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Managing Injuries of the Great Toe

R. Sean Churchill, MD; Brian G. Donley, MD


In Brief: Most of the common great-toe injuries that affect active people are self-limiting and easily treated if detected early. Reviewed here are the causes, symptoms, diagnosis, and treatment of hallux valgus, turf toe, hallux rigidus, sesamoid dysfunction, nail abnormalities, dislocations and fractures, calluses, and blisters. Conservative treatment will usually enable patients to return to activity relatively quickly. Continued disability may require referral to an orthopedist.

Great-toe injuries are common in people who are involved in all kinds of sports, but particularly in dancers, runners, and soccer players. Without proper care, these injuries can interrupt a person's exercise program or severely limit an athlete's performance. With proper diagnosis and conservative treatment, however, most patients can anticipate relief from symptoms and a resumption of previous activities.

Hallux Valgus

Hallux valgus is a subluxation of the first metatarsophalangeal (MTP) joint manifested by the medial deviation of the first metatarsal and lateral deviation of the proximal phalanx. ("Bunion" refers to any enlargement of the MTP joint caused by disorders such as osteoarthritis, enlarged bursa, or a ganglion cyst.) Originally described in 1870 (1), the condition has since been attributed to the wearing of high-fashion women's shoes (2,3). Common causes include hereditary conditions, pes planus (flatfoot), and hyperelasticity disorders.

Hallux valgus in active individuals depends on a number of factors. Different sports put varied pressures on the foot. Walking generates a force in the forefoot equal to 80% of the body's weight; running increases it to 250% of body weight (2). The severity and progression of deformity depend on the particular sport. For instance, dancers develop hallux valgus at a younger age than is seen in the general population (4,5). A deformity may affect one patient differently from another because various sports make different demands on the foot. For example, sprinters require an extended range of motion in both dorsiflexion and plantar flexion of the first MTP joint, while middle- and long-distance runners do not (6).

Anatomy. The anatomy of the first MTP joint is complex (figure 1). Since no muscles insert into the head of the first metatarsal, its position is primarily influenced by the position of the proximal phalanx. With increasing lateral deformity of the proximal phalanx, the first metatarsal head is progressively deformed medially, resulting in widening between the first and second metatarsals. This widening, coupled with lateral deviation of the great toe, creates a prominent and painful bunion along the medial aspect of the first metatarsal head.

[Figure 1]

Diagnosis. The patient's primary symptom is pain over the prominent medial eminence, often caused by irritation and pressure from shoes. Repetitive athletic activities such as running can lead to the development of an inflamed bursa, skin blistering, and skin breakdown. Localized pressure can even cause compression of the dorsal medial sensory nerve to the great toe, causing neuritic pain or numbness.

As the deformity progresses, the first metatarsal can no longer support the forces across the forefoot, and increasing forces subsequently are transferred to the second metatarsal. Ultimately, this leads to the development of a painful, intractable plantar keratosis (callus) beneath the second metatarsal head.

The physical examination should begin with the patient standing. Hallux valgus deformities are often accentuated with weight bearing. Observe for other postural abnormalities, such as pes planus, or a contracted Achilles tendon, which may contribute to the deformity. Check for decreased great-toe range of motion, joint crepitus, and pain, which are often the first signs of degenerative arthritis. Local irritation may occur over the medial eminence and the plantar calluses, and either site may be tender to palpation. Finally, a thorough vascular and neurologic examination should be completed.

Radiographic evaluation should consist of weight-bearing anteroposterior (AP), lateral, oblique, and sesamoid views. The severity of the deformity can be quantified using the AP view (figure 2).

[Figure 2]

Treatment. Conservative care is the cornerstone of treatment for patients who have hallux valgus. This is especially true for athletically active individuals because postoperative stiffness can occur.

