Achilles tendon due to rupture risk 3
• Do not rely solely on initial radiographs to exclude stress fractures given only 12-56% sensitivity 3
• Reexamine 3-5 days post-injury if initial examination is limited by excessive swelling, as physical findings become more reliable for distinguishing injury severity 4
• In patients with diabetes and foot pain, always assess for PAD and infection simultaneously, as their combination dramatically worsens prognosis 1
• Do not delay vascular consultation in patients with diminished pulses, as revascularization may be needed before definitive treatment 1