Toe Pain & Toe Injuries

Toe pain

Toe injuries include common conditions, such as an ingrown toenail, black toenail, as well as fractured, broken toe, or dislocated toes.

Deformities such as hallux rigidus (stiff big toe) and hammer toe are also explained with advice on treatment, prevention, and when to see a doctor or seek professional medical advice.

On this page:

  • Black toenail
  • Broken toe
  • Ingrown toenail
  • Hallux rigidus
  • Hammer toe
  • Dislocated toe

Black toenail

Black Toenail

A black toenail or Subungual Hematoma is a common problem resulting from direct trauma and impact to the toe or overuse. The toenail turns black from blood between the nail and the skin, which may cause pressure and a throbbing sensation under the nail. This toe injury normally heals by itself but if it is more severe, further treatment may be necessary.

A black toenail can also be caused by repetitive rubbing against the inside of a shoe, for example in the case of long distance runners, which is frequently known as Jogger’s Toe. This is more common in ultra distance runners and soldiers who undertake long marches.

Signs and symptoms

The toenail appears black due to blood between the nail and the nail bed. The patient may feel a throbbing pain as the pressure increases under the nail with a pulse. Eventually, the nail may loosen from the nail bed and eventually fall off.

Treatment for a black toenail

There are two main treatments for a black toenail; trephining or nail removal.

Trephining is the process of making a hole in the nail, using a heated instrument about the size of a paperclip to pass easily through the nail.

The purpose of trephining is to relieve the pressure and pain under the toenail. The nail is then covered with a small dressing to prevent infection.

Nail removal is used in more extreme cases where the nail becomes misshaped or disrupted by the hematoma, or if there is a more serious underlying injury such as a fracture of the toe. Anaesthetic is not usually supplied, but sometimes nerve blocks are used.

Subungual Hematomas usually heal by themselves with little incident other than the pain but can become infected or disrupt the nail.

Ingrown toenail

Ingrown Toenail

Ingrown toenail or onychocryptis is a common and frustrating cause of toe pain. It is often caused by improper footwear that doesn’t allow the nail to grow properly, or due to poor nail cutting. Pain and redness around the side of the toenail are the main symptoms, and infection may occur. Read more on the symptoms and treatment of ingrown toenail.

Symptoms

It is usually the big toe or great toe that is affected. The sides of the nail will appear to grow downwards into the skin of the toe. Pain will be felt in the toe with tenderness when applying gentle pressure to the area at the side of the nail

Redness may be seen on the toe around the sides of the nail, particularly the side where the nail has grown inwards. Swelling may also be seen and infection is often possible in the form of fungal infection or becomes an infected ingrown toenail.

Treatment

Treatment in most cases is simply to soak the toe in warm salt water 3-4 times a day. This is often a simple answer to how to treat an ingrown toenail. If your toe is infected, you have diabetes or you have unusually bad foot circulation, seek medical attention from a doctor immediately.

ingrown toenail treatment

When trimming your nails, cut straight across the toenail. Do not round the corners of the toenail as this is thought to encourage growth down into the toe. Do not attempt to cut out the ingrowth yourself. Some people may advocate home remedies, although the medical profession will advise against it as this will only encourage the nail to grow back the same way again.

A Chiropodist or Podiatrist will usually elevate the troublesome section of the nail, make a V-shaped cut and attempt to stretch the surrounding soft tissue with a cotton bud. If the toenail is infected with a nail fungal infection, then treatment with oral antibiotics or local anti-fungal treatment is necessary.

Surgery for ingrown toenails

Surgery is sometimes used in very severe cases to remove the nail border. This is known as resection of the outer aspect of the nail and its purpose is to prevent the edge of the nail damaging the soft tissue of the toe at the side of the nail.

It may be done under local anesthetic with any bad tissue being removed. The nail matrix is then treated with Phenol to prevent re-growth.

Hallux Rigidus

Hallux Rigidus

Hallux Rigidus is a common cause of big toe pain. Symptoms include a stiff big toe with swelling and inflammation in the joint. There will also be a pain, particularly when walking. This may cause the person to limp or alter their walking gait and eventually the pain will be felt even when resting. Halllux Rigidus can be caused by a direct impact or from overuse.

