Painful lump under middle toe

by Tricia C.
(Houston, TX)

I am a 49 year old woman who is in good shape. I walk at least 2 miles a day plus I lift weights. I have suddenly developed a very painful lump at the base of my middle toe on my left foot. I didn't step on anything and I always wear supportive athletic shoes when I walk. There is redness at the base of the toe around the edge of the lump. Otherwise, everything looks normal. I cannot see any swelling but I can feel the lump under the skin. It hurts to touch and to walk on it.

I have been diagnosed with high blood pressure and hypo-thyroidism and I take medication for each. I was also diagnosed with RA but I really haven't had any symptoms except occasional swelling and pain in my hands and I am not being treated for that.

What's going on with my toe?

RESPONSE

Hi Tricia,

The lump could be a variety of different things and without actually examining you I cannot give you a definitive diagnosis. Having said that I will discuss the most probable cause for your lump underneath the second toe.
More than likely the problem exists with what is known as the flexor tendon; the tendon underneath the toe that bends the toe downward. That is basically the only structure located between the bone and the skin on the bottom of the toe.
You may have a partial tear of the tendon that has caused it to swell but in most cases the lump is the result of a ganglion cyst that grows off the tendon.
Most people are familiar with ganglion cysts on the top of the hand or the top of the foot, but a ganglion cyst can occur anywhere in the body growing off any tendon.
A ganglion cyst is essentially a herniation off of the tendon. When you press on the lump most times it will have a spongy texture to it. As you walk and your toe stretches particularly as your toes bend when you stride forward, the growth gets stretched and that will cause pain.
A cousin of the ganglion cyst that might give you the same sensation and same appearance would be what is known as a synovial cyst. This cyst instead of coming off the tendon, will arise from the soft tissue that makes up the joint where two of the toe bones comes together.
You mention that you have been diagnosed with rheumatoid arthritis and even though you do not have symptoms, another possibility causing the growth on the bottom of your toe is a rheumatoid nodule. It would not be my first choice in a diagnosis but it must be taken into account, as rheumatoid nodules quite often occur on the bottom of the foot.
So, assuming your problem actually is a ganglion cyst, what can you do about it?
Obviously it is going to cost you a visit to a foot specialist, one to make an accurate diagnosis and two, to get treatment.
I generally offer my patients a cortisone injection with the hopes that the needle itself will burst the growth and of course, the cortisone will reduce the associated inflammation. This can, in many cases, solve the problem, however, almost every doctor will tell you that ganglion cysts can grow back. If that is the case, you can always have another injection and the notion of having injections once or twice a year would not be the worst decision you could ever make.
If the prospect of repeated injections does not work for you, the other option would be surgical excision of the growth. It is not a complicated procedure, but like the injections, surgical excision is not a guarantee that the growth will not grow back.

Marc Mitnick DPM
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