What the Heck is a Sausage Toe?

A patient came in the other day with a swollen tip of her second toe. She also had a funny looking, thick toenail and really thought that was the cause of her pain and swelling. She related that she had been experiencing throbbing pain, redness and swelling for several months in just the tip of the toe. It had never spread or gotten much worse. She had never experienced drainage or infection symptoms around the toenail. She was unable to wear a closed in shoe and was to the point that she wanted her toe amputated. She had been treated with topical anti-fungals and antibiotics without much result. She was sent to me for another opinion after taking two months of oral anti-fungals and having no change in the nail or toe appearance. What a strange presentation....or is it?

Sausage toe is a whimsical term used to describe a red, hot swollen toe often seen in psoriatic arthritis. It can also be seen in Reiter's syndrome and other seronegative arthropathies. In English, a non-rheumatoid type arthritis. Sausage toe is inflammation of the distal interphalangeal joints (tip of your toe and adjacent knuckle) that looks like a sausage or lollipop. In psoriatic arthritis, it is often accompanied by nail changes that mimic onychomycosis or a fungus in the nails. The nails can be pitted, yellow, thickened, fragmented, and lifting from the tip of the toe. Psoriatic arthritic can occur without the typical skin changes seen in psoriasis, but most patients have some skin lesions.

Sausage toes should be treated aggressively to decrease the inflammation and joint destruction. Long term inflammation can lead to erosive changes and permanent joint pain and stiffness. Joint ankylosis (complete fusion of the joint) can occur in severe cases. Basic treatment starts with nonsteroidal anti-inflammatory drugs, exercise, physical therapy and education. Patient should be taught the "move it or lose it" principal of arthritis management. Exercise and mobilization of the joints, but not overuse and abuse, should be reinforced. Some patients need more aggressive treatment, and this should be part of a comprehensive treatment plan by a rheumatologist.

Sausage toes should not be ignored. They can be caused by many factors such as trauma, infection, osteomyelitis (infection of the bone), and many different rheumatologic disorders as discussed. If you experience a painful, red, swollen toe that just seems to persist; seek the opinion of your podiatrist. Treated early, sausage toe can just be part of a whimsical story instead of a long term disability.

Ankle pain with no sprain?

I see several patients on a weekly basis that complain of ankle pain that have no history of recent ankle sprain or any trauma. They describe their pain as sharp and burning on the inside of the ankle with swelling and pain that is worse with walking, but continues as aching pain at rest. Some patients can have so much pain that they are unable to walk without crutches.

On exam, I will find that the posterior tibial tendon is swollen and painful usually from behind the ankle bone down to where the tendon inserts in the foot. The job of this tendon is to help the foot swing inward in gait and support the arch. But with flat feet, the tendon is overworked and often then forms small tears in the area just described which then causes pain and swelling. When asking a patient to walk in my office, the affected foot will show minimal to no arch height and the ankle will appear to be falling inward, sometimes almost touching the ground. There is usually pain with isolating this tendon on a muscle exam as well.

So how does this really happen? Overuse is the most common mechanism of injury. Wearing flip flops or going barefoot on a regular basis. Starting a vigorous exercise program when you previously were not exercising. Walking a significant amount on a vacation like Disney World when this is unusual for your daily amount of activity.

Treatment starts with an evaluation and xrays to ensure you do not have anything else that may be causing your pain and to get a better idea of your bone and joint structure. Next, rest, ice and compression are the key to getting your swelling and pain under control. In severe cases, bracing may be necessary to achieve this goal. Once your pain and swelling have resolved, the next thing you need to do is prevent this from happening again. The best way to do that is wear good supportive shoe gear and be fitted for custom orthotics. Without preventative care, this tendonitis can because a chronic dysfunction of the foot and ankle requiring surgical reconstruction.

If you think you may have this condition, the physicians at Foot and Ankle Associates of North Texas are here to help!