Symptoms

Initial symptoms include pain and stiffness at the base of the big toe called the MTP joint, especially when walking. Swelling and inflammation may also be present. As the condition gets worse the patient may also experience loss of movement and walk with a limp. Eventually, pain is felt even when resting and the top of the joint will be tender to touch. Bone growth on top of the joint may occur. Pains in the lower back, hips, or knees may result due to changes to walking patterns.

Causes

The Hallux is the Latin word for the big toe and rigidus literally means rigid or stiff. The big toe is important in walking and running as it dorsiflexes (bends back) during the push-off phase of the gait cycle.

In Hallux Rigidus, the movement in the joint at the base of the big toe gradually decreases. Initially, the term Hallux Limitus is often used and the term rigidus is used later as the movement becomes considerably reduced. It is a form of degenerative arthritis, although is often initially confused with a bunion.

The condition can cause lots of further problems, especially with walking, as we require at least 60 degrees of dorsiflexion at the MTP joint for a normal walking pattern. If this is not available, compensations are made elsewhere, for example, the ankle, knee, and pelvis.

It can be caused by either a traumatic injury or through overuse. Overpronation or where the foot rolls inwards too much increases the stress on the joint. Repetitive weight-bearing in a dorsiflexed position such as when walking up mountains or driving forward in a rugby scrum or similar can be a factor.

Other causes include traumatic injury, such as stubbing the big toe causing cartilage damage in the joint. A hypermobile 1st metatarsal bone or bone, which has too much movement can also cause the big toe to stiffen over time. Rheumatoid arthritis, which is inflammatory wear and tear of the joint as well as Gout which is a form of arthritis caused by excessive uric acid in the joint can also cause Hallux Rigidus.

Treatment

Treatment of hallux rigidus is usually conservative, starting with a period of relative rest. Avoiding painful activities and substituting swimming or cycling may be necessary. This should allow pain and inflammation to reduce and normal movement return.

Anti-inflammatory medications may be prescribed. Always check with a Doctor before taking medications as some, such as Ibuprofen should not be taken my asthmatic for example. A doctor may also prescribe a Corticosteroid injection.

Any contributing biomechanical factors, such as overpronation should be corrected. Physical therapy may be employed to try to increase the range of motion at the joint using.

X-rays may display degeneration and excess bone growth at the MTP joint. In extreme cases, surgery may be required to remove bony growth on top of the joint, or even a total arthroplasty (joint replacement) can be done.

Hammer toe

Hammer Toe

Hammer toe is a condition which causes one or more of the smaller toes to become bent upwards. It is often caused by wearing shoes that are too small the toes are pushed into a shortened position, making them bend upwards. A corn or callus may develop at the top of the toe and the joint may feel painful.

Each of the 4 smaller toes consists of 3 bones called phalanges, forming two interphalangeal joints. The toe bends at the proximal or first interphalangeal joint. Initially, it can be straightened, but if left untreated, this can become a permanent deformity.

People with a hammer toe will often find that a corn or callus will develop on the top of the toe, where it rubs against the top of the footwear. This can be painful when pressure is applied or when anything rubs on it. The affected joint may also be painful and appear swollen.

Causes

Hammer toe is often caused by wearing shoes that do not fit properly. If shoes are too small either in length or width, then the toes are held in a shortened position for long periods and the muscles eventually shorten and pull the toes into the bent position.

Alternatively, it can be caused by over-activity in the extensor digitorum dongus muscle and weakness in the counteracting muscle under the foot, such as flexor digitorum longus.

Flexor digitorum longus muscle causes the toes to grip and mold to the floor’s surface which is vital in maintaining balance on rough surfaces. The tendons pass under the foot. Walking barefoot on an uneven surface is an excellent exercise for this muscle and it can be stretched by pulling the foot and toes upwards.

