What is the likely diagnosis and first‑line management for mild erythema, swelling, and pain of the second toe and forefoot after a prolonged car ride?

Likely Diagnosis: Metatarsalgia with Possible Extensor Tendonitis or Stress Reaction

Your presentation of second toe pain with redness on pressure, dorsal foot swelling, and metatarsal head tenderness after prolonged driving most likely represents metatarsalgia (forefoot pain from repetitive pressure) with possible extensor tendon inflammation or early stress reaction.

Clinical Reasoning

Your symptom pattern suggests mechanical overuse rather than acute trauma:

• Prolonged pedal pressure during driving can cause repetitive microtrauma to the metatarsal heads and dorsal soft tissues 1
• Redness with pressure application indicates localized inflammation rather than infection or systemic disease 2
• Dorsal foot puffiness suggests extensor tendon inflammation from sustained dorsiflexion positioning during driving 2
• Ball-of-foot pain worse barefoot is classic for metatarsalgia, as cushioned footwear normally redistributes plantar pressure 3

Initial Management Algorithm

Immediate Conservative Measures (First 2-4 Weeks)

• Activity modification: Avoid prolonged driving, walking barefoot, and high-impact activities 1
• Footwear changes: Wear well-cushioned shoes with adequate arch support to redistribute metatarsal pressure 3
• NSAIDs: Use for pain and inflammation control 4, 5
• Ice application: Apply for 10-15 minutes, 3-4 times daily—avoid prolonged ice immersion which can cause tissue damage 3
• Elevation: Elevate the foot when resting to reduce swelling 3

When to Obtain Imaging

You should obtain weight-bearing foot radiographs if:

• Pain persists beyond 1 week despite conservative measures 2
• You cannot bear weight or take 4 steps (Ottawa rules criteria) 3, 4
• Point tenderness localizes to specific metatarsal shafts suggesting possible stress fracture 4

Important caveat: Initial radiographs have only 12-56% sensitivity for stress fractures, so negative X-rays do not exclude the diagnosis 2. If pain persists beyond 1 week with negative radiographs, MRI without contrast is the next step 2.

Physical Examination Findings to Assess

• Palpate for point tenderness along the second metatarsal shaft, metatarsal head, and extensor tendons on the dorsal foot 2
• Perform calcaneal squeeze test: Compress the heel from medial to lateral—pain suggests stress fracture 4
• Test resisted dorsiflexion: Pain with this maneuver confirms extensor tendonitis 2
• Assess for vertical instability of the second metatarsophalangeal joint by applying vertical stress—this reproduces pain if the plantar plate is disrupted 6

Critical Pitfalls to Avoid

• Do not rely solely on initial radiographs to exclude stress fractures, as they are often negative early in the course 2
• Avoid prolonged ice water immersion or continuous fan use, which can cause tissue damage (immersion foot, windburn-equivalent injury) 3
• Do not ignore persistent symptoms beyond 6-8 weeks—this warrants subspecialist referral and advanced imaging 4
• Reexamine in 3-5 days if initial swelling limits your examination 4, 2

Progression of Treatment if Conservative Measures Fail

If symptoms persist after 2-4 weeks of conservative treatment:

• Consider metatarsal padding or custom orthotics to offload the metatarsal heads 3
• Physical therapy for stretching and strengthening exercises 4
• Advanced imaging (MRI or bone scan) if stress fracture is suspected 4, 2

When to Seek Urgent Evaluation

Seek immediate medical attention if you develop:

• Inability to bear weight at all 3
• Severe, progressive swelling or skin color changes 3
• Numbness, tingling, or burning sensations suggesting nerve involvement 4, 2
• No improvement after 6-8 weeks of appropriate conservative treatment 4

The most likely scenario is that your symptoms will improve with rest, proper footwear, and activity modification over 2-4 weeks. However, persistent symptoms warrant imaging to exclude stress fracture, which is common after increased activity and may not show on initial X-rays 4, 2.