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a painful big toe.

I suppose the first thing that comes to mind when a patient presents with a painful
big toe is gout - that is, assuming there is no history of trauma. When the gouty
attack is full-blown, diagnosis is usually simple - a red, painful, exquisitely sensitive
toe, with pain exacerbated by active or passive joint movement. When less acute,
diagnosis can be problematic, as the pattern is similar to any other form of toe
arthritis. An elevated serum uric acid usually makes the situation clear.

If the onset of pain was preceded by trauma, traumatic arthritis, subungual
hematoma, ligament strain or fractures need to be ruled out. All of these will
display local symptoms and signs when examined carefully.

Where diagnosis becomes more challenging is when minimal signs of
tenderness, swelling or pain on movement are present. Then we must start
thinking about referred pain. (Some tenderness may be present with referred pain.)

Elementary neuroanatomy tells us that irritation of a L5 nerve root can cause
pain in a first toe, although it is usually accompanied by pain down the posterior
leg.

An uncommon cause of first toe pain is pain referred from the liver through the
corresponding acupuncture meridian. The liver meridian extends down to the
lateral side of the first toe. One method of diagnosing is checking the liver by
autonomic response testing. Treatment may be neural therapy of the liver.

Pain can also be referred from musculoskeletal structures. A quick check of
Hackett's map of referred pain from low back ligaments shows no referral of pain to the
first toe. However pain can be referred to the first toe from hip ligaments.

And then there are muscles, in particular, their trigger points. I personally have been
unable to memorize all the pain referral patterns from muscle trigger points, so I depend
on Travell and Simon's 2-volume "Myofascial pain and dysfunction: The trigger
point manual". Not only are these books well written and well illustrated but also the
organization is superb.

The first volume is about the upper part of the body, the second the lower. In the inside
of the front cover is a list of the muscles in the volume and on the facing page a guide to
where they can be found. In the case of toe pain, we are quickly directed (in the second
book) to Chapter 18 where one finds that great toe pain can be referred from three
different muscles: the tibialis anterior, the extensor hallucis longus and the flexor
hallucis brevis. Each pattern is somewhat different, e.g. the tibialis anterior trigger
point (TP) also refers to the anterior ankle. The extensor hallucis longus referral pattern

those conditions that give rise to TPs in the first place. The factors that created the TP should be addressed as well as associated interference fields. in old bone contusions. To these. A trigger point was detected distal to the junction of the medial and lower thirds of the lower leg. He gave no history of trauma or strain. the Travell "spray and stretch" technique can be used or the TP can be treated directly with an energetic device such as the Tenscam. but centers more on the dorsal aspect of proximal first toe. probably related to chronic sacroiliac instability. especially during the weight-bearing phase of gait. Travel and Simons always give advice about "perpetuating factors". Identification and treatment of trigger points is an important part of neural therapy and often helps solve difficult-to diagnose pain problems. The patient who reminded me of this was an otherwise healthy 70-year old man who presented with pain over the proximal first toe. He felt it most while walking. a tight piriformis muscle was present. But the neural therapist should not stop at simply treating the TP. in injection sites and in the L3 sympathetic ganglion. Examination including muscle strength can give clues. anterior to the fibula. the neural therapist can add the possibility of other interference fields and the osteopath can search for somatic dysfunction. When it is found an injection of procaine ½% into the TP combined with stretching the muscle can give relief from the toe pain. the leg and pelvis should be searched for interference fields in scars. . In the patient mentioned above. In the case of toe pain from tibialis anterior or extensor hallucis longus trigger points. but ultimately the TP has to be found in the muscle. Alternatively.does not include the anterior ankle.