Big toe pain

Common causes of big toe pain

You use your big toe every time you walk, stoop or stand, so a problem in its main joint (the first metatarsophalangeal, or MTP, joint) is hard to ignore.^[3] The table compares the usual causes. It’s a guide for your visit, not a way to diagnose yourself.

Cause	How it starts	Where it hurts	Other clues
Gout	Suddenly, sometimes waking you at night	The whole joint: red, hot and swollen	Too tender to bear a bedsheet; attacks come and go[1]
Bunion	Slowly, over years	A bump on the inner side of the joint	Hurts in narrow shoes; the toe leans toward the second toe[2]
Big toe arthritis (hallux rigidus)	Gradually	In and on top of the joint	A stiff toe; pain pushing off or squatting[3]
Turf toe	Suddenly, when the toe is forced upward	The base of the big toe	Swelling and bruising after a sports injury[4]
Sesamoiditis	Gradually, with overuse	Under the joint, on the ball of the foot	Common in runners and dancers[5]
Broken toe	Right after stubbing or crushing it	The injured bone	Bruising and swelling; the toe may look crooked[7]

Is big toe pain gout?

Sometimes. Gout is arthritis caused by uric acid crystals that settle in a joint, and the first attack often hits the big toe.^[1] An attack comes on suddenly and can wake you at night with pain so intense that you can’t bear a bedsheet on the toe. The joint turns red, swollen and hot. An attack can last 3 to 10 days and settles much faster with treatment, but attacks tend to return, and repeated attacks can damage the joint.^[1]

An infection in the joint can look just the same, and a uric acid blood test can be normal during an attack. Testing a small sample of fluid from the joint is the more accurate way to confirm gout.^[1] See gout in the foot.

Bunion or arthritis?

Both affect the same joint and are often confused, but they need different treatment.^[3]

A bunion is a bony bump on the inner side of the joint, with the big toe leaning toward the second toe. It hurts mostly where the shoe presses on the bump, which can look red and swollen.^[2] Bunions develop slowly and tend to grow.^[2,8] See bunions.

Big toe arthritis (hallux rigidus) is the most common arthritis in the foot.^[6] The joint becomes stiff and sore when you walk, stand or bend the toe, often worse in cold, damp weather. Later, a bony bump on top of the joint can make shoes uncomfortable, and the toe may hurt even at rest.^[3] Read more in big toe arthritis and arthritis of the foot and ankle.

Injuries: turf toe and a broken toe

Turf toe is a sprain of the big toe joint from forcing the toe too far upward, common in football, soccer, basketball, dancing and wrestling.^[4] A mild sprain often allows a return to sport within days; a partial tear usually means 2 to 4 weeks out, and a complete tear longer. Fewer than 2% need surgery.^[4] See our article on turf toe.

A broken toe usually comes from stubbing or crushing it. An X-ray shows whether the bone is broken and out of place.^[7] A broken big toe that is still in line is often treated in a walking boot or cast for two to three weeks, then a stiff-soled shoe for three to four more.^[9] One that is out of place often needs to be set and held in position.^[7] See fractures and trauma.

Pain under the big toe joint

Under the joint sit two small bones called the sesamoids. They act as pulleys for the tendons that bend the toe and help carry your weight. When the tendons around them become irritated, the result is sesamoiditis: pain under the big toe that builds up gradually, common in ballet dancers, runners and baseball catchers. A sesamoid can also break, from repeated stress or when the toe is bent sharply backward.^[5]

Most sesamoid problems settle without surgery, with rest from the activity that hurts, ice, low-heeled shoes, a felt pad that takes pressure off the bone, and taping. If symptoms continue, a removable short leg brace for 4 to 6 weeks may be needed.^[5] For pain further across the ball of the foot, see ball of foot pain.

When it isn’t the big toe joint

• A bent second, third or fourth toe. A hammertoe is bent at its middle joint and rubs on the shoe, often with a corn on top.^[10] See hammertoes.
• Corns and calluses, which are often linked to shoes that don’t fit.^[11] See corns and calluses.
• Pain under the base of a smaller toe, sometimes with the toe drifting out of line, can be a plantar plate tear, a common but easily missed cause of forefoot pain.^[12] Our Center for Lower Extremity Surgery has a guide to plantar plate tears (external site).
• Burning, tingling or a pebble-like feeling near the third and fourth toes can be a Morton’s neuroma, a thickening around a small nerve.^[13]

How we evaluate and treat big toe pain

Dr. Ozturk is a Foot and Ankle Surgeon and podiatrist who sees patients with big toe pain at our offices in Lyndhurst, Paramus and Millburn, NJ. We ask how the pain began, check how far the toe bends and where it is tender, and look at your shoes. X-rays at the practice show arthritis, bone spurs and broken bones.^[3,7] When gout or infection is possible, a blood test and a sample of fluid from the joint help confirm the cause.^[1]

Treatment depends on the cause:

• Shoes: a roomy toe box for a bunion, a stiff or rocker-bottom sole for an arthritic toe, soft low-heeled shoes for sesamoid pain.^[2,3,5]
• Pads, inserts and orthotics that take pressure off a bunion or the sesamoids.^[2,5] For big toe arthritis, two small trials found that arch-supporting orthotics and shoe-stiffening inserts worked about as well as sham (dummy) inserts, so we don’t rely on inserts alone for an arthritic toe.^[14]
• Calming inflammation: ice, anti-inflammatory medicine if it is safe for you, and sometimes a corticosteroid injection for an arthritic joint or an irritated sesamoid.^[3,5]
• Gout flares are calmed with anti-inflammatory medicine, colchicine or a steroid, chosen around your other health conditions; see gout in the foot. Frequent attacks may need long-term medicine to lower uric acid, usually managed by your primary care doctor or a rheumatologist.^[1]
• Surgery, from removing bone spurs to realigning or fusing the joint, is considered for a bunion or arthritic joint that stays painful and keeps limiting your walking despite these measures.^[6,8] Dr. Ozturk performs it himself; see bunion surgery (external site) at our Center for Lower Extremity Surgery.

Common questions

Why does my big toe hurt at night?

Gout is the classic cause: an attack can wake you at night with intense pain.^[1] Advanced big toe arthritis can also ache at rest.^[3] Night pain with a red, hot, swollen joint should be checked promptly, and the same day (or in an emergency department) if you have a fever or chills.

Why does my big toe joint hurt when I walk?

An arthritic joint hurts as the toe bends with each step, a bunion hurts where the shoe presses, and an irritated sesamoid hurts under the joint as the toe moves.^[3,2,5] For an arthritic toe, shoes with a stiff or rocker-bottom sole, which limit how far the toe bends, are often recommended.^[3]

When to seek care