Flexor and extensor tendons insert at the proximal portions of the middle and distal phalanges. Vollman, D. and G.A. Proximal phalanx fractures - displaced or unstable If a proximal phalanx fracture is displaced or if the fracture pattern is unstable it is likely that surgery will be recommended. Note that the volar plate (VP) attachment is involved in the . Diagnosis is made clinically with the inability to hyperextend the hallux MTP joint without significant pain and the inability to push off with the big toe. Smooth K-wires or screw osteosynthesis can be used to stabilize the fragment. They most often involve the metatarsals and toes. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Fractures of the lesser toes are four times as common as fractures of the first toe.3 Most toe fractures are nondisplaced or minimally displaced. Toe fractures of this type are rare unless there is an open injury or a high-force crushing or shearing injury. RESULTS: Stable fractures can be successfully treated nonoperatively, whereas unstable injuries benefit from surgery. Indications. Patients typically present with pain, swelling, ecchymosis, and difficulty with ambulation. Joint hyperextension, a less common mechanism, may cause spiral or avulsion fractures. most common injuries to the skeletal system, distal phalanx > middle phalanx > proximal phalanx, 40-69 years old - machinery is most common, assess for numbness indicating digital nerve injury, assess for digital artery injury via doppler, proximal fragment pulled into flexion by interossei, distal fragment pulled into extension by central slip, apex volar angulation if distal to FDS insertion, apex dorsal angulation if proximal to FDS insertion, diagnosis confirmed by history, physical exam, and radiographs, type III - unstable bicondylar or comminuted, proximal fragment in flexion (due to interossei), distal fragment in extension (due to central slip), extraarticular fractures with < 10 angulation or < 2mm shortening and no rotational deformity, 3 weeks of immobilization followed by aggressive motion, extraarticular fractures with > 10 angulation or > 2mm shortening or rotational deformity, Unstable patterns include spiral, oblique, fracture with severe comminution, Eaton-Belsky pinning through metacarpal head, minifragment fixation with plate and/or lag screws, lag screws alone indicated in presence of long oblique fracture, proximal fragment in flexion (due to FDS), distal fragment in extension (due to terminal tendon), due to inherent stability provided by an intact and prolonged FDS insertion, proximal fragment in extension (due to central slip), results from hyperextension injury or axial loading, unstable if > 40% articular surface involved, represents avulsion of collateral ligaments, usually stable due to nail plate dorsally and pulp volarly, often associated with laceration of nail matrix or pulp, shearing due to axial load, leading to fracture involving > 20% of articular surface, avulsion due tensile force of terminal tendon or FDP, leading to small avulsion fracture, terminal tendon attaches to proximal epiphyseal fragment, nail matrix may be incarcerated in fracture and block reduction, distal phalanx fractures with nailbed injury, dorsal base fractures with > 25% articular involvement, displaced volar base fractures with large fragment and involvement of FDP, predisposing factors include prolonged immobilization, associated joint injury, and extensive surgical dissection, treat with rehab and surgical release as a last resort, Apex volar angulation effectively shortens extensor tendon and limits extension of PIPJ, surgery indicated when associated with functional impairment, corrective osteotomy at malunion site (preferred), metacarpal osteotomy (limited degree of correction), most are atrophic and associated with bone loss or neurovascular compromise, Lunate Dislocation (Perilunate dissociation), Gymnast's Wrist (Distal Radial Physeal Stress Syndrome), Scaphoid Nonunion Advanced Collapse (SNAC), Carpal Instability Nondissociative (CIND), Constrictive Ring Syndrome (Streeter's Dysplasia), Thromboangiitis Obliterans (Buerger's disease). A fractured toe may become swollen, tender, and discolored. DAVID BICA, DO, RYAN A. SPROUSE, MD, AND JOSEPH ARMEN, DO. Copyright 2023 Lineage Medical, Inc. All rights reserved. from the American Academy of Orthopaedic Surgeons, Bruising or discoloration that extends to nearby parts of the foot. Treatment Most broken toes can be treated without surgery. The injured toe should be compared with the same toe on the other foot to detect rotational deformity, which can be done by comparing nail bed alignment. In some cases, a Jones fracture may not heal at all, a condition called nonunion. In an analysis of 339 toe fractures, 95% involved less than 2 mm of displacement and all fractures were managed conservatively with good outcomes.25, The most common mechanisms of injury are axial loading (stubbing) or crush injury. The thumb connects to the hand through the next joint, known as the metacarpophalangeal (MCP) joint. PMID: 22465516. hand fractures orthoinfo aaos metatarsal fractures foot ankle orthobullets phalanx fractures hand orthobullets fractures of the fifth metatarsal physio co uk 5th metatarsal . Metatarsal shaft fractures most commonly occur as a result of twisting injuries of the foot with a static forefoot, or by excessive axial loading, falls from height, or direct trauma.2,3,6 Patients may have varying histories, ranging from an ill-defined fall to a remote injury with continued pain and trouble ambulating. However, return to work and sport can generally take six to eight weeks depending on activity level; some high-level athletes may require more time.6, Initial management of lesser toe fractures (Figure 14) includes buddy taping to an adjacent toe, use of a rigid-sole shoe, and ambulation as tolerated. If your doctor suspects a stress fracture but cannot see it on an X-ray, they may recommend an MRI scan. Referral is recommended for children with fractures involving the physis, except nondisplaced Salter-Harris type I and type II fractures (Figure 6).4. After anesthetizing the toe with ice or a digital block, the physician holds the tip of the toe, applies longitudinal traction, and manipulates the bone fragments into proper position. Copyright 2003 by the American Academy of Family Physicians. Diagnosis can be made clinically and are confirmed with orthogonal radiographs. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. An attempt at reduction and immobilization is made in the field by his unit physician assistant, and he returns to your office one week later. For several days, it may be painful to bear weight on your injured toe. Despite theoretic risks of converting the injury to an open fracture, decompression is recommended by most experts.5 Toenails should not be removed because they act as an external splint in patients with fractures of the distal phalanx. CrossRef Google Scholar PubMed 7 DeVries, JG, Taefi, E, Bussewitz, BW, Hyer, CF, Lee, TH. Although referral rarely is required for patients with fractures of the lesser toes, referral is recommended for patients with open fractures, fracture-dislocations (Figure 5), displaced intra-articular fractures, and fractures that are difficult to reduce. Fracture Fixation, Internal Bone Plates Fracture Fixation Bone Nails Fracture Fixation, Intramedullary Bone Screws Bone Wires Range of Motion, Articular Hemiarthroplasty Arthroplasty Casts, Surgical Treatment Outcome Arthroplasty, Replacement Internal Fixators Retrospective Studies Bone Transplantation Reoperation Injury . The Ottawa Ankle and Foot Rules should be applied when examining patients with suspected fractures of the proximal fifth metatarsal to help decide whether radiography is needed14 (Figure 815 ). Most patients with acute metatarsal fractures report symptoms of focal pain, swelling, and difficulty bearing weight. Diagnosis can be confirmed with orthogonal radiographs of the involve digit. In children, a physis (i.e., cartilaginous growth center) is present in the proximal part of each phalanx (Figure 2). Treatment is generally straightforward, with excellent outcomes. (OBQ05.209) Fractures of the proximal phalanx of the hallux involving the epiphysis may be intra-articular. Patient examination; . X-ray shows an avulsion fracture at the base of the fifth metatarsal (arrow). Phalanx fractures: The most common foot fractures Phalanx fractures typically occur by crush injury, hyperextension, or direct axial force (eg, stubbing the toe). What is the most likely diagnosis? Epub 2017 Oct 1. Follow-up/referral. An unmineralized physis is biomechanically weaker compared with the surrounding ligamentous structures and mature bone, which makes fractures about the physis likely. Pain that persists longer than a few months may indicate malunion, which may limit a patient's future activities significantly. Injury. The appropriate treatment depends on the location of the fracture, the amount of displacement (shifting of the two ends of the fracture), and activity level of the patient. Great toe fractures are generally treated with a short leg walking cast with a toe plate (Figure 1311 ) that extends past the great toe or with a short leg walking boot for two to three weeks.6 After this time, and in the absence of significant symptoms, the patient can progress to buddy taping and use of a rigid-sole shoe for three to four weeks.6,23,24 Range-of-motion exercises can generally be initiated at four weeks. Your video is converting and might take a while Feel free to come back later to check on it. Patients with displaced fractures of the first toe often require referral for stabilization of the reduction. A common complication of toe fractures is persistent pain and a decreased tolerance for activity. The collateral ligaments and volar plate at the