Many treatments for toe injuries

Conway McLean, DPM

As is my inclination, I hope to subdue another dragon of an old wive’s tale. In other words, I want to destroy another medical cliche, a truism which is not actually true. There are so many of them, I have an abundance of choices. I won’t include the one about getting a cold by sitting in a draft. That one has been laid to rest in most technologically advanced countries, although it remains part of the belief system in some old world Eastern European lands.

One of my personal favorites is the one about sprained or injured toes. You know that one, the concept that physical trauma to a digit is untreatable. As long as there is no break or deficit in the skin, no treatment is necessary. To my way of thinking, this is reprehensible. How did toes become so unworthy of attention? What happened to keep that little piggy from going to the doctor? Toes are important too!

Similar to the fingers, the digits of the pedal extremity (aka toes) have many nerves, making shoe pressure to some injured region often quite uncomfortable. After all, there they are, hanging out there in front of the rest of your body, ready to be the subject of some blunt trauma from any passing piece of furniture. The opportunities for toe injuries are considerable.

Probably not experienced by everyone, toes suffer greatly in cleated sports, that is, those games requiring the use of shoes with cleats. This type of shoe is not generally endowed with tremendous protective abilities. Thus, a cleat to the foot often results in a sudden crushing force from the cleat itself. This insult can result in a fracture of a toe bone. The conversation on the consequences is very different if we are talking about the big toe versus the smaller, or lesser, toes.

The great toe is critical for a propulsive gait, meaning that if you are able to stride forward forcefully, with some speed and power, you have this type of gait. When someone, either because of age, injury or the consequence of some disease process, walks flat-footed, they do not use their big toe in the same way. Thus, an injured big toe will not cause the same pain or problems as someone who can stride. When a bone in the great toe is broken, aka fractured, definitive treatment is essential. This may consist of a cast or walking boot, possibly even surgery if the fracture site is unstable or displaced.

Much more common is an injury of one of the small toes, especially the fourth and fifth digits, stuck out there on the side of the body, waiting to receive the impact of any wayward piece of furniture. As you might predict, shoe gear has an important part to play in this discussion. When someone walks barefoot or in socks (which is the same thing), they are inviting an injury. Unfortunately, slippers are often insufficient protection, although this form of foot gear varies tremendously.

Just as common as a broken toe bone is a sprain of a toe joint. All four of the lesser toes have three bones and two joints, not counting the joint at the base of each toe, which is the joint that comprises the ball of the foot. Stubbing a toe can cause one of the small joints to be pushed out of position. As with any joint sprain, the ligaments of the damaged joint are stretched or torn. Ligaments do not have a high metabolic rate and so, they do not heal quickly. These injuries can be symptomatic for years if not treated correctly.

But wait … toe injuries don’t need any treatment, right?!

If you suffer a toe injury and the pain doesn’t resolve in a day or two, it is likely some structure has been damaged. Believe it or not, many therapeutic measures are possible. Naturally, the techniques and therapies utilized will depend on the specifics of the injury. Let’s examine what can be done for a sprain. And in case you haven’t heard this one before, I’ll be the first. An individual is often better off with a fracture than a sprain, specifically because of the difficulty in healing a torn ligament. Reconstruction of one or more of these ligaments is never attempted surgically, so the sufferer who doesn’t get adequate treatment can experience recurrent dislocations of the damaged digit with only the slightest provocation.

When you injure a toe, and notice it is bent at an odd angle, this is a clear indication the joint is dislocated. The joint must be held in normal alignment during the healing process, thus encouraging the ligament to heal with the correct configuration. Obviously, we don’t apply actual casts to toes, but there are many ways to immobilize the part. Many non-specialists will propose the application of the age-old buddy taping, whereby the affected toe is taped to an adjoining digit. This is an ancient technique, one that should have been put to rest long ago. Not only is this type of taping usually uncomfortable, it doesn’t do a very good job of immobilization. But there are certain types of tapings or soft casts that can provide tremendous relief of symptoms and help speed healing as well.

Basic home physical therapy techniques can help, the obvious example being the application of ice. Use of a stiff soled “medical” shoe, also known as a surgical shoe, can also help. It’s rare there is so much trauma an actual cast boot is needed. But immobilization, beneficial in soft tissue injury, is a necessity in bone healing. This is why casts are rigid. Bones heal through a complex process, but your body has a harder time building solid bone when there is motion at the break. And it certainly feels better to be immobilized.

Its rare that a lesser toe requires the surgical insertion of a thin metal rod, termed a Kirschner wire, to fixate the broken bone. But a break to the big toe is another matter. If the break is stable and in good position, any of the previously mentioned options may be sufficient. When the break goes into a joint, it’s a different story. A misaligned fracture that enters the big toe joint will result in degenerative joint disease, a type of arthritis of sorts.

I’m hoping the picture is becoming clearer: toe injuries can be serious and have long term repercussions. And there are many treatments. Prevention is also a good idea, like steel-toed boots in various occupations. Slippers providing some protection are helpful. Obviously, an accurate diagnosis is the basis of an effective treatment plan. Then again, maybe you like pain: try buddy taping!

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.