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The Doctors Lounge Message Archive

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Big Toe problem

Bone trauma and fractures


Post subject: Big Toe problem
swifteye
- Sun Jan 16, 2005 12:59 pm

About roughly 3 months ago I fell down a few steps on a staircase, landing on my feet but with the big toe of my left foot facing downwards which jarred it badly. It ached constantly for the next 8 hours or so until I got some painkillers, after taking the next two days off as I couldn't walk well enough I visited a hospital, where they told me they wouldn't take an x-ray because had it been broken or not due to it being a toe, there would be nothing they could do. They strapped my toe with some tape and bandage and sent me on my way.
After about two weeks my walking greatly improved, and after a month it was more or less completely normal, the only problem being that I could not bend my big toe at the second joint at all. The first joint seemed fine, but i was physically unable to move my toe along the second joint. It would actually bend, if i took it in my hand and moved it manually, but i couldn't bend it otherwise. My toe did bruise visibly for a time, and to touch it was never particularly painful, and moving it with my hand wasn't either, but like I said walking for a while was particularly painful. Anyway, after a few weeks I was still worried and visited a doctor who gave me some anti-inflamatory tablets which i took for a few weeks. Slightly over a month since the accident, I managed to put a lot of weight on my toe by accident which seemed to set it back and made it more painful than it was to begin with, however this seemed to be temporary as it cleared up once more within about a week. 3 months on, I can walk perfectly, and I think even jogging would be ok, but, I still cannot bend my toe at the second joint without forcing it by hand.
I'm guessing it's to do with muscle damage rather than bone damage, as having broken bones before they're usually painful to touch and definitely to move, whereas this is not so much, and of course bone injuries typically clear up after 6 weeks, whereas this has been now more like 12. Also, i've shyed away from moving my toe by hand, but i've noticed lately when I have it does hurt slightly to bend it, like an ache rather than a sharp pain. This is all pretty worrying considering how ambiguous what is actually wrong with it is, the hospital and doctor not taking a great deal of interest, and considering how long its been without being able to bend my toe along the second joint at all. It's a big problem because I don't know when it's safe to excercise fully again, as it was excercising that made it far worse after I thought it was ok the first time.
I might add that I think ever so slightly I can bend my toe along the second joint slightly now, though I may just be imaging it, as it may have always been like that since the accident.
Thanks
Post subject:
saif
- Mon Jan 17, 2005 8:32 pm

Hello Swift eye,

Most toe injuries are as you see managed quite conservatively, and indeed an X-ray rarely changes any decision that is actually taken. Quite understandably you feel that, "its all very well saying the management is the same, but it would be nice to know if...etc".

I presume that every thing is undisplaced, or now you would have mentioned a wonky toe. The way i would classify your injury, in the absence of any extra information is firstly either you have broken it or you haven't, and if you did break it, it either involves the joint or doesn't. Secondly, there is a soft tissue injury...we accept that, but either this involved a musculosketal soft tissue (ligaments, tendons, joint capsule) or doesn't.

Most bony injuries of your big toe heal sponateneously, without any intervention by about 4 to six weeks as you say, although X-rays may show signs for several more months after that. Joint capsule and ligamants in your toe will also take around the same time to heal. Tendons (and by the mechanism you describe, the extensor tendon of your big toe, could be damaged) also heal, but unless immobilised may heal long ...we will talk about it later. The healing process involves the generation of scar tissue,..the body's glue that sticks broken and torn bits together. This scar tissue, or fibrosis, is not as supple as your normal tissue, and if toccurs at close proximity to a joint, it leads to stifness, and pain when the joint is moved for sometime after the tissues have healed. This stiffness is more likely if the fracture involved the joint, or the injury involved the joint capsule. In fact by the mechanism you describe, it is probable that the joint capsule was involved. How long this stiffeness and discomfort lasts is difficult to predict, but if there was a fracture, and it involved the joint surface it may last( to a lesser extent than it is at present), for some considerable time.

Another injury I alluded to in the last paragraph (but unlikely in your case), is an injury to the extensor tendon of your big toe. If this was damaged then the mechanism that allows you to straighten your big toe fails. You may be able to flex (bend the toe) at the joint nearest to the tip of your toe, but be unable to straighten it. You seem to suggest that your toe is straight and that you are unable to bend it...so this probabaly doesn't apply to you.

So the treatment now...after 12 weeks, you should do gentle stretching exercises to get the toe moving. you wilol probably get good days and bad days, but gradually there will be more good days than bad. If, after another month or so, it is still giving you jip...it may be worth being referred to your friendly neighbourhood orthopod...but chances are that you will be cured by the time your appointment comes through, mate.

Cheers

saif
Post subject: Clarify
swifteye
- Tue Jan 18, 2005 8:08 pm

Thank you very much for the prompt response.
I'll clarify that my toe is straight, and I cannot bend it along the second joint. I describe second joint as the joint closest to the tip of my toe. The joint after that, connected to the rest of my foot if you will, seems fine.
I also forgot to mention swelling for quite some time around my toe and foot, which has seemed to subside. I did wonder if i had displaced my toe, as sometimes I think that it doesn't look quite the same as my other big toe, but I think this is me being paranoid, and obviously that they wouldn't be entirely identical anyway.
I thought perhaps though that the fact that I can bend my toe at the joint if I use my hand may be an indication that it isn't displaced? I can say that immediately after the accident I lost my ability to bend it, if that is any help.
After having so many breaks before I'm fairly accustomed to knowing how one 'feels' as such, which is why I've thought more towards it being muscular rather than a bone problem, it not seeming like the rest. Though I suppose all breaks are different to some extent.
It seems that even now it only takes a slight bump for my toe to be painful, if only for a minute, which I thought perhaps was a sign of it still being 'unhealed' or weak.

Thanks for the information, I'm not sure if what I say here has narrowed down the options any.
Post subject:
saif
- Fri Jan 21, 2005 3:20 pm

Dear swifteye,

I guess you know what your talking about being, by the sounds of things, fairly accident prone icon_smile.gif , comments I would make are:-
If there was a fracture and it was intra-articular, you may have stiffness for some considerable time afterwards. But in this case usually both active and passive (using your hand) movements are painful. It may reamin tender when knocked for some many months as well
If there was a capsular injury, as is the most likely, the toe remains stiff, and painful to knocks, but both active and passive movements are possible. You did mention that you were starting to be able to move the toe actively...so I will assume that the tendons governing the movement are intact. If they were not, then loss of active movement of the toe would be permanent and absolute. Pain itself is usually not a feature for established tendon rupture.
Fractures that do not involve the joint usually remain tender when knocked while the bone is not fully united. Movement is not usually affected after 4 weeks or so from the injury.
In addition to these other non-musculoskeletal soft tissue injuries can reamin tender after all the mechanical structures have healed. This could potentially lead to inhibition of the muscle that work your toe...essentially this is a subconscious reflex that prevents you moving a joint that might hurt...even though passive manipulation suggests that it would not. This is recognised in other joints such as the knee...but I guess it could happen elsewhere.

Regards

Saif
Post subject: Toe
swifteye
- Sat Jan 22, 2005 6:18 pm

Thanks for the response

I guess i'll just have to wait and see, i'll do some excercises. It's just pretty disconcerting; not being able to move it actively at all (I don't know that there has really been any progress there) after 12 weeks. Hopefully it'll start moving again sometime, just that excercising a while after i had the accident originally undid a lot of the healing as it must not have been ready for it, which I don't want to repeat. I've generally been estimating that a safe time to start using it fully in excercise again would be when it starts bending again, hence it not moving seeming like such a problem.

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