top of big toe pain

by cheryl
(USA)

Hello, I am a 33 yo female runner, at currently about 25mpw. I was working my mileage back up to where I like it for the spring, trying to increase distance at 10%ish per week, but I probably got a little aggressive with a couple of my more recent long runs in terms of speed increases. Over the last week I've started having pain on impact on my left big toe. It is on the top of the toe, between the metatarsal head and the smaller joint on the big toe. It hurts when I run but not so much when I walk. If I press on the top of my toe on the bone, in between the metatarsal head and the joint (the toe 'knuckle' I guess you could say), I can find a tender spot, as well as slightly to the left of the bone (in between the big toe and 2nd toe). There's no pain on the ball of my foot or under my toe, nor on the metatarsal behind the toe on my foot. It's pretty localized to the top of the big toe, but not the tip.

I'm going to see a doc next week because I have a history of stress fractures (have had two metatarsal sfxs, one in the navicular, and one in my hip). But I know well enough to expect he'll say 'lets treat it conservatively' even if the x ray shows nothing, and I will press for an MRI but that usually is a couple weeks out to schedule (I love my doc but I've been through this process before and I want to get an answer sooner rather than later.)

Is this possibly what people call 'turf toe'? Or just maybe tendonitis?

Thanks in advance for any thoughts.

RESPONSE

Hi Cheryl,

First, lets start off by saying this is not turftoe. Turftoe, although it does affect the big toe joint, occurs on the bottom of the foot and as you state your pain is limited to the top of the toe.

I am no clairvoyant but I would be very surprised if you had a stress fracture, although possible, generally does not occur in the area you are complaining hurts.

Two possibilities come to mind. The first would be what we call an extensor tendonitis which is an inflammation of the tendon that brings your big toe upwards. Certainly an act like running could over work the tendon and cause it to start hurting. This pain would probably be evident when running, when walking in shoes and even walking barefoot. If you pull the toe downwards (away from you) and the toe hurts in that area then there is a chance of extensor tendonitis.

The other and probably more common possibility would be a bone spur on the top of your first metatarsal head and even possibly the base of the big toe that attaches to the first metatarsal to form the first metatarsal-phalangeal joint.

Depending on your foot biomechanics and the fact that you have been a runner for a long time there can be a constant jamming effect of the toe into the first metatarsal head when you run and walk. This jamming effect over time causes a stress reaction and the first metatarsal head and even the great toe start to hypertrophy, meaning the bones start to produce an overgrowth of bone.

Eventually you end up with a bone to bone jamming and thus you get pain. Typically the big toe will not be able to bend up as high as it once did. As you bend your big toe towards you with your hand you should experience an increase in pain.

Both these conditions are treatable, but it will require an x-ray. Do not get to hung up on having an MRI just yet as they are generally not required unless your doctor suspects something else.

If it is tendonitis it can be readily treated; if it turns out to be a bone spur issue also known as hallux limitus, this too can be treated but treatment may end up being more involved. In most of these cases an orthotic is required to re-balance the great toe joint, otherwise the pain will only worsen.

Surgical intervention is occasionally recommended to remove the bone spurs to increase range of motion and eliminate the jamming effect. This is all predicated on how bad your problem is.

Marc Mitnick DPM
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