Shoe modifications can be helpful. Stretching of shoes in constricted areas may relieve symptoms, but custom-made shoes, though expensive, may provide more relief. In any case, wearing shoes with a broad toe box to accommodate the prominent medial eminence should help. High-heeled shoes should be replaced with flatter dress shoes that do not increase the downward pressure that forces the toes into a narrow toe box.

Besides footwear modifications, bunion pads, night splints, and toe spacers can also offer relief. Orthoses can help redistribute weight away from a painful callus under the second metatarsal head. Athletes who have a tight Achilles tendon may benefit from daily stretching exercises. Conservative treatment of hallux valgus generally should continue indefinitely or until pain and discomfort force the patient to make significant changes in athletic activities (7).

Surgery may then be considered, but the patient should first be counseled regarding options. Postsurgery stiffness can make running more difficult than the pain the athlete was trying to eliminate in the first place (8). If a patient is willing to change activities—for example, to substitute a nonimpact sport such as bicycling for running—he or she may reduce pain and further deformity and avoid surgical intervention. If a patient is unwilling to make such changes, an orthopedic surgeon should be consulted.

Turf Toe

Turf toe is simply a hyperextension injury to the great toe. The term was originally coined for football and soccer players who injured their great toes on artificial turf (9-11). Runners and other athletes who do not compete on artificial turf can also sustain this injury.

Anatomy. The first metatarsal head articulates with the medial and lateral sesamoids on its plantar aspect (figure 3). The sesamoids are contained within the flexor hallucis brevis tendon and are distally connected to the base of the proximal phalanx by the plantar plate. Medial and lateral stability of the sesamoids is imparted by the tendons of the abductor and adductor hallucis as well as by the intersesamoidal ligament. This complex stabilizes the plantar aspect of the first MTP joint.

[Figure 3]

A forced hyperextension of the first MTP joint results in a capsular injury of varying severity, with associated compression injury to the dorsal articular surface in severe cases.

Diagnosis. Patients usually report a sudden onset of great-toe pain after a forced dorsiflexion, such as can occur when a football player whose crouched position has already maximally extended his MTP joint takes the weight of a falling opponent (12).

On physical exam, the patient walks with an antalgic gait, either externally rotating the lower extremity to avoid first MTP dorsiflexion during push-off or walking on the outside of the foot to minimize pressure on the first MTP joint. Periarticular swelling and ecchymosis vary according to the severity of the injury. Passive motion at the MTP joint is painful (13) and demonstrates decreases in dorsiflexion, plantar flexion, or both. Normal active range of motion of the first MTP joint is from 80° of dorsiflexion to 25° of plantar flexion (figure 4) (7). An additional 25° of dorsiflexion can be obtained passively (14).

[Figure 4]

AP, lateral, oblique, and sesamoid radiographs often show no bony abnormalities. However, occasionally a capsular avulsion fracture on the first metatarsal head or proximal phalanx can be identified. Other radiographic findings in more severe injuries include sesamoid bone fracture or intra-articular loose bodies caused by a compression fracture.

Turf toe injuries are classified into three grades, as described in table 1 (12).

Table 1. Grading of Turf Toe Injuries

GradeSigns and SymptomsTissue Disruption
1Plantar or medial tenderness, minimal swelling, no ecchymosis, negative x-raysStretched plantar capsuloligamentous complex
2Diffuse tenderness, moderate swelling, ecchymosis, restriction of motionPartially torn plantar capsuloligamentous complex without articular injury
3Severe dorsal tenderness, plantar tenderness considerable swelling, ecchymosis, marked range-of-motion restrictionCompletely torn plantar capsuloligamentous complex with compression injury to dorsal articular surface; may represent a spontaneously reduced great-toe dislocation

Treatment. The initial treatment for all grades of turf toe is rest, ice, compression dressings, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs), but other treatment measures vary with the grade.

Grade 1 injuries can usually be treated effectively with conservative measures. Patients may continue sports activity if (1) they wear stiff-soled shoes to prevent dorsiflexion beyond 30° during the push-off phase, and (2) the great toe is taped by bringing tape from the dorsal surface of the great toe to the plantar surface to prevent dorsiflexion beyond 30° (15).

