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Fat toe...????

Discussion in 'General Issues and Discussion Forum' started by phil, Feb 2, 2006.

  1. phil

    phil Active Member

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    Picture this-

    16 year old female, recently returned from France with a swollen, erythematous, painful right second toe (right foot).

    Been to GP, xrays show nothing. No history of trauma, just started getting swollen.

    Toe is only painful to walk on in the mornings for a little while, otherwise it dosn't bother her too much. Main concern is that it looks strange and it is sore to touch.

    2nd MPJ is fine. Squeezing the distal phalanx dosn't hurt. Moving the IPJ's is painful, as is squeezing the proximal and intermediate phalanxs.

    I'm pretty much lost for answers. No history of trauma says its not a Fx. I suppose it could be RA, OA, Gout or some other arthritis but its a pretty wierd presentation. I'm even thinking things like vasospasm or cellulitis, but it just dosn't look like any of those things.

    Is there any sort of vascular thing that would happen to cause such a strange presentation in only one digit?

    It just looks like a boring old fracture, except it can't be!!!

    Any ideas? Am i missing something really obvious??
  2. Craig Payne

    Craig Payne Moderator

    My first thought is that its the dactylitis ('sausage' toe) usually associated with one of the seronegative spondyloarthropathies, usually psoriatic or reactive (Reiters)
  3. A 16 year old girl in France???? Do pointy-toed tight shoes being worn all day on long walks while on vacation (to match what the French girls/women are wearing) sound like something that a 16 year female old would do?

    As my medicine professor always liked to say, when you hear hoofbeats clomping outside your house, think horses, not zebras.

    Advise for her to wear comfortable shoes, no dress shoes, for two weeks along with icing of the affected digit for 20 minutes every evening. I think that you will find that the digital pain, erethema and swelling have virtually subsided. If not, then start doing blood tests.

    However, I have been wrong before....maybe once??? ;)
  4. phil

    phil Active Member

    I thought of the pointy shoe situation, but she swore black and blue that she wore her Converse All Stars the whole time.

    I might advise the 20 minutes icing everynight and see if it helps, but im still concerned that its something a little more sneaky than that.

    Would seronegative arthritis related dactylitis just occur in one toe and no other joints in the body? I made sure to check she didn't have a history of other joint sympoms or family history.

    Thanks for your help.
  5. kimharman

    kimharman Member

    in my world a asausage toe is osteomyelitis (I work in diabetes) so look id for secondary bacterial infection following primary fungal especially if warm weather in pointy shoes making feet sweat! Kim
  6. W J Liggins

    W J Liggins Well-Known Member

    I go along with Kevin in that it is sensible to look for the usual before the unusual. However, as Sherlock Holmes said (I paraphrase) 'When the usual has been eliminated then that which remains, however unusual, must be the truth'.
    Given the age of the patient and the symptoms, it would certainly be worth running an MRI to discount malignancy. The scan should pick up any unusual soft tissue problems in addition.
    Alkl the best

    Bill Liggins
  7. A digital photo of the affected digit during relaxed bipedal stance along with a photo of her shoe insole would help us immensely. If this were my patient, I would make her wear loose fitting shoes at least 2 weeks before more extensive testing is done. You must personally check her shoe fit with her standing in the shoes to make sure the toe isn't banging against the end of the shoe since many 16 year old girls wear shoes that are 1-2 sizes too short, which they consider a "normal shoe fit".

    A word of advice.....if a girl or woman says their shoes aren't too short, I don't believe them since, in my 20+ years of clinical experience, this has little representation in reality. Girls and women in Western Culture generally consider a normal shoe fit to be at least 1.0 shoe sizes too short. Sometimes an isolated long digit will not be accounted for by the female patient when they are fitting shoes so that shoe irritation to that digit will occur with long periods of weightbearing activity.

    I still hear horse's hoofbeats outside my door until the shoe issue is thoroughly ruled out in this patient.
  8. One Foot In The Grave

    One Foot In The Grave Active Member

    But mine really do fit properly!! But then I'm not pretending my feet are size 8!!

    Back to the OP - I had a client 2 weeks ago who had a massivly enlarged hallux on one foot. He did have a history of trauma (jumping a fence at age 70!!), but no pain, redness, or loss of movement. You've reminded me I must call him and see how his toe is going.
  9. John Spina

    John Spina Active Member

    She was in France?Well,what do you do a lot of while you are in France?EAT AND DRINK.Consider gout as a diagnosis(yes,she is rather young,still it is something to think about)Run bloods just to be sure.
  10. It would be nice to hear how this young lady is doing as she progresses, Phil. Followup postings by the original author on these clinical cases is essential to provide those following along with useful clinical information.
  11. davidh

    davidh Podiatry Arena Veteran

    Screams psoriatic arthropathy to me.
    Do a simple skin check before anything else. Does she have rough patches on an elbow or knee?
    Are there any dry patches on her scalp?
    Easy and non-invasive. If these are blank then you can widen your search....
    As Bill Liggins has suggested though, malignancy should not be ruled out either.
    Keep us all up to speed on this interesting case.
  12. martinharvey

    martinharvey Active Member

    Swollen toe

    :confused: embolism from a long flight? is such a migration, ?query from a DVT, possible to a digit? - martin
    Last edited: Feb 17, 2006
  13. CAS

    CAS Member


    Female presented today with a 'sausage' toe (2nd right digit) today and wondered if your pt's problem was resolved with clarification of aetiology?