metacarpophalangeal (MCP) joint stabilize the proximal portion and the extensor tendon pulls the distal fragment into extension. Treatment involves immobilization or surgical fixation depending on location, severity and alignment of injury. Go to: History and Physical The main component to focus on assessment are: History - handedness, occupation, time of injury, place of injury (work-related) Your foot may become swollen and discolored after a fracture. This is called internal fixation. In many cases, anteroposterior and oblique views are the most easily interpreted (Figure 1, top and bottom). These rules have been validated in adults and children.16 If radiography is indicated, a standard foot series with anteroposterior, lateral, and oblique views is sufficient to make the diagnosis. An AP radiograph is shown in FIgure A. Bony deformity is often subtle or absent. The forefoot has 5 metatarsal bones and 14 phalanges (toe bones). A 39-year-old male sustained an index finger injury 6 months ago and has failed eight weeks of splinting. X-rays. (Right) Several weeks later, there is callus formation at the site and the fracture can be seen more clearly. Patients usually cannot bear full weight and sometimes will ambulate only on the medial aspect of the foot. Toe fractures, especially intra-articular fractures, can result in degenerative joint disease, and osteomyelitis is a potential complication of open fractures. Surgical repair is indicated for patients with progressive and persistent symptoms who fail nonoperative management. Great toe fractures are treated with a short leg walking boot or cast with toe plate for two to three weeks, then a rigid-sole shoe for an additional three to four weeks. During this time, it may be helpful to wear a wider than normal shoe. Differential Diagnosis The same mechanisms that produce toe fractures. 2012 Oct; 43 ( 10 ): 1626-32. doi: 10.1016/j.injury.2012.03.010. FPnotebook.com is a rapid access, point-of-care medical reference for primary care and emergency clinicians. Reduction of fractures in children can usually be accomplished by simple traction and manipulation; open reduction is indicated if a satisfactory alignment is not obtained. Stress fractures of the base of the proximal phalanx have been reported in athletes and dances, but these are uncommon. Patients with Jones fractures should be referred if there is more than 2 mm of displacement, if conservative therapy is ineffective after 12 weeks of immobilization and radiography reveals nonunion, or if the patient is an athlete or is highly active.2,13,2022, Toe fractures are the most common fractures of the foot.23,24 Most fractures involve minimal displacement and are treated nonsurgically. While many Phalangeal fractures can be treated non-operatively, some do require surgery. An X-ray can usually be done in your doctor's office. Fracture of the proximal phalanx of the little finger in children: a classification and a method to measure the deformity . To unlock fragments, it may be necessary to exaggerate the deformity slightly as traction is applied or to manipulate the fragments with one hand while the other maintains traction. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. Fractures of the toe are one of the most common lower extremity fractures diagnosed by family physicians. The image shows a diagram of where these bones lie in the footthe midpoint of the proximal phalanges being where to the toes branch off from the main body of the foot. Because Jones fractures are located in an area with poor blood supply, they may take longer to heal. MTP joint dislocations. She is active in ballet and her pain is exacerbated with push-off and en pointe maneuvers. Your next step in management should consist of: Percutaneous biopsy and referral to an orthopaedic oncologist, Walker boot application and evaluation for metabolic bone disease, Referral to an orthopaedic oncologist for limb salvage procedure, Internal fixation of the fracture and evaluation for metabolic bone disease, Metatarsal-cuneiform fusion of the Lisfranc joint. Proximal interphalangeal joint (PIPJ) dislocation is one of the most common hand injuries. Toe fractures most frequently are caused by a crushing injury or axial force such as stubbing a toe. Surgery may be delayed for several days to allow the swelling in your foot to go down. If no healing has occurred at six to eight weeks, avoidance of weight-bearing activity should continue for another four weeks.2,6,20 Typical length of immobilization is six to 10 weeks, and healing time is typically up to 12 weeks. Non-narcotic analgesics usually provide adequate pain relief. A radiograph taken at the time of injury is shown in Figure A, and a current radiograph is shown in Figure B. Foot fractures are among the most common foot injuries evaluated by primary care physicians. Author disclosure: No relevant financial affiliations. Rotator Cuff and Shoulder Conditioning