There are several conditions that manifest in the big toe joint causing pain, swelling, and bony prominences. The following are three common problems that are often confused with another. It’s possible for all of these conditions to occur in conjunction with another, and it’s important to understand your problem for proper treatment.

1. Bunion (Hallux Abductovalgus)

A bunion is the most common musculoskeletal problem that affects the big toe joint. Medically termed hallux abductovalgus, a bunion is a bony, knobby structure that occurs at the base of the big toe, located on the inside of the foot. Bunions are not bone growths but, instead, are the result of a malpositioned big toe joint. Bunions vary in size and severity. They could be small bony prominences or large bumps with a deviated big toe that angles towards the second toe. Symptoms of bunions may include pain, swelling, and redness.

Treatment of bunions first begin with simple measures to reduce pressure on the bunion, which can include modifying shoes, stretching shoes, and/or wearing pads on the bunion. When the big toe deviates towards the second toe as part of the bunion, toe spacers can be used to limit the ongoing progression. Nighttime toe splints may also be used to reposition the big toe while you sleep.

Pain and anti-inflammatory medication may be used. In some cases, cortisone injections may be recommended to reduce symptoms. Bunion surgery generally involves a procedure to correct the malalignment of the bones. Two common bunion surgery methods involve either a bone cut to reshape the malaligned bone into better alignment (Austin bunionectomy) or surgery to reposition the entire deviated bone via joint fusion at the foundation of the bone (Lapidus bunionectomy). Bunion surgery is generally curative for bunions when the structural realignment has occurred.

2. Big Toe Arthritis (Hallux Rigidus)

Degeneration of the articular cartilage of the big toe joint is another common problem of the big toe. Pain, swelling, and inflammation with limitation of motion are hallmarks of arthritis. Pain with moving the joint and a grinding sensation may distinguish arthritis from other conditions. Large bone spurs may develop with more advanced arthritis and can be confused for a bunion; however, the bony prominences tend to form on the top of the joint with arthritis, whereas bunions are prominent on the inside of the foot.

Treatment for arthritis of the big toe joint first involves supportive measures to decrease inflammation. Anti-inflammatory and pain medications are a cornerstone in treatment but manage the symptoms. Changing shoes to those with a stiffer sole or a bend at the big toe joint may also decrease symptoms. Physical therapy can be helpful by keeping the joint supple and mobile because arthritis can eventually limit motion.

More advanced, painful arthritis can be treated with a cortisone shot into the joint, with the sole purpose of decreasing pain and inflammation. Surgical treatments for big toe arthritis may involve removing bone spurs (a procedure called cheilectomy), joint replacement, or big toe fusion. In some cases, surgeons may try specialized bone cuts to reorient the cartilage and preserve the joint, and this method is best for mild to moderate arthritis.

3. Gout

Gout is well known to commonly affect the big toe joint, and when this occurs it is medically termed “podagra.” Gout is a condition where uric acid crystals precipitate from the blood stream into a joint causing intense pain, swelling, redness, and transient stiffness. Gout is the result of having too much uric acid in the blood stream, and foods rich in purines can elicit a gouty attack. Gout can eventually lead to “gouty arthritis” of the joint, which is loss of the joint cartilage with accumulation of this gouty material within the joint, also known as tophi. Gout can be confused with infections of the big toe joint because the big toe can become very red, although the intense pain may be a distinguishing factor.

Treatment of gout should be managed on two fronts—the first being to medically manage the uric acid in the blood stream, and the other locally within the foot to manage the symptoms. With regard to the medical management, blood tests are needed to find the cause of gout, and this is best managed by your internist who may prescribe medications to treat excessive levels of uric acid on the bloodstream. With regard to the gout in the foot, the treatment is based on whether you are having an acute gout attack or dealing with chronic gouty arthritis. Acute gout attacks are generally treated with oral medication that rapidly decreases inflammation (such as cortisone and anti-inflammatories). Cortisone injections may be used for acute gouty attacks as well as chronic arthritis. Patients with painful, chronic gouty arthritis may seek surgery which is treated similar to that of regular arthritis.

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