Extensor digitorum longus muscle (often shortened to EDL) is found in the front of the lower leg, in the outer more muscle-bound compartment. When the muscle contracts the toe are puled upwards. Toe raises are a good strengthening exercise for this muscle and it is stretched by pulling the toes and foot downwards as in a shin stretch.

Sometimes it can be a congenital condition, meaning it is present from birth. It is also more common in those with arthritis in the foot or diabetes.

Treatment

In the earlier stages of hammer toe, when the toes can still be manually straightened, then conservative treatment is appropriate. This means wearing shoes which are a half size bigger than normal and which are not narrow around the toes. Exercises to stretch the toes out and strengthen the muscles under the foot, which balances the tightness of the top tendons are important. Padding or corn plasters can be used to ease the discomfort of any associated corns and calluses.

If this fails or if treatment is not sought until the toes are permanently misaligned, then surgery may be required. Surgery may involve either cutting the tendon or fusing the joint. Congenital conditions should be treated in early childhood with manipulations and splinting.

Broken toe/toe fracture

Broken Toe

Broken toes can be painful and usually occur as a result of severe impact or trauma. The big toe and the little toe are the most commonly fractured as they are the most exposed. Any pain will be instant at the time of the fracture, with swelling and bruising sometimes developing. However, when smaller toes are broken, there may not be such obvious signs.

Symptoms of a toe fracture include pain at which is felt instantly at the time of injury. The toe may swell up quickly and bruising may appear if there is associated soft tissue injury. In severe fractures which have become displaced the toe may look deformed. Often with fractures of the smaller toes, the patient is not aware that they have a fracture.

Toe fractures explained

The toes are made up of 14 bones called phalanges, 3 in each of the small toes and 2 bones in the big toe or hallux as it is known. Fractured phalanges are different from a fractured metatarsal, which is actually in the foot, rather than the toes.

Fractures to the phalanges usually occur as a result of direct trauma, such as something being dropped on the foot, or even stumping your toe! The Hallux (or big toe) can suffer a stress fracture, which is common in adolescent athletes.

The most common toe fractures are a broken big toe and broken little toe or pinky toe as it is also known. This is because these two toes are more exposed and more likely to come into contact with hard objects. The other toes are protected more by the other toes beside it.

Treatment

Treatment of a broken toe will often mean rest to start with. Take the weight off the foot, elevate it and apply cold therapy as soon as possible. Applying ice to the toe will help relieve the pain and prevent swelling which will delay the healing process.

If you suspect a broken bone then visit your Doctor who may refer you for an X-ray to confirm the diagnosis. However, often a minor fracture in one of the smaller toes will not require any treatment and the patient will not be disabled for any period of time.

Fractures in the Hallux or big toe or more complex fractures may require the patient to wear a walking boot for 2-4 weeks to protect the foot. Alternatively, the buddy taping is done where the injured toe is strapped to the adjacent one.

Dislocated Toe

Dislocated Toe

Dislocated toes are normally caused by direct trauma to the toe. This can sprain the toe ligament and displace the phalanges bones in the toe. Severe pain will appear at the time of impact and can be reproduced by trying to bend the toe. Seeing a doctor is recommended to ensure the bone heals properly.

Signs and symptoms include immediate intense pain in the toe at the time of injury. The toe will be extremely painful when attempting to bend the toe. A visible deformity may be obvious but this is not always the case. Swelling, bruising, tenderness, or numbness may also be present.

Some people are more prone to dislocations due to lax ligaments or malformed joint sockets. Dislocated toes are very painful, and medical assistance should be sought immediately. Never attempt to reduce or pop the toe back into place yourself.

Treatment

  • Apply the principles of R.I.C.E.(rest, ice, compression, elevation) until medical attention can be sought.
  • Try to see a doctor within 6 hours to ensure proper healing. The doctor will manipulate the toe back into place and may buddy-strap the toe (to the one next to it) to ensure that it heals correctly.
  • An X-ray may be taken before treating the dislocation to ensure there are no other complications.
  • After the reduction (manipulation to put the joint back in place), a period of care should take place which might include strapping, ice and heat, whirlpool treatments, and strengthening exercises.
This article has been written with reference to the bibliography.