  14. CAS

    CAS Member

    Hello all,

    The female pt, above, popped in to see me last Friday to tell me what had caused her "fat toe". Incidentally, that wasn't the reason for her visit to me last August, it was met pain in the other foot. The toe was asymptomatic but was already in the process of being dealt with by the gp/hospital. The pt wasn't really bothered about it as it wasn't painful.

    Anyway, transpires after an MRI scan in January!!! that it was a giant cell tumour, which are commonly found in the long bones, but have been reported to occur in the foot. I googled and found the following:-

    Giant cell tumours are made up of a large number of benign (non-cancerous) cells that form an aggressive tumour, usually near the end of a bone near a joint. Cause unknown but in some cases (not in this one), has been linked to Paget's disease. They can re-occur.

    The toe actually increased to twice the size before surgery to remove the tumour from the tendon sheath in May and would have kept growing, so she was told.

    It was good to know the outcome for this pt and another differential diagnosis if any of you come across it. I did take a photograph last year but the file is too big to insert here.

    Hope this has been helpful.

  15. Mr liggins wins the cigar.
  16. martinharvey

    martinharvey Active Member

    Thanks for the feedback Caroline, most interesting. PS. I think Bill may prefer a pint of Ruddles.


  17. sausagetoe24

    sausagetoe24 Welcome New Poster


    I am a 24 year old female that came across this post and it struck my interest since I am going through the same issue with my middle toe on my right foot, and now several more toes on both of my feet for several years now and went to over 6 or 7 doctors who still were not able to pin point the exact cause/cure for this.

    I took high res pictures of my right & left foot and would love to hear any insight or feedback from everyone.

    Right Foot IMAGE
    Left Foot IMAGE

    The most obvious "big toe" is the middle toe on the right foot which started back in 2003-2004 when I was 19-20 years old.

    On the left foot my big toe and index toe are also inflamed. These 2 toes became inflamed about 2 years ago. Now I feel like the middle toe on the left foot is starting to inflame because I feel the same type of pain like when my other toes started to inflame.

    I have done MRI's & X-Rays and the doctors found nothing wrong with the bone.

    Any information that can help get my once beautiful toes back into shape I will owe the world to them!

    Thanks in advance.

  18. drsarbes

    drsarbes Well-Known Member

    Hi Phil:
    Lots of advice here!
    idiopathic swollen digit in a 16 year old with neg x-ray and no HX of truama.

    I first think of repeated microtrauma.
    If nothing there psoriatic arthritis is fairly common.
    I would do the usual, i.e., more detailed history, blood work.

    Sometimes when I KNOW it's not an infection I'll Rx oral cortisone for a week and see what response I get.

    Good luck
  19. sausagetoe24

    sausagetoe24 Welcome New Poster

    Dr S Arbes,

    What did you think of the post before yours and the images attached?

  20. Mart

    Mart Well-Known Member


    Is your toe constantly like this or episodic?

    Please could anyone with good understanding of MRI and it's limitations explain what might have been revealed.

    My assumption is that not only bone but also joint and surrounding soft tissues should have been nicely depicted.

    Therefore evidence of joint effusion (indicating some form of arthritis), subcuteneous edema (problem with lymphatic vessels?), space filling lesion would have been differentiated throwing some light on this?

    Imaging experts out there?



    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
  21. sausagetoe24

    sausagetoe24 Welcome New Poster


    My toe has constantly been like this since 2004 and is spreading on to more toes.

  22. drsarbes

    drsarbes Well-Known Member

    This does not look infected. There is fusiform swelling, chronic apparantly, around the PIPJ.
    The remaining toes and joints that I can see appear normal.
    There appears to be a small amount of interdigital dermatitis in the first interspace bilaterally and a small papulosquamous macule at the base of the left secend digit. The nails are covered.

    If (BIG IF) you have ruled out truama and an old osteo, (and not seeing any x-rays or lab work)
    the most likely Dx is arthritic.

    Given the age and the normal appearance of the rest of the toes, the lack of complaints in other joints (you didn't mention any) my best educated guess is:
    1. psoriatic arthritis,
    2. RA,
    3. seronegative arthropathy.

  23. Mart

    Mart Well-Known Member


    I agree with you, but am still curious regarding my intial question, since this person has had an MRI done could we expect at least to differentiate articular problem from bone or peri-articular cause of swelling.