Program. Metatarsal shaft fractures near the head or base of the first to fourth metatarsal with any degree of displacement or angulation are often associated with concomitant injuries and generally take longer to heal. (Left) The four parts of each metatarsal. Patients have localized pain, swelling, and inability to bear weight on the. 11(2): p. 121-3. . The Ottawa Ankle and Foot Rules should be used to help determine whether radiography is needed when evaluating patients with suspected fractures of the proximal fifth metatarsal. In one rural family practice,1 toe fractures comprised 8 percent of 295 fractures diagnosed; in an Air Force family practice residency program,2 they made up 9 percent of 624 fractures treated. Other symptoms may include: If you think you have a fracture, it is important to see your doctor as soon as possible. Initial management of a Jones fracture includes a posterior splint and avoidance of weight-bearing activity, with follow-up in three to five days. Treatment may be nonoperative or operative depending on the specific metatarsal involved, number of metatarsals involved, and fracture displacement. A walking cast with a toe platform may be necessary in active children and in patients with potentially unstable fractures of the first toe. Proximal articular. All Rights Reserved. One of the most common foot fractures in children, Open fractures require irrigation & debridement, Nail-bed injuries involving the germinal matrix should be repaired, Displaced intra-articular fractures of the hallux require reduction. High-impact activities like running can lead to stress fractures in the metatarsals. Methods: We reviewed the most current literature on various treatment methods of proximal phalanx fractures, focusing on the indications and outcomes of nonoperative as well as operative interventions. Proximal phalanx fractures are often angulated at the time of presentation (independent of mechanism) as muscle forces deform the unstable shaft. In some practice sites, family physicians manage open toe fractures; a discussion about the management of this type of injury can be found elsewhere.3,4 Patients also may require referral because of delayed complications such as osteomyelitis from open fractures, persistent pain after healing, and malunion. Patients have localized pain, swelling, and inability to bear weight on the lateral aspect of the foot. Jones fractures are located in a watershed area for blood supply (zones 2 and 3) and have high rates of delayed union and nonunion17 (Figure 10). Physical examination should include assessment of capillary refill; delayed capillary refill may indicate circulatory compromise. Distal metaphyseal. Fourth and fifth proximal/middle phalangeal shaft fractures and select metacarpal fractures. A stress fracture, however, may start as a tiny crack in the bone and may not be visible on a first X-ray. The next bone is called the proximal phalanx. These include metatarsal fractures, which account for 35% of foot fractures.2,3 About 80% of metatarsal fractures are nondisplaced or minimally displaced, which often makes conservative management appropriate.4 In adults and children older than five years, fractures of the fifth metatarsal are most common, followed by fractures of the third metatarsal.5 Toe fractures, the most common of all foot fractures, will also be discussed. Content is updated monthly with systematic literature reviews and conferences. Objective Evidence Taping your broken toe to an adjacent toe can also sometimes help relieve pain. About OrthoInfoEditorial Board Our ContributorsOur Subspecialty Partners Contact Us, Privacy PolicyTerms & Conditions Linking Policy AAOS Newsroom Find an FAAOS Surgeon. Following reduction, the nail bed of the fractured toe should lie in the same plane as the nail bed of the corresponding toe on the opposite foot. The skin should be inspected for open fracture and if . Proper . Magnetic Resonance Imaging (MRI) scans. Phalanx Fractures are common hand injuries that involve the proximal, middle or distal phalanx. When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture. X-rays provide images of dense structures, such as bone. Hatch, R.L. If the bone is out of place, your toe will appear deformed. and S. Hacking, Evaluation and management of toe fractures. 