Big Toe Joint Pain: Causes and Treatments

Bunions – hallux valgus

It’s estimated that more than one-third (36 percent) of Americans over 65 have bunions. The bony growth can form on any toe, but it commonly occurs at the base of the big toe, on the inside of the foot. Everything from genetics — for example, inherited foot structure (a reason your gait might be similar to a family member’s) — to regularly wearing pointy, tight-fitting shoes can increase your risk for bunions.

When the big toe moves sideways and crowds the other toes, it puts more pressure on that MTP joint. This, in turn, can break down cartilage and can cause arthritis. The term “valgus,” which is synonymous with “crooked,” refers to the angling of the big toe away from the midline toward the other toes.

Treatments are similar to those for hallux rigidus. Nonsteroidal anti-inflammatory medications, icing and steroid injections can all help reduce inflammation. But they don’t address the bunion itself.

“Bunion pain in this case is due to pressure from the shoe rather than compression of the joint,” says Milad Kashani, a podiatric surgeon at Seattle’s Integrative Foot & Ankle Centers of Washington. The goal of treatment is to reduce this pressure, Kashani says. This can be done with wider shoes, stretching shoes, adding padding or surgery, he notes.

Surgical options include a procedure to shave the bony bump on the side of the foot, called an osteotomy, and fusing of the joint.

Gout: A flare affecting the big toe signals a whole body problem

Gout, another form of arthritis, can cause intense pain, swelling and redness in the big toe and other joints. Unlike osteoarthritis, the “flares” associated with this chronic disease, caused by a buildup of uric acid in the blood, come on more suddenly, the result of acid hardening into sharp crystals in the big toe joint.

More than 12 million adults in the United States have gout, and for most, the most common initial symptom is big toe pain, says Dr. Theodore Fields, an attending rheumatologist at the Hospital for Special Surgery and a professor of clinical medicine at Weill Cornell Medicine at Cornell University in New York City.

Call it the canary in the coal mine — or maybe a screaming eagle, to more aptly describe the pain. Identifying gout usually requires taking a patient’s medical history, conducting a physical exam and testing, Fields notes. A joint fluid analysis can detect the presence of monosodium urate crystals under a microscope.

Flares are typically treated with anti-inflammatory drugs and, in some cases, a cortisone injection in the affected joint. Medicine to lower uric acid levels, most commonly allopurinol, can prevent future flares, Fields notes, if a person is able to continue taking it. Medication side effects range from drowsiness and dizziness to joint pain, stiffness and swelling. 

Sesamoiditis: More bones, more problems

The big toe’s bone structure is different from its counterpart digits to account for the extra pressure applied to the toe in daily activities. Two little bones on the bottom portion of the big toe, called sesamoid bones, aren’t found in the other toes, and with an attached tendon they help us get up and around.

“That’s really one of the most powerful muscles in our big toe ... that flexor that helps us push off during gait,” Holleran explains. “So the sesamoids attach within that tendon and help that tendon glide and move.”

All that pressure put squarely on the big toe, and its uniquely complex skeletal anatomy, can open it up to even more issues. Turf toe is a sprain of the tissue around these tiny, round sesamoid bones. The injury is most common in athletes. You can also get an overload or stress fracture of a sesamoid, which can cause pain, Holleran notes.

Sesamoiditis is “kind of a grab bag term for all of those issues,” she says.

Initial treatments are generally similar to those for other causes of big toe pain:

• Taking a break from the activity.
• Icing the affected joint.
• Taking anti-inflammatory medication available over the counter, as needed, for pain relief.
• Wearing a stiffer-soled shoe, a shoe with a little rocker on the bottom or inserts to provide support can be helpful.

For an injury, as when you stepped wrong and have a stress fracture in your sesamoid, immobilization of the joint temporarily might be necessary, Holleran says. That could include walking around in a medical “boot” for some time before gradually again wearing a regular shoe.

Functional hallux limitus

Big toe not at 100 percent? It could be functional hallux limitus. Allowing big toe joint issues to snowball can make it harder to effectively treat underlying conditions, experts say.

For example, a person’s big toe joint may start “jamming” when pressure is applied, says Kashani, who is also a clinical educator in the podiatric medicine and surgery residency program at Seattle’s Swedish Medical Center. The range of motion is restricted when bearing weight, but a person may be able to move the toe just fine while seated. This is called functional hallux limitus.

Addressing this early — say, through footwear changes or orthotics— can prevent more significant issues later, Kashani says.

“I feel like that’s one of the things that sometimes gets missed … you have that functional limitation of motion that can lead to arthritis,” he says. “You’re in the early stages, and in those cases we really try to improve function to improve that joint long term.”

X-rays won’t pick up on this issue, so experts say it’s important to get checked out quickly to avoid more pressing problems — and get back on your feet sooner.