Addressing Longtime ‘Big Toe Pain’ In A Younger, Active Patient

I recently heard from a 27-year-old active male, who noted big toe pain in his left foot for the last seven to eight years. Exercise seems to exacerbate the pain and it calms down when he rests the foot. The patient noted the pain does not seem to be getting worse although it does tend to be quite tender after running. He has no bone spurs that he can feel and retains the same range of motion as the other foot. The patient had X-rays about seven years ago when he noticed it and the podiatrist suggested hard sole shoes and orthotics, which he didn't follow through with using.

The patient asked me if he should be treating this like a sore joint and avoiding exacerbating activities, or look into surgery. If it is the latter, he asked which surgery might ultimately help him retain maximum functionality of the toe.

In a situation like this, one has plenty of time to find three to five modalities that help de-stress the joint and perhaps slow down the joint breakdown. The patient is way too young to have joint surgery and there is no surgery out there that makes the joint better in my opinion. You can make a toe straighter. You can remove bone spurs that get in the way of motion. You can fix or remove broken bones. However, unless we have more info in terms of a diagnostic workup you cannot make the joint better by cleaning it out.     

What typically makes the big toe joint better are effecting biomechanical changes (via shoes, pads, orthotics, activity modifications), anti-inflammatory measures (icing, physical therapy, contrast bathing, topical and oral meds), immobilization measures (cross training, plates, spica taping, stiff sole shoes, removable boots) and getting further information (X-rays, magnetic resonance imaging, bone scans, computed tomography scans).    

My goal for the patient would be to try one modality a month for the next seven months (like icing for 10 minutes twice a day). Definitely use the KISS principle (Keep It Simple, Stupid) by using the least invasive modalities first. Find three to five modalities that help somewhat (10 to 20 percent pain reduction) and make a cocktail for less pain.