9(5): p. 308-19. Treatment typically includes surgery to replace the fractured bone with an artificial implant, or to install hardware and screws to hold the bone in place. He undergoes closed reduction and pinning shown in Figure B to correct alignment. Your doctor will then examine your foot and may compare it to the foot on the opposite side. Referral also should be considered for patients with other displaced first-toe fractures, unless the physician is comfortable with their management. toe phalanx fracture orthobulletsforeign birth registration ireland forum. Follow-up should occur within three to five days to allow for reduction of soft tissue swelling. ORTHO BULLETS Orthopaedic Surgeons & Providers Referral should be strongly considered for patients with nondisplaced intra-articular fractures involving more than 25 percent of the joint surface (Figure 4).4 These fractures may lose their position during follow-up. All the bones in the forefoot are designed to work together when you walk. Hallux fractures. However, if you have fractured several metatarsals at the same time and your foot is deformed or unstable, you may need surgery. Proximal phalanx fractures often present with apex volar angulation. Most displaced fractures of the lesser toes can be managed by family physicians if there are no indications for referral. Nondisplaced or minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts with less than 10 of angulation can be treated conservatively with a short leg walking boot, cast shoe, or elastic bandage, with progressive weight bearing as tolerated. Proximal phalanx fractures occur in an apex volar angulation (dorsal angulation). (Kay 2001) Complications: All Rights Reserved. Each metatarsal has the following four parts: Fractures can occur in any part of the metatarsal, but most often occur in the neck or shaft of the bone. abductor, interosseous and adductor linked with proximal phalanx may aggravate fracture of the toe bones if these muscles get sudden pull. The most common injury in children is a fracture of the neck of the talus. During the exam, the doctor will look for: Your doctor will also order imaging studies to help diagnose the fracture. The distal phalanx is the most common location for a non-physeal injury which typically involves a crushing mechanism, and the most common location for physeal injury is the proximal phalanx. Nondisplaced fractures usually are less apparent; however, most patients with toe fractures have point tenderness over the fracture site. 118(2): p. e273-8. Transverse and short oblique proximal phalanx fractures generally are treated with Kirschner wires, although a stable short oblique transverse shaft fracture can be managed with an intrinsic plus splint. Most children with fractures of the physis should be referred, but children with selected nondisplaced Salter-Harris types I and II fractures may be treated by family physicians. Clin J Sport Med, 2001. Thank you. Diagnosis requires radiographic evaluation, although emerging evidence demonstrates that ultrasonography may be just as accurate. If the wound communicates with the fracture site, the patient should be referred. Which of the following acute fracture patterns would best be treated with open reduction and internal fixation? Ulnar gutter splint/cast. There is typically swelling, ecchymosis, and point tenderness to palpation at the fracture site. To control pain and swelling, patients should apply ice and elevate the affected foot for the first few days after the injury. (Left) In this X-ray, a fracture in the proximal phalanx of the fifth toe (arrow) has caused the toe to become deformed. Clinical Features Acute fractures to the proximal fifth metatarsal bone: Development of classification and treatment recommendations based on the current evidence. Avertical Lachman test will show greater laxity compared to the contralateral side. The skin should be inspected for open wounds or significant injury that may lead to skin necrosis. If you need surgery it is best that this be performed within 2 weeks of your fracture. The fifth metatarsal is the long bone on the outside of your foot. Because of the first toe's role in weight bearing, balance, and pedal motion, fractures of this toe require referral much more often than other toe fractures. Application of a gentle axial loading force distal to the injury (i.e., compressing the distal phalanx toward the foot) may distinguish contusions from fractures. What is the optimal treatment for the proximal phalanx fracture shown in Figure A? Fractures of the toes and forefoot are quite common. Metatarsal fractures are among the most common injuries of the foot that may occur due to trauma or repetitive microstress. Unlike an X-ray, there is no radiation with an MRI. This is followed by gradual weight bearing, as tolerated, in a cast or walking boot. (OBQ05.226) Pain is worsened with passive toe extension. Stress fractures can occur in toes. A radiograph, bone scan, and MRI are found in Figures A-C, respectively. Surgery is not often required. Nail bed injury and neurovascular status should also be assessed. For acute metatarsal shaft fractures, indications for surgical referral include open fractures, fracture-dislocations, multiple metatarsal fractures, intra-articular fractures, and fractures of the second to fifth metatarsal shaft with at least 3 mm displacement or more than 10 angulation in the dorsoplantar plane. A Jones fracture has a higher risk of nonunion and requires at least six to eight weeks in a short leg nonweight-bearing cast; healing time can be