Burning 2nd toe

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Hi all,

I have a case that is baffling me a little that I'm hoping for some advice with. Complicating the issue is that the patient is a friend's father who lives 8 hours away, I see him only occasionally. He has seen a podiatrist where he lives who I regard as very competent.

HISTORY
58 year old male
No significant medical history
Osteoarthritis right knee
Has had left heel pain (plantarfasciitis) which was resolved with orthoses and
acupuncture
Wears orthoses daily at work (mine site)

CURRENT ISSUE
Occasional severe burning in 2nd toe only right foot. Location is the two distal phalanges, possibly isolated to the distal interphalangeal joint.
Not an obvious pattern (timing of symptoms) except it usually occurs twice each day, once in the morning and once in the late afternoon. I have not seen the patient while the toe was sore.
Does not swell or change colour
No initiating factor obvious (eg: injury, change in footwear / activities)
5 months duration
Occurs despite wearing orthoses plus the recent addition of a metatarsal dome. Is not worse when without orthoses. Is not worse when OA knee is particularly sore.
Acupuncture (one event) no help

EXAMINATION
No toe deformity
No reproduction of symptoms on movement of IPJs and MPJ through range of motion
Mild discomfort to palpation of 2nd/3rd plantar webspace. No Mulders sign. I would expect something a bit more definitive to make me suspect a neuroma.
Mild discomfort to plantar 2nd MPJ and plantar proximal phalanx
First ray is not excessively compliant to dorsiflexion
FPI +5 bilaterally
Lunges reveal no limitation of ankle joint dorsiflexion, but the feel (nonweightbearing dorsiflexion) is there is increased stiffness.
Very dry skin, reduced elasticity of skin and plantar fat pad

DIFFERENTIAL DIAGNOSES
1. Intermetatarsal neuroma - most likely due to the definite burning symptom. Although orthoses with met dome and calf stretches haven't helped, diagnostic ultrasound to confirm.
2. Osteoarthritis of the IPJs - although no pain on range of motion, radiographs will rule out.
3. Dorsal interosseus trigger point - unlikely as acupuncture did not help
4. Sausage toe - unlikley as no swelling or colour change

PLAN
1. Check with you guys to make sure there is nothing I've missed - don't you hate it when friends / family come to you with something curly and you feel like a dill because you don't immediately know what it is and how to fix it!
2. Radiographs - have requested
3. Diagnostic ultrasound once radiographs confirmed negative with a view to ultrasound guided cortisone injection if neuroma demonstrated.

Thanks in advance for your help. The patient is in town for the next week (though he has forgotten to bring his orthoses with him).

Rebecca

 

Does he get any burning on the lateral 1st aswell? Deep peroneal impingement from shoes?

 

Hi Nicole,

Nothing on the hallux but thanks, I hadn't thought of that. I will assess for anyway.

Regards

Rebecca

 

I have found this joint to be associated with the acromioclavicular joint on the contra lateral side. The constant reflex from the AC joint when the rest of the body is at rest can bring the symptom to the surface of consciousness. which is why it is most prevalent upon awakening and when resting after work.
It could be part of the posture pattern that is the source of the right knee arthritis.
Hans Albert Quistorff, LMP
Antalgic Posture Pain Specialist

 

Antalgic Posture Pain Specialist, try saying that fast!

 

Antalgic Posture Pain Specialist If I say it often enough they are sure to think I am precocious even though I am 70 years old and say it often enough so that it comes out easily. Then on the other hand [oops should say foot in this forum] I have been saying tung twisters since I was 4.

 

Rebecca:

The most common cause of this finding would be an intermetatarsal neuritis/neuroma or neuritis caused by a plantar plate tear. These are often difficult to differentiate. I will treat these with an orthosis with a forefoot accommodation for the 2nd metatarsophalangeal joint (3 mm of korex under 1, 3, 4, 5), leave the orthosis anterior edge about 4-5 mm thick, use a metatarsal pad with a 3 mm thick neoprene topcover for these patients. Have him ice 20 minutes twice daily to reduce inflammation in the area, avoid barefoot and I think a periarticular cortisone injection may also work well.

Often times, patients with an affected interdigital nerve will have decreased sensation in the interspace to light touch and sharp/dull sensation, which will help you determine whether the pain is neurological in origin or not. Also, to aid in your palpation of the area, try using a skin lubricant such as K-Y jelly on the plantar metatarsophalangeal joint to see if any irregularities can be detected in the area.

Hope this helps.

 

An update:

Radiographs reveal no degenerative change at the interphalangeal or metatarsophalangeal joints.

Burning is experienced only on the 2nd toe, and more on the lateral side than the medial side, ruling out deep peroneal nerve impingement.

there are no AC joint symptoms.

Treatment options at this stage are:
1. Do nothing
2. Further orthotic modification as per advice above
3. Diagnostic ultrasound for intermetatarsal neuroma and plantar plate tear with view to guided cortisone injection if confirmed.

The patient feels that his toe doesn't give him enough trouble to warrant an injection at this stage and has decided to do nothing for now. I have referred back to his original podiatrist for further orthotic modification should the patient present with the same problem.

Thanks for your help.

Rebecca