What is the appropriate initial management for a 48‑year‑old woman with a history of plantar fasciitis and heel spur who now presents with great toe pain and normal foot radiographs?

Initial Management of Great Toe Pain with Normal Radiographs

Given the normal radiographs of the great toe, proceed with a focused clinical examination to differentiate between soft tissue pathology (sesamoiditis, turf toe, plantar plate injury) versus early inflammatory arthropathy (gout, seronegative arthritis), and initiate conservative management with NSAIDs, activity modification, and consider ultrasound imaging if symptoms persist beyond 2-3 weeks.

Clinical Assessment Priority

The normal radiographs effectively exclude acute fracture, dislocation, and advanced osteoarthritis, but radiographs are insensitive for many causes of great toe pain 1. Your clinical examination should focus on:

• Sesamoid pathology: Palpate the plantar aspect of the first metatarsophalangeal (MTP) joint for focal tenderness over the medial or lateral sesamoid bones, as radiographs may miss sesamoiditis and have difficulty distinguishing bipartite sesamoids from fractures 1
• Turf toe/plantar plate injury: Assess for pain with passive dorsiflexion of the great toe and instability of the MTP joint, which indicates capsular or plantar plate disruption not visible on plain films 1
• Inflammatory arthropathy: Evaluate for joint swelling, erythema, warmth, and systemic symptoms suggesting gout or seronegative arthritis, which may show normal radiographs early in disease 1

Initial Conservative Management

Begin with a 2-3 week trial of conservative therapy while monitoring response:

• Rest and activity modification: Reduce weight-bearing activities and avoid push-off movements that stress the great toe 2, 3
• Oral NSAIDs: Provide analgesia and reduce inflammation for soft tissue pathology 2, 3
• Ice massage: Apply 15-20 minutes several times daily to reduce acute inflammation 2
• Stiff-soled shoes or Morton's extension: Limit MTP joint motion to protect injured structures 3

Advanced Imaging Algorithm

If symptoms persist beyond 2-3 weeks despite conservative management, ultrasound is the appropriate next imaging study for great toe pain with normal radiographs 1. Ultrasound can effectively diagnose:

• Sesamoid pathology including sesamoiditis and fractures 1
• Plantar plate tears and intermetatarsal bursitis 1
• Soft tissue inflammation and effusions not visible on radiographs 1

MRI should be reserved for cases where ultrasound is inconclusive or when comprehensive evaluation of bone marrow edema, occult fractures, or complex soft tissue pathology is needed 1. The ACR guidelines explicitly state that MRI is not indicated as first-line imaging for chronic foot pain 1.

Common Pitfalls to Avoid

• Don't assume heel spur/plantar fasciitis explains great toe pain: While this patient has a history of plantar fasciitis and heel spur, these conditions affect the hindfoot and do not cause isolated great toe pain 2, 3
• Don't overlook gout: Great toe pain (podagra) is the classic presentation of acute gout, which shows normal radiographs initially and requires clinical diagnosis with possible joint aspiration for uric acid crystals 1
• Don't order MRI prematurely: MRI is not appropriate as initial advanced imaging for forefoot pain when ultrasound can provide diagnostic information at lower cost 1

Specialist Referral Indications

Consider referral to podiatry or orthopedics if:

• Symptoms persist beyond 6-8 weeks despite conservative management 2, 3
• Advanced imaging reveals structural pathology requiring specialized treatment 2
• Suspected inflammatory arthropathy requires rheumatology evaluation for systemic disease 1