as long as 10 to 12 weeks. We help you diagnose your Toe fractures case and provide detailed descriptions of how to manage this and hundreds of other pathologies . Most toe fractures are caused by an axial force (e.g., a stubbed toe) or a crushing injury (e.g., from a falling object). If it does not, rotational deformity should be suspected. Turf Toe is a hyperextension injury to the plantar plate and sesamoid complex of the big toe metatarsophalangeal joint that most commonly occurs in contact athletic sports. Foot radiography is required if there is pain in the midfoot zone and any of the following: bone tenderness at point C (base of the fifth metatarsal) or D (navicular), or inability to bear weight immediately after the injury and at the time of examination.14 When used properly, the Ottawa Ankle and Foot Rules have a sensitivity of 99% and specificity of 58%, with a positive likelihood ratio of 2.4 and a negative likelihood ratio of 0.02 for detecting fractures. Unless it is fairly subtle, rotational deformity should be corrected by further manipulation. It ossifies from one center that appears during the sixth month of intrauterine life. Patients with circulatory compromise require emergency referral. The metatarsals are the long bones between your toes and the middle of your foot. After that, nonsurgical treatment options include six to eight weeks of short leg nonweight-bearing cast with radiographic follow-up to document healing at six to eight weeks.2,6,20 If evidence of healing is present (callus formation and lack of point tenderness) at that time, weight-bearing activity can progress gradually, along with physical therapy and rehabilitation. A positive metatarsal loading test, which involves manual axial loading of the metatarsal, may exacerbate the pain and help differentiate a fracture from a soft tissue injury.3. Evidence has shown that, depending on symptoms, short leg walking boots are superior to short leg walking casts.18,19 Immobilization in a cast or boot is typically only needed for two weeks, with progressive ambulation and range of motion thereafter as tolerated. Indications to treat proximal phalanx fractures operatively include all of the following EXCEPT: (OBQ12.49) Your doctor will tell you when it is safe to resume activities and return to sports. Type in at least one full word to see suggestions list, 2022 California Orthopaedic Association Annual Meeting, COA Foot and Ankle End - Glenn Pfeffer, MD, Comminuted Fifth Metatarsal Fracture in 28M. The patient notes worsening pain at the toe-off phase of gait. Foot phalanges. Published studies suggest that family physicians can manage most toe fractures with good results.1,2. Initial follow-up should occur within one to two weeks, then every two to four weeks for a total healing time of four to six weeks.6,23,24 Radiographic follow-up in seven to 10 days is necessary for fractures that required reduction or that involve more than 25% of the joint.6, Indications for referral of toe fractures include a fracture-dislocation, displaced intra-articular fractures, nondisplaced intra-articular fractures involving more than 25% of the joint, and physis (growth plate) fractures. 2 ). Most broken toes can be treated without surgery. and C.W. Stress fractures have a more insidious onset and may not be visible on radiographs for the first two to four weeks after the injury. Phalangeal fractures are very common, representing approximately 10% of all fractures that present to the emergency room. While celebrating the historic victory, he noticed his finger was deformed and painful. Referral is indicated in patients with circulatory compromise, open fractures, significant soft tissue injury, fracture-dislocations, displaced intra-articular fractures, or fractures of the first toe that are unstable or involve more than 25 percent of the joint surface. They typically involve the medial base of the proximal phalanx and usually occur in athletes. As your pain subsides, however, you can begin to bear weight as you are comfortable. Minimally displaced (less than 3 mm) fractures of the second to fifth metatarsal shafts (Figure 2) and fractures with less than 10 of dorsoplantar angulation in the absence of other injuries can generally be managed in the same manner as nondisplaced fractures.24,6 Initial management includes immobilization in a posterior splint (Figure 311 ), use of crutches, and avoidance of weight-bearing activities. Phalanx fractures are classified by the following: Phalangeal fractures are the most common foot fracture in children. Radiographic studies of a toe should include anteroposterior, lateral, and oblique views (Figure 1). Petnehazy, T., et al., Fractures of the hallux in children. Hyperflexion or hyperextension injuries most commonly lead to spiral or avulsion fractures. Treatment for a toe or forefoot fracture depends on: Even though toes are small, injuries to the toes can often be quite painful.