Diagnostic Approach for Sudden Severe Pain in the Left Great Toe

Initial Assessment and History

The American College of Physicians recommends obtaining a detailed history focusing on trauma, systemic symptoms, and risk factors for gout or infection, followed by immediate physical examination to assess for signs of infection, fracture, or acute inflammatory arthritis, with urgent laboratory testing and plain radiographs as the initial imaging modality 1, 2
Systemic symptoms such as fever, chills, or constitutional symptoms raise concern for infection or systemic inflammatory process, according to the Infectious Diseases Society of America 3
Risk factors for infection, such as diabetes or immunosuppression, should be assessed, as recommended by the Clinical Infectious Diseases journal 4, 5, 3

The physical examination should include inspection for erythema, swelling, warmth, open wounds, or deformity, and palpation for point tenderness over specific structures, as suggested by the Diabetes/Metabolism Research and Reviews journal 3
Vascular assessment, including palpation of dorsalis pedis and posterior tibial pulses, is crucial, especially in diabetic patients, according to the Diabetes/Metabolism Research and Reviews journal 3
Laboratory testing should include complete blood count, C-reactive protein, serum uric acid, and blood glucose, as recommended by the Diabetes/Metabolism Research and Reviews journal 3
Blood cultures should be obtained if fever or systemic signs of infection are present, as suggested by the Diabetes/Metabolism Research and Reviews journal 3

Weight-bearing radiographs of the foot are the initial imaging modality for all patients with great toe pain, as recommended by the Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1, 2
Advanced imaging, such as MRI or CT, may be necessary if initial radiographs are negative and pain persists, according to the Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1, 2, 6
MRI is preferred for suspected osteomyelitis, as recommended by the Diabetes/Metabolism Research and Reviews journal 3

The differential diagnosis for sudden severe pain in the left great toe includes acute gout, septic arthritis, fracture, and turf toe, as suggested by the Clinical Infectious Diseases journal 4, 5
Septic arthritis requires urgent arthrocentesis, blood cultures, and empiric antibiotics, according to the Clinical Infectious Diseases journal 4, 5, 3
Diabetic patients with foot infections require prompt evaluation and treatment, including probing any wound to assess depth and bone involvement, obtaining wound cultures, and admitting for IV antibiotics if necessary, as recommended by the Clinical Infectious Diseases journal 4, 5, 3

Infection should not be dismissed in diabetics without fever, as recommended by the Clinical Infectious Diseases journal 4, 5
Initial radiographs should not be relied upon solely, as stress fractures and early osteomyelitis may not be visible initially, according to the Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1, 2, 6
Corticosteroid injections near tendons should be avoided due to the risk of tendon rupture, as recommended by the Praxis Medical Insights: Practical Summaries of Clinical Guidelines 1, 6