If you are a runner and you have pain in the big toe joint, the first step in treating it is figuring out what is actually causing the problem. There are lots of different causes of pain in the big toe joint, but there are really five that affect runners most often. These are the most common that I see in runners, so I’m going to explain all 5 of the conditions to you.
The first thing is turf toe. Now turf toe is an injury to the big toe joint where you basically damage the joint capsule surrounding the big toe joint. This is usually something that you get with a sudden, traumatic injury. The term “turf toe” actually comes from AstroTurf, or playing football on artificial turf, where you can actually really jam the toe, get a lot of force through the toe, and it damages the joint capsule and causes an injury.
It is really unusual in runners to get that kind of turf toe injury. I have seen turf toe a couple of times in triathletes who have gotten it when they kicked somebody during the swim, but it’s rare by comparison. But if you get it, it really hurts when you move the big toe in pretty much any direction, but it’s hard to pinpoint exactly where it hurts. But it does move when you move the big toe joint, and it’s usually swollen and really aching. It starts with a really sudden onset. So, that’s one of the keys.
Now, the second in jury affecting the big toe joint is a sesamoid injury. Sesamoid injuries are injury to either of these two little bones that sit under the big toe joint, and they’re basically like tiny little kneecaps, but they’re sitting under the big toe joint. They are called sesamoid bones. The seamoids are about the size of kidney beans. If you get too much pressure, or too much irritation, to one of those little sesamoid bones, you can develop inflammation in the sesmaoid bone, which we call sesamoiditis.
If you apply pressure to the injured sesamoid, continue to stress to it, too much over and over and over by the way that you are running, because of your running form, you can get an actual sesamoid stress fracture. A sesamoid stress fracture is much more serious than a case of sesmaoiditis. If you really damage the sesmaoid bone enough, you can actually get a true sesamoid fracture…and that’s a terrible thing. But that sesmoaid pain is very specifically on the bottom of the big toe joint, and you can usually find the specific spot where it hurts. So, if you push around on the bottom of the big toe joint, and you find one spot where it hurts way more than another, and that’s the spot where that particular sesamoid bone is, then you can tell you probably have sesamoiditis.
But you have to think about this, because sesamoid injuries are so serious, you need to take it really seriously, because sesamoid injiuries are a risky thing for runners. You do not want to ignore a sesamoid injury and just keep running on it, making it worse. So, if it’s hurting when you run, you need to figure out what’s going on first.
The next thing is gout. Now, gout is a condition runners often ask me about. They will say, “I think I have gout because I have pain in my big toe joint.” But I don’t really think gout is very common in runners. I think it’s just that there’s so much stuff written online about gout and about how you get these uric acid crystals in the joint, but the truth is is it’s very rare for athletes. I’ve only seen this a few time in athletes, and in those cases, they’re people who have gotten severely dehydrated. So, they’re probably prone to getting gout, but then because they lose so much water in their system to dehydration during a race or during training, their relative concentration of the uric acid in the blood goes up, and they get an attack of gout.
But gout is pretty unmistakable. It’s extremely painful. It starts relatively suddenly, usually when you’re dehydrated, or you’ve eaten some huge meal that’s high in protein, meat. It’s very rapid onset, and it’s excruciatingly painful. The big toe joint is also usually red, hot and swollen when you have gout. The classic description is that people will say it hurts so much that they can’t even sit in bed because the bedsheets hurt when they touch it. It’s bright red, it’s really swollen, it is supremely inflamed, and it’s not really easy to confuse it with the other conditions.
Now, the next thing is bunions. A bunion deformity is one of the most common things that podiatrists treat, but it’s pretty obvious when you have it. Your big toe is changing position. It’s drifting over toward the second toe and the first metatarsal bone at the base of the big toe joint is sticking out in the other direction. The bump at the base of the big toe gets red and irritated when you rub it the wrong way in running shoes.
A bunion can really flare up too. Some people will say, “My bunion got way worse overnight.” Well, that’s not true. If your bunion got way worse overnight, the bunion or the positioning of the bone didn’t really change, but the bursa overlying the bone got irritated, and then it swelled up, and it makes it look way worse. So that is the fourth condition that causes pain in the big toe joint in runners…bursitis.
Sometimes people mistake big toe joint bursitis for gout just because it is bright and red right where the bursa is irritated, but it’s a completely different condition. The redness is also usually only in one spot with bursitis, but the whole area around teh big toe joint gets red and swollen with gout.
Now, the fifth thing is hallux rigidus, or hallux limitus. They’re basically the same condition. They’re just different names for the same condition. “Hallux” means big toe, “rigid” obviously means it’s stiff, and “limitus” means that the big toe joint motion is limited or it doesn’t move as much. In cases of hallux rigidus or hallux limitus, this is basically the opposite of a bunion deformity. This is a condition where you get stiffness and limited range of motion in the joint, and then because it’s limited, when you move the big toe joint, you’re actually jamming the cartilage, irritating the cartilage, and in some cases, lining the inside of the joint, or the synovial tissue in the joint, and it becomes painful.
Now, that’s pretty easy to calm down, and it’s not too difficult to get it to calm down to the place so that you can run with it. I actually have that condition myself, and I still run…A LOT! All I do is lots of things to make sure I don’t irritate the joint doing other exercises. And I keep running without any trouble.
But not all these conditions mean you have to stop running. There’s whole range of conditions in the big toe joint, but you have to figure out which one of these is most likely to be causing your pain, to decide whether or not you should stop running, or whether or not you can keep running and get it to calm down while you’re still running. You just have to make sure you know which is causing the problem to figure out if you can keep running.
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!
Dr. Christopher Segler is a podiatrist and ankle surgeon who has won an award for his research on diagnosing subtle fractures involving the ankle that are often initially thought to be only ankle sprains. He believes that it is important to see the very best ankle sprain doctor in San Francisco that you can find. Fortunately, San Francisco has many of the best ankle sprain specialists in the United States practicing right here in the Bay Area. He offers house calls for those with ankle injuries who have a tough time getting to a podiatry office. You can reach him directly at (415) 308-0833.
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