A careful history and examination will allow you to identify one main cause for the patient's problems in most people. You can then apply the investigation and treatment principles in the section of the Hyperbook dedicated to that condition:
Some judgements are more complicated. The commonest are:
  • a mixture of hallux valgus and rigidus. In this situation, if joint pain is produced on examination throughout the range of movement, and/or imaging shows a severely worn joint, it's usually best to treat as for hallux rigidus. On the other hand, if pain is mainly present at the extremes of movement, and imaging shows a reasonably well-preserved joint, a standard hallux valgus procedure can usually be offered if otherwise indicated. There is a chance of continued pain in the joint and, particularly in more borderline situations, it's important to discuss with the patient whether they prefer
  1. to preserve as much movement as possible at the risk of continuing pain - using a standard hallux valgus operation
  2. to maximise the chance of pain resolution, accepting a less functional big toe - using a fusion or excision arthroplasty
  • Trying to make a judgement about the cause of generalised pain all over the toe. As mentioned previously, looking for definite evidence of infection or a neuropathic pain source is important, and our experience is that the commonest cause in such circumstances is neuropathy. Ultimately it may not be possible to be sure and imaging to exclude underlying infection or bone pathology may be necessary, followed by a neurological and/or pain medicine consultation.