Patients with grade 2 injuries should refrain from athletic activities for 1 to 2 weeks and wear stiff-soled shoes; a rigid orthosis should be inserted to further prevent dorsiflexion of the first MTP joint. Grade 3 injuries require the same modalities as grade 2, but the restriction of athletic activities is 3 to 6 weeks. If these conservative measures fail for grade 3 injuries, surgery for plantar capsule repair or loose-body removal may be necessary (9).

A patient's return to activities should progress gradually from weight bearing to walking to jogging, using discomfort as a guide. A complete return to play should be permitted only after full-speed running and cutting maneuvers are pain free (15). With proper care, the prognosis for full recovery is excellent.

Hallux Rigidus

Hallux rigidus is the painful, progressive loss of motion of the first MTP joint. Patients report a history of trauma that can be a single episode of axial compression of the first MTP while playing football or soccer or multiple, less traumatic events that can occur in many activities, from ballet to track and field. Predisposing factors include repetitive hyperextension of the first MTP joint (16) and an abnormally long first metatarsal (17).

The condition develops over months to years when a dorsal osteophyte forms on the first metatarsal head and a circumferential rim of osteophytes develops at the base of the first proximal phalanx (figure 5). As these osteophytes enlarge, they eventually impinge on one another, leading to decreased range of motion and pain.

[Figure 5]

Diagnosis. The primary symptom is decreased great-toe range of motion, primarily in extension. Patients also have pain with walking and running. Pain also occurs when a patient walks without shoes and is exacerbated when he or she walks in a shoe that has an elevated heel. Intermittent swelling and pain at the base of the great toe are also common symptoms.

A physical exam reveals an enlarged, tender first MTP joint, with limited dorsiflexion. Dorsal metatarsal osteophytes, usually dorsolateral, may be palpable. Pain is produced by passive and active hyperextension and maximal plantar flexion, which tents the dorsal capsular structures over the osteophytes, resulting in increased tenderness before any appreciable mechanical block. In contrast, dorsiflexion is limited but less tender, and the maneuver often seems to indicate a mechanical block, both objectively and subjectively. Pain in the chronic condition occurs only at the extremes of motion, but in the acute phase accompanied by synovitis, it occurs with any joint motion (15).

Initial radiographs should include AP, oblique, and lateral views. Although these may be normal, they eventually show progressive osteoarthritis of the MTP joint. The lateral radiograph (figure 6) reveals dorsal osteophytes on the proximal phalanx and the first metatarsal.

[Figure 6]

Treatment. Initial treatment should include rest, ice, NSAIDs, and shoe modifications. A stiff- soled shoe to decrease dorsiflexion combined with an enlarged toe box to accommodate swelling may be adequate to relieve symptoms. A rocker-bottom shoe can be prescribed, but this may adversely affect athletic performance and thus be unacceptable.

If symptoms persist, an intra-articular corticosteroid injection (15) can provide some relief. However, injections should be used sparingly because they do cause damage to the remaining cartilage surface. Patients who have continued disability should consult an orthopedic surgeon about surgical options, which may include the removal of loose bodies from the joint, excision of osteophytes (cheilectomy), osteotomy of the proximal phalanx, or MTP joint arthrodesis.

Sesamoid Dysfunction

The primary functions of the sesamoid bones (figures 1 and 3) are to increase the moment arm of the flexor hallucis brevis muscle, reduce friction, and distribute the pressure of weight bearing.

Athletic injury to the sesamoids is not uncommon and can occur acutely or with repetitive stress. An acute sesamoid fracture usually follows a specific event, such as a dancer's landing from a leap (15) or a forced dorsiflexion stress in football linemen and soccer players. Sesamoiditis is a specific term that indicates inflammation and swelling of the peritendinous structures of the sesamoid complex. However, it is also used for any condition affecting the sesamoid—with or without inflammation—such as bursitis, arthritis, plantar digital nerve compression, osteochondritis, and a painful bipartite sesamoid.

