Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 27 Aug 2026Clinical review pending
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A hot, ulcerated or ischaemic great toe is not routine bunion pain
Rapid erythema, fever, ulceration, drainage, acute severe joint pain, blue or pale toe, absent pulses or tissue loss suggests infection, gout, septic arthritis or limb ischaemia rather than uncomplicated hallux valgus or rigidus.
Action: Assess observations, skin, perfusion, sensation and glucose, obtain urgent blood tests and radiographs or joint sampling as indicated, and involve diabetic-foot, vascular or orthopaedic services immediately for spreading infection, septic joint, critical ischaemia or threatened tissue.
Synopsis
Distinguish symptomatic hallux valgus from first-metatarsophalangeal osteoarthritis, quantify deformity and function with weight-bearing assessment, protect skin and circulation, and match footwear, injections and reconstructive surgery to the actual pain generator.
Hallux valgus is lateral deviation and rotation of the great toe with a medial first-metatarsal prominence; symptoms come from shoe pressure, joint pain, crowding and transfer metatarsalgia, not appearance alone.
Hallux rigidus is first-metatarsophalangeal osteoarthritis causing painful loss of dorsiflexion, dorsal osteophyte and impaired push-off; advanced disease hurts through mid-range.
First-line investigation for symptomatic deformity being considered for referral is weight-bearing foot radiography, because non-weight-bearing images underestimate alignment and load relationships.
Key red flags
A hot exquisitely painful first metatarsophalangeal joint with fever, skin breach or immune compromise requires urgent septic-joint assessment even when gout is plausible.
Investigation priorities
01
First-line standing foot examinationFirst stepFirst line
Define deformity, flexibility, pain generator, callus, footwear conflict, sensation and circulation under load.
02
First-line weight-bearing foot radiographsFirst line
Measure alignment and arthritis and identify sesamoid, lesser-ray and midfoot disease for referral or planning.
Management branches
First-lineLocalise deformity-related pain
Great-toe deformity or stiffness causes shoe, joint or transfer symptoms without acute infection or ischaemia.
Identify whether medial rubbing, joint arthritis, transfer metatarsalgia or second-toe conflict is the principal target.
Key medicines
Topical diclofenac gelApply 2–4 g of diclofenac 1.16% gel over intact painful first-joint skin per use, up to three or four uses daily for a short course within the licensed maximum.
First-metatarsophalangeal corticosteroid injectionWhen selected after infection exclusion, give one accurately placed intra-articular corticosteroid dose under the trained local small-joint protocol, using image guidance where needed and reviewing benefit before any repeat.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.