Causes of Pain in the Big Toe Joint

There are several conditions that manifest itself in the big toe joint causing pain swelling and bony prominences. Below are three common problems that are often confused with another. It’s possible for all of these conditions to occur in conjunction with another and it's important to understand your problem for proper treatment.   

Bunion (Hallux Abductovalgus)

Bunions can rub against the shoe and get irritated with exercise. Dr. Neal Blitz /

A bunion is the most common musculoskeletal problem that affects the big toe joint. Medically termed hallux abductor valgus, a bunion is a bony knobby structure that occurs at the base of the big toe, located on the inside of the foot. Bunions are not bone growths but instead are the result of a malpositioned big toe joint. Bunions vary in size and severity. They could be small bony prominences or large bumps with a deviated big toe that angles towards the second toe. Symptoms of bunions may include pain, swelling, and redness.  

Treatment of bunions first begins with simple measures to reduce pressure on the bunion, which can be modifying shoes, stretching shoes and/or wearing pads on the bunion. When the big toe deviates towards the second toe as part of the bunion, toe spacers can be used to limit the ongoing progression. Night time toe splints may also be used to reposition the big toe while you sleep. Pain and anti-inflammatory medication may be used. In some cases, cortisone injections may be recommended to reduce symptoms. Bunion surgery generally involves a procedure to correct the malalignment of the bones. Two common bunion surgery methods involve either a bone cut to reshape the mal-aligned bone into better alignment (i.e. Austin Bunionectomy), or surgery to reposition the entire deviated bone via joint fusion at the foundation of the bone (Lapidus Bunionectomy).  Bunion surgery is generally curative for bunions when the structural realignment has occurred.  

Big Toe Arthritis (Hallux Rigidus)

Large Bone Spurs on the top of the Big Toe Joint are common with Hallux Rigidus (arthritis) and can be removed with surgery. Dr. Neal Blitz /

Degeneration of the articular cartilage of the big toe joint is another common problem of the big toe. Pain, swelling and inflammation with the limitation of motion are hallmarks arthritis. Pain with moving the joint and a grinding sensation may distinguish arthritis from other conditions. Large bone spurs may develop with more advanced arthritis and can be confused for a bunion, however, the bony prominences tend to form on the top of the joint with arthritis whereas bunions are prominent on the inside of the foot.  

Treatment for arthritis of the big toe joint first involves supportive measures to decrease inflammation. Anti-inflammatory and pain medications are a cornerstone in treatment but manage the symptoms.  Changing shoes to those with a stiffer sole or a bend at the big toe joint may also decrease symptoms. Physical therapy can be helpful by keeping the joint supple and mobile because arthritis can eventually limit motion. More advanced painful arthritis can ​be treated with a cortisone shot into the joint, with the sole purpose of decreasing pain and inflammation. Surgical treatments for big toe arthritis may involve removing bone spurs (a procedure called Cheilectomy), joint replacement or big toe fusion. In some cases, surgeons may try specialized bone cuts to reorient the cartilage and preserve the joint and this method is best from mild to moderate arthritis.  


Gout can cause a red, hot, swollen, big toe joint. Getty Images / BSIP/UIG

Gout is well known to commonly affect the big toe joint and when this occurs it is medically termed “Podagra”. Gout is a condition where uric acid crystals precipitate from the blood stream into a joint causing intense pain, swelling, redness and transient stiffness. Gout is the result of having too much uric acid in the bloodstream, and foods rich in purines can illicit a gouty attack. Gout can eventually lead to “​gouty arthritis” of the joint which is the loss of the joint cartilage with an accumulation of this gouty material within the joint, also known as tophi. Gout can be confused with infections of the big toe joint because the big toe can become very red, though the intense pain may be a distinguishing factor.  

Treatment of gout should be managed on two fronts, the first being to medically manage the uric acid in the bloodstream, and the other locally within the foot to manage the symptoms. With regard to the medical management, blood tests are needed to find the cause of gout, and is best managed by your internist who may prescribe medications to treat excessive levels of uric acid on the blood stream. With regard to the gout in the foot, the treatment is based on whether one is having an acute gout attack or dealing with chronic gouty arthritis. Acute gout attacks are generally treated with oral medication rapidly decrease inflammation (such as cortisone, anti-inflammatories).  Cortisone injections may be used for acute gouty attacks as well as chronic arthritis. Patients with painful chronic gouty arthritis may seek surgery which is treated similarly to that of regular arthritis.   

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