Diagnosis. A physical exam typically reveals decreased range of motion of the first MTP joint and increased tenderness with dorsiflexion. Active plantar flexion is painful and thus weak. Direct palpation over the sesamoids routinely indicates whether the medial or lateral sesamoid is the source of the patient's symptoms. Ordinarily the patient who has sesamoiditis presents with pain under the head of the first metatarsal that ceases with rest and elevation.

Radiographs, including AP, lateral, oblique, and sesamoid views of the foot, should be carefully interpreted. About 19% of the population has a bipartite sesamoid, and 89% of these are the medial sesamoid (18). The sesamoid edges are smooth and relatively sclerotic in the bipartite sesamoid (figure 7), while they appear rough and irregular in an acute or stress fracture. If radiographic findings are unclear, a bone scan can help distinguish an acute fracture from a bipartite sesamoid.

[Figure 7]

Treatment. Treatment for sesamoid pain is conservative. Symptoms can be relieved by eliminating the use of high-heeled shoes to reduce forefoot pressure and by using a J-shaped pad or orthotic donut to decrease pressure on the affected sesamoid. NSAIDs are also prescribed to reduce inflammation. Treatment for sesamoiditis may take 4 to 6 weeks.

Sesamoid fractures are treated with 3 weeks of great-toe immobilization and the use of crutches. When the patient resumes bearing weight, he or she should use a stiff-soled shoe until pain subsides. Following a sesamoid fracture, dancers may gradually resume practice when symptoms resolve (15), but complete recovery may require a full year.

If the condition fails to respond to 6 weeks of treatment, radiographs should be repeated. These may reveal a loss of joint space between the sesamoid and the metatarsal head, characteristic of degenerative arthritis, or fragmentation of the involved sesamoid, indicating osteonecrosis. Treatment of degenerative arthritis and osteonecrosis should be similar to that of sesamoiditis but should last 4 to 6 months. If the condition fails to improve, referral to an orthopedic surgeon for possible excision of the involved sesamoid should be considered.

Toenail Abnormalities

Ingrown nails. Ingrown toenails are ordinarily a minor nuisance, but they can disable an active person if they are not treated early. The condition occurs most commonly in athletes in their teens and early 20s and can be caused by an acute trauma, such as stubbing the toe, or repetitive stress such as occurs in long-distance running. Improper nail care is a common cause. Cutting on a curve or tearing predisposes nails to be ingrown. As the nail grows, the nail corner presses on the nail fold. If this pressure is not relieved, the nail may penetrate the nail fold and cause infection. Tight-fitting shoes can also increase pressure between the nail and nail fold, which results in ingrowth (19).

Diagnosis. Physical examination reveals a characteristic erythematous nail fold that is edematous and tender to palpation. Care should be taken to verify that there is no fluctuance to the nail fold, indicating a purulent fluid collection that would require drainage and antibiotics. In chronic or more severe acute cases, radiographs should be obtained to rule out coexisting osteomyelitis.

Treatment. Initial treatment involves local measures. The affected border of the toenail should be gently elevated from the nail fold, and a wisp of cotton carefully inserted beneath the nail plate edge. The patient should soak the toe twice daily in a warm salt solution, carefully dry the toe, and wipe the area with alcohol.

Follow-up should occur in 5 to 7 days, when the cotton should be changed. Cotton packing should be continued until the nail plate has grown beyond the distal nail fold edge. Patients should be instructed on proper nail cutting: trimming straight across the nail without curving the medial and lateral edges. The fit of the patient's street and athletic shoes should be checked to prevent recurrence.

Patients who have chronic or severe conditions and severe cases that do not respond to local measures are candidates for operative treatment.