    A bit of cut and paste below regarding distinguishing features of potential foot monoarthritis to support your view.



    Psoriatic arthritis may be indistinguishable from rheumatoid arthritis in onset and progression,and there are no diagnostic laboratory tests for psoriatic arthritis. However, it more typically is asymmetrical oligoarticular or monoarticular.

    Most cases of psoriatic arthritis are controlled with NSAIDs; for those whose arthritis is not satisfactorily controlled with NSAIDs and for those who are experiencing joint damage the DMARDs used for the treatment of rheumatoid arthritis are effective.

    Seronegative spondyloarthopathies such as reactive arthritis and Reiter's syndrome most commonly present as asymmetric oligoarthritis affecting the lower extremity joints.

    Reactive arthritis is a sterile inflammatory arthritis that occurs as a consequence of infection at a remote site. It should be suspected when there is a recent history of diarrhea, chlamydial infection, unexplained genitourinary symptoms, prostatitis, cystitis or conjunctivitis. Reiter's syndrome is a reactive arthritis that occurs within 3 weeks of a chlamydia infection of the genitourinary tract or after an intestinal infection, typically caused by Salmonella spp., Shigella spp., Campylobacter spp. or Yersinia spp. Extra-articular symptoms associated with the full-blown syndrome include conjunctivitis, circinate balanitis and hyperkeratotic skin lesions on the soles called keratoderma blennorrhagica.

    The triggering infection should be treated as appropriate; screening of contacts at risk must be included in the management of patients with genitourinary reactive arthritis and selected patients with enteropathic Reiter's syndrome. Management of the arthritis must be individualized and may include NSAIDs, oral or intra-articular steroids and, in resistant cases, DMARDs.

    Osteoarthritis affecting DIP, PIP and CMC joints may be associated with symptoms and signs of inflammation.Onset is common in perimenopausal women, and there is often a family history of Heberden's osteoarthritis. Patients complain of joint tenderness and episodes of swelling usually in 1 or several finger joints at a time. Examination discloses Heberden's and Bouchard's nodes in finger and sometimes toe joints; MCP and MTP joints are not affected. Radiographs of affected joints show narrowing, osteophytes, sclerosis and, in the advanced stages, PIP or DIP joint erosions. Because of the prominent involvement of DIP joints, it may be difficult to distinguish inflammatory osteoarthritis from psoriatic arthritis, which may also develop in older patients. It is important to remember that rheumatoid arthritis can occur in patients who also have osteoarthritis.

    The St. James Foot Clinic
    1749 Portage Ave.
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    Last edited: Feb 12, 2008
  24. drsarbes

    drsarbes Well-Known Member

    Hi Mart

    >>>>>>>>>>>>>"I agree with you, but am still curious regarding my initial question, since this person has had an MRI done could we expect at least to differentiate articular problem from bone or peri-articular cause of swelling.'<<<<<<<<<<<<<<<<<<<<<<<

    We've all seen a lot of "idiopathic" joint inflammation that do not necessarily have pathonomonic changes on MRI. I know when I read MRI’s it’s always helpful to have the plain films as well as the History to steer me in the right direction.

    In short, I would not say that merely having the MRI done is going to make a diagnosis (in these cases). If there is no specific & characteristic joint destruction or specific periarticular or intraarticular synovial thickening or proliferation, it would be difficult to label. It's difficult sometimes just deciding if a tendon has a tear or just lots of synovitis in the sheath!!!!!! I always find it incredibly educational to perform surgery on patients that have had an MRI and relate surgical anatomy to the MRI appearance. Frequently it's an eye opener.

    Don’t you agree?

  25. Mart

    Mart Well-Known Member

    Hi Steve

    Interesting perspective, and I envy your opportunity to compare imaging with the real thing.

    As a non surgical podiatrist I do not get that opportunity and have long suspected that would be a very useful. I have no training in MRI and my interpration requires guidance.

    thanks for your insight

    did you start doing any US yet?


  26. anjana

    anjana Welcome New Poster

    I have just seen a patient today c/of a ''fat toe''. The patient is female, 42yrs old. The toe affected is her R/hallux and the swelling and redness is very localised just proximal to the PNF. Temperature around the area is normal. It is a soft tissue lesion and just feels like a fluid filled blister but just under the skin. There is no cuticle and when probing there is no evidence of paronychia or obvious sign of nail trauma, or any history of trauma. The toenail is slightly discoloured-she has seen her GP re-this and he has prescibed a 3month course of oral anti-fungal meds. She is also taking anti-inflammatories and has had a course of anti-biotics. X-rays, blood tests, skin scrapings, toenail clippings..have all been done with no problems reported. There is no history of diabetes or arthritis. Footwear is good, either trainers or open toed flat sandals. The patient has M.E. however and says she is mostly resting and footwear at home are always slippers. I have referred the patient to a dermatologist for further investigation and she should be seen within the next 2 weeks. I'm just lost as to what it could be and would like some help with this please.

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