Toe Pain/Swelling
Toe pain and swelling can be caused by local processes such as infection or trauma, or it may be a symptom of a systemic disorder, such as rheumatoid arthritis, endocarditis, or atherosclerotic vascular disease. Gout, or podagra, is the most common cause of pain, redness, and swelling of the great toe (first metatarsophalangeal joint). It is often so severe that the weight of a bed sheet can be excruciating.
Differential Diagnosis
- Gout
–Monosodium urate crystal deposition occurs secondary to hyperuricemia
–Severe pain, redness, and swelling occurring in one joint (80% of cases), usually of the lower extremity, and most classically at the metatarsophalangeal joint of the great toe (podagra)
–Tophi: Collections of solid urate in
connective tissue
-
Ingrown toenail
–Causes severe pain in the distal nail folds with associated erythema, edema, and tenderness
Trauma
–Contusion
–Fracture
Pseudogout
–Calcium pyrophosphate deposition disease
–Can affect the toe, but the knee is most
common
- Seronegative spondyloarthropathy
–Psoriatic arthritis: Spondyloarthropathy involving middle-aged patients at multiple joints associated with classic skin lesions
–Reiter's syndrome: Arthritis, uveitis, urethritis
- Septic arthritis
–Fever, joint redness, pain with passive and active range of motion
–Most often due to skin flora such as Staphylococcus aureus and various streptococci
–Neisseria gonorrhoeae in young sexually active adults
–Often associated with previous penetrating trauma to the toe
- Less common etiologies (“zebras”) include cholesterol emboli, infective endocarditis, Lyme disease (presents as monoarticular arthritis in 10% of cases), and paronychia (bacterial infection of the posterior nail folds)
Workup and Diagnosis
-
History and physical examination
-
Initial laboratory studies may include CBC, electrolytes,
BUN/creatinine, calcium, magnesium, phosphorus, ESR
–Blood cultures and Lyme titers may be indicated
–Iron studies (ferritin, iron, TIBC) may be useful if suspect
pseudogout, as many patients have underlying hemochromatosis)
- Aspiration of the affected joint and synovial fluid analysis
–Look for infection, inflammation, blood (hemarthrosis of
trauma), and crystals
–Gram stain, culture, and polarized light microscopy
–Fluid cell counts typically reveal <50,000 white blood
cells/mL in inflammatory processes, and >50,000 white
blood cells in infectious arthritis
–Gout: Needle-shaped, negatively birefringent crystals
–Pseudogout: Linear-shaped weakly positively birefringent
crystals
- Radiographs may reveal fractures, chondrocalcinosis (pseudogout), signs of osteomyelitis (septic arthritis), or erosive distal bone changes (psoriatic arthritis)
Treatment
-
Gout: NSAIDs, corticosteroids, colchicines for acute attacks; colchicine, urate-lowering agents (e.g., allopurinol, probenecid) for chronic management
-
Ingrown toenails: Warm soaks, removal of toenail if persistent
-
Pseudogout: NSAIDs, corticosteroids, colchicines for acute attacks; NSAIDs, colchicine, urate for chronic management
-
Trauma: Most closed toe fractures can be treated with stiff-soled shoes (to unload the metatarsal heads); “buddy-tape” immobilization may help relieve pain; rest, ice, NSAIDs, elevation
-
Reiter's syndrome: Prednisone, indomethacin, sulfasalazine, methotrexate; local injection of steroid
-
Septic arthritis: Treatment is based on clinical scenario and initial Gram stain; ceftriaxone for gram-negative infections, cefazolin for gram positives, add gentamicin for pseudomonal infections
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Book Source Details
- Book Title: In a Page: Signs and Symptoms
- Author(s): Scott Kahan, Ellen G. Smith
- Year of Publication: 2004
- Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.
Other Book Chapters Related to Toe pain
Read excerpts from these other book chapters related to Toe pain:
Medical Books Excerpts
- Toeing In
- "In A Page: Pediatric Signs and Symptoms" (2007)
- [ read ]
Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.
More About Causes of Toe pain
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More About This Book:
Title: In a Page: Signs and Symptoms
Authors: Scott Kahan, Ellen G. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2004
ISBN: 1-4051-0368-X
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» Next page: Toeing Out (In A Page: Pediatric Signs and Symptoms)
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