Dorsal Great Toe Pain Without Visible Inflammation
The most likely diagnosis is hallux rigidus (early stage) or a stress injury to the great toe, and initial management should include continuing NSAIDs, activity modification with stiff-soled footwear, and obtaining weight-bearing radiographs of the foot to exclude fracture or arthritis. 1, 2, 3
Most Likely Diagnoses
Hallux rigidus (early stage) is a leading consideration given the dorsal toe pain with walking and normal appearance, as this condition causes pain with dorsiflexion during gait before visible joint changes develop 3, 4. The fact that ibuprofen provides significant relief supports an inflammatory or mechanical etiology 5.
Stress injury or occult fracture of the proximal phalanx or first metatarsal head must be considered, particularly since symptoms began 1.5 weeks ago and worsen with weight-bearing activity 2, 4. Pain may precede radiographic findings by days to weeks 5, 1.
Turf toe (mild grade I sprain) affecting the dorsal capsule is possible even without recalled trauma, as repetitive hyperextension during walking can cause cumulative microtrauma 2, 6, 7.
Diagnostic Approach
Obtain weight-bearing radiographs of the foot as the initial imaging study, which has 85-95% sensitivity/specificity for identifying arthritis, fractures, or bone abnormalities 1, 4. Look specifically for joint space narrowing at the first metatarsophalangeal joint, dorsal osteophytes, or subtle fracture lines 3, 4.
Physical examination should focus on:
- Palpating the dorsal first metatarsophalangeal joint, proximal phalanx shaft, and metatarsal head to localize tenderness 1, 8
- Testing passive dorsiflexion and plantarflexion range of motion compared to the contralateral side 6, 3
- Assessing for crepitus with joint motion, which suggests early arthritis 3, 4
- Performing vertical stress testing of the hallux to evaluate capsular stability 7
If radiographs are negative but pain persists beyond 1 week, obtain MRI without contrast or CT without contrast to detect occult stress fractures, osteochondral lesions, or early avascular necrosis 1, 8. Technetium bone scanning is an alternative for suspected stress fracture 5, 1.
Initial Management
Continue NSAIDs (ibuprofen) for pain control and anti-inflammatory effect, as oral NSAIDs provide effective short-term pain relief without significantly increasing adverse events in otherwise healthy patients 5. The British Journal of Sports Medicine confirms NSAIDs reduce pain in the short term (<14 days) with level 1 evidence 5.
Implement activity modification by reducing walking distance and avoiding activities that require forceful toe push-off 9, 3. However, avoid complete immobilization to prevent muscle atrophy 9.
Use stiff-soled footwear or a steel-plate shoe insert to limit dorsiflexion of the first metatarsophalangeal joint during gait, which reduces mechanical stress 3, 7. This is particularly important if hallux rigidus or turf toe is suspected 7.
Apply ice therapy through a wet towel for 10-minute periods to reduce pain and inflammation 9, 4.
When to Refer
Refer to a podiatric foot and ankle surgeon if:
- No improvement occurs after 6-8 weeks of appropriate conservative treatment 5, 1, 8
- Advanced imaging reveals fracture, significant arthritis, or osteochondral defect requiring surgical consideration 1, 8
- Pain becomes constant at rest or is accompanied by numbness, increasing swelling, or redness suggesting infection or nerve compression 9
Common Pitfalls
Do not inject corticosteroids near the first metatarsophalangeal joint without definitive diagnosis, as injections near tendons increase rupture risk and may accelerate cartilage degeneration in undiagnosed arthritis 5, 9.
Recognize that normal radiographs do not exclude stress fracture, as symptoms often precede radiographic changes by 1-3 weeks 5, 1, 4. Maintain high suspicion if pain progressively worsens with activity 4.
Avoid dismissing the complaint based on normal appearance alone, as early hallux rigidus and stress injuries present before visible deformity or swelling develops 3, 4.