Alex is an apprentice plumber. One afternoon he hobbled into the surgery. “Gee, my toe’s sore”, he said. “And everywhere I go I knock the bloody thing!”
He carefully took of his right boot and climbed onto the couch. When I removed his sock, I could see why he was so upset. His big toe was quite swollen. On the inner side of the nail was some infected-looking tissue that appeared to be growing in from the side. A small amount of pus seeped out from underneath. He had an infected ingrown toenail
Alex was pleased to hear that ingrown toenails are very common and that they might settle down without surgery. I suggested that he take a course of antibiotics and bathe his foot twice a day in warm salty water.
When I reviewed him a week later, his toe had improved considerably. However, a few months later he was back again with the same problem. I referred him to a consultant surgeon and he subsequently had a wedge resection of his toenail. He was back a to work the following week and his toe has caused him no further problems.
It is surprising how many people come to their doctor with a sore big toe. Frequently, the cause is not obvious, especially if there has been no recent injury to the foot.
Trauma: The big toe has a remarkable capacity to get in the way. Stubbing the toe on a bed post or a door is common. It tends to happen at night when undressing or walking to the bathroom and it often triggers the most colourful expletives. Injuries including bruising, fractures, collections of blood under the nail, lacerations and even the tearing away of the nail. The big toe is also prone to being trod on by others. It can be a target for dropped tools and pot plants and even a well-placed yorker can do some damage.
Ingrown toenails tend to occur in adolescents, especially males. The toenail typically appears too broad for the available space and tends to push out and fold under. The chronic irritation that follows predisposes to infection. The condition can run in families and both sides of the toe may be affected at the same time. It is often a recurrent problem and antibiotics may be necessary. Several minor procedures can give relief. The more complete operation, called a wedge resection, involves removing the side of the nail all the way to where it grows from, well below the base of the nail. This usually fixes the problem.
Gout often causes a hot, swollen joint at the base of the big toe. Other joints can also be affected. The underlying disorder is due to a build up of uric acid in the blood. Crystals of uric acid form in the joint and cause it to become acutely inflamed. It is extremely painful and usually leaves a person limping around in slippers. Even the weight of bedclothes on the foot can be unbearable. Chronic elevation of the uric acid level can also cause damage to the kidneys. In some cases gout can be precipitated by excessive alcohol, eating too much rich foods, especially meats, and even certain medications. It is more common in men and there may be a family history. Acute attacks of gout usually settle well with ant-inflammatory medication. However, if it becomes recurrent, further investigations and preventative medication may be advised. For anyone with gout, a general health check is a good idea.
Osteoarthritis may affect the main joint at the base of the toe and cause considerable pain. It may develop after years of strain on the joint, or from previous trauma. It usually causes an intermittent ache rather than the acute pain of gout. An X-ray can assist with the diagnosis. Sometimes a course of anti-inflammatory medication is advised. Correcting any arch problems with orthotics may also help. In severe cases, referral to a specialist may be required.
A bunion is an enlarged sac of fluid overlying the inside part of the base of the big toe. The toes are usually sharply angulated towards the outer part of the foot. Bunions are very common in women and can be caused by years of tight-fitting footwear. Because they tend to get inflamed they are sometimes mistaken for gout. Occasionally they can discharge fluid, especially if they become infected. Prevention is the best approach ... Wear broader, proper-fitting shoes and avoid high heels. With more troublesome bunions, referral to an orthopaedic surgeon may be advised; an operation can be performed to remove bunions permanently.
The big toe can be the site of other problems as well, for instance a foreign body like a splinter, or fungal infections under the nail. Tinea can also occur in the web space between the toes and this may become further infected. Sometimes other infections such as papillomas or warts can also cause the toe to become sore.