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Big Toe Pain or Stiffness

What is big toe pain?

When we talk about big toe pain, we usually mean pain, stiffness or discomfort that applies primarily to the big toe on either foot, and not the other toes or the ball of the foot.

What causes big toe pain?

There are a number of things that can cause big toe pain. Naturally, if you stub your toe, drop something on it or otherwise injure your toe, pain is a common consequence. But what about big toe pain that has no apparent cause?

First metatarsal-phalangeal joint osteoarthritis (1st MTPJ OA)

One of the most common causes of big toe pain or stiffness is osteoarthritis. The big toe joint plays a significant role when we walk, and as a result, it bears a great deal of weight and mechanical stress throughout daily life. Osteoarthritis develops when the cartilage at the joint begins to degenerate (wear and tear) and the joint space becomes narrowed. This causes the pain and stiffness we associate with osteoarthritis.

What causes 1st MTPJ OA?

1st MTPJ OA develops as a result of gradual wear and tear of the protective cartilage that surrounds the bones which form the big toe joint. As the cartilage wears away, the joint space between the two bones of the big toe joint becomes more narrow, which causes the joint to become more restricted. There are multiple reasons why you might develop 1st MTPJ OA. These include:

Secondary arthritis from a previous injury or medical condition e.g., a fracture or gout
Foot anatomy or altered foot mechanics – varying anatomical alignment or how the foot moves and functions can increase your risk of developing OA
Genetics
Lifestyle

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What are the treatment options?

There are multiple big toe joint pain treatment options for 1st MTPJ OA. The following advice can be very helpful:

Do ✓

Wear flat, stiff-soled shoes such as firm trainers or walking shoes/boots. This will reduce movement and stress at the joint, which will reduce pain.
Rest the foot where possible to avoid putting undue pressure on the joint.
Use painkillers, such as paracetamol or ibuprofen, to help relieve pain and inflammation.
Use hot and cold therapies: heat can help alleviate stiffness and cold can help alleviate swelling.
Support the feet: adding a supportive insole into your shoes, such as ZeroSole Contour, may help further reduce stress (and pain) at the joint.

Don’t X

Avoid soft flexible shoes or heels as this will increase stress and pain at the joint.

Do not wear pointy shoes or those with a narrow toe box.
Do not stand or walk for long periods of time.

If at-home treatments don’t work, you may be offered a steroid injection. Cortical steroid injection (CSI) therapy would be one of the first options. A steroid is injected into the joint to help reduce pain and inflammation. Pain relief is generally temporary and the duration of relief can vary significantly from person to person. General risks include infection, bleeding, depigmentation, skin atrophy, post injection flare-up and immunosuppression up to one month following the injection.

Conservative (non-surgical) treatment is usually advised first as it is less invasive and is often effective. However, if this fails to alleviate your pain then surgery may be required. There are different types of procedures that can be performed depending on your condition. This usually involves (1) removing any bony growths/protrusions extending from the OA joint (cheilectomy) or (2) fusing the joint with plates and screws. There are multiple risks associated with surgery including infection, scar sensitivity, ongoing or worsening of pain and other general risks which will be discussed with you by your surgeon.

Other causes of big toe pain

Another common condition that can cause pain and inflammation of the big toe is gout: a type of inflammatory arthritis caused by the accumulation of urate crystals in the joint. This causes a short-term, intense pain episode in the joint accompanied by inflammation (red, hot, swollen skin) and can sometimes make the affected skin look shiny.

Gout pain is usually so intense that even slight pressure from bed sheets is difficult to tolerate. Gout attacks generally occur spontaneously overnight and last a few days to a week. If you suspect you have symptoms of gout, it is important that you consult with your GP as they will need to run certain blood tests to confirm the diagnosis. If you are diagnosed with gout, your GP will normally prescribe you with a temporary course of medication to settle the acute symptoms, followed by a long-term prescription to prevent future attacks.

Regardless of the suspected cause of your big toe pain, you should consult a GP or healthcare professional if you have diabetes as well. This is because injuries and infections to the foot can cause diabetic complications.

What are the symptoms of 1st MTPJ OA?

Arthritis will affect everyone differently, and symptoms may not always be present early on but may gradually develop over time as the condition advances. Symptoms can include:

Pain – It might feel like there’s pain in the joint itself, on top of the joint or underneath your foot at the base of the big toe joint. Pain can be worse first thing in the mornings or throughout the day when you’ve been on your feet a lot.
Stiffness in your big toe – The range of motion in your big toe may gradually reduce and you may find it harder to bend your toe upwards.
Heat or swelling around the joint – Sometimes the big toe can appear swollen or inflamed if the joint has become aggravated by daily activities such as walking and activities that bend the joint, such as kneeling.
The joint may appear more prominent or enlarged and protrusions or growths of bones may form on top of the joint.
Difficulty or altered walking due to pain or reduced motion in the joint.

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