Subungual hematoma. This common condition usually occurs when someone steps forcibly on the great toe or when the toe is repeatedly jammed against the end of the toe box during activities such as soccer or tennis. In fact, the average soccer player loses 2 to 3 toenails per year of soccer playing time from subungual hematomas (15).

If the patient presents acutely, the hematoma can easily be decompressed by penetrating the nail plate vertically with a hot paper clip, providing immediate relief. The patient should be told that the nail will eventually detach as the new nail grows. Chronic cases can result in deformed and thickened nails.

Dislocations and Fractures

Dislocations of the first MTP joint are usually the result of a violent force, as when the forefoot strikes an immovable object or a blocked ball (15). Dorsal dislocation is more common than plantar dislocation and may be associated with intra-articular fractures.

Patients will usually present with a history of trauma, followed by spontaneous or self-reduction of the joint at the scene. The physical examination should focus on the neurovascular status of the great toe. A subungual hematoma is often present and is not diagnostic of a phalanx fracture. AP, lateral, sesamoid, and oblique views of the foot should be obtained and evaluated for fractures and small, loose bone fragments in the first MTP joint.

The foot should be immobilized in a splint and the patient referred to an orthopedic surgeon. Final treatment depends on injury severity. For a simple dislocation, treatment may include rest, ice, and a stiff-soled shoe, with return to play 4 weeks after injury. More complicated injuries may require operative reduction of fractures and removal of cartilage fragments from the joint. Aggressive treatment of great-toe dislocations and fractures is warranted because of the toe's importance in daily and sports activities.

Plantar Calluses

Calluses are hyperkeratotic lesions. Primarily located on the sole of the foot under the metatarsal heads, they are a protective response to imbalanced weight distribution. They are commonly seen under the first metatarsal head and on the plantar medial aspect of the great toe in soccer players (16) and may eventually become symptomatic as their size increases.

In symptomatic patients, examination reveals tenderness with deep compression of the callus. A plantar wart and a callus can be confused, but distinguishing them is quite simple: Plantar warts are painful on medial-lateral compression, but calluses are not. In addition, shaving causes pinpoint bleeding in a plantar wart but not in a callus.

Treatment involves thinning the callus by shaving it, followed by daily filing with a pumice stone after showering. Total-contact molded inserts manufactured by a local orthotist will help redistribute uneven weight-bearing forces and prevent recurrence. Patients whose calluses do not respond to this program should be referred to an orthopedist to be evaluated for possible structural foot abnormalities that may require surgical correction.


Blisters are a common annoyance for most people, but can impair the performance of an athlete. They form as a result of friction and resulting shearing forces on the skin that cause the accumulation of fluid between the epidermal layers. A common cause of foot blisters is wearing new shoes that have not been properly broken in.

A large blister that interferes with an athlete's performance should be drained by sterile aspiration with a 27-gauge needle. The skin should be kept intact to prevent infection and should be protected with gauze and tape for the first 24 hours. A patient can continue athletic activity comfortably by placing a donut pad around the blister for protection. Preventive measures include properly fitted athletic shoes, adequate shoe break-in before hard workouts or competition, and the use of lubricants such as petroleum jelly on susceptible areas of the foot.

Excellent Prognosis

Active patients are susceptible to a wide spectrum of injuries to the great toe, from the minor annoyance of a blister to the severely disabling dislocation or fracture. With the exception of the fracture or dislocation, primary care physicians can manage most of these conditions. Early diagnosis and conservative treatment should enable most patients to recover fully and resume previous levels of activity.


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Dr Churchill is a resident and Dr Donley an associate staff orthopedic surgeon in the section of foot and ankle surgery in the Department of Orthopaedic Surgery at the Cleveland Clinic Foundation in Cleveland. Address correspondence to Brian G. Donley, MD, Cleveland Clinic Foundation, Dept of Orthopaedic Surgery/A41, 9500 Euclid Ave, Cleveland, OH 44195.



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