Bobby Moltisanti: A 48-Year-Old Meat Cutter With a Painful Bump on His Big Toe

Learning Objectives

•

Learn the common causes of toe pain.
•

Learn the common causes of toe deformity.
•

Develop an understanding of the anatomy of the toe.
•

Develop an understanding of the causes of hallux valgus.
•

Develop an understanding of the differential diagnosis of toe pain.
•

Learn the clinical presentation of hallux valgus.
•

Learn how to use physical examination to identify hallux valgus.
•

Develop an understanding of the complications associated with untreated hallux valgus.
•

Develop an understanding of the treatment options for hallux valgus.

Bobby Moltisanti

Bobby Moltisanti is a 48-year-old meat cutter with the chief complaint of, “I can’t find shoes that will fit because of my big toe.” Bobby stated that over the past couple of months, he has been having increasing foot pain. “Doctor, I have ugly feet. My mother, of blessed memory, used to tease me about them. But lately, my feet are killing me. I stand on my feet all day long. It takes a lot of work to cut up those steaks that you and your family like to eat. I thought I needed new shoes, but I bet I tried on 100 pairs and none of them fit. I feel like the bump on my big toe has gotten bigger, and my shoes are just too tight. Doctor, ugly feet I can live with, but my feet hurt all of the time. I go home each day after work and soak my feet in Epsom salts, take some Advil, and go to bed. I don’t do anything anymore but watch TV.” Bobby went on to say that over the last few months, he began to notice that the bump on the side of his right big toe seemed swollen and a little irritated. “Doc, I’ve been a meat cutter my whole life. It’s all I know, and I can’t do it lying in bed. I wish now I had paid a little more attention in school. All I could think about was girls and cars and having fun. Well, let me tell you, I’m not having much fun with this foot pain. I really need to do something about it.”

I asked Bobby if he had experienced any numbness or weakness in his feet, and he shook his head and replied, “Never. Doc, the pain is around the bump on my big toe, and it can hurt a bit when I move my toe. I can live with the bump, but the pain is becoming a real problem. I just don’t want it to be cancer. If you push on the bump, oh boy! The pain gets a lot worse.” I asked Bobby how he was sleeping, and he said, “Not worth a crap, Doc. Every time I roll over, if I move my toes, the pain wakes me up. And the worry about what I’m going to do if I can’t work hasn’t helped.”

I asked Bobby to show me where the pain was, and he pointed to the bump on the side of his great toe ( Fig. 9.1 ).” Doc, the pain is right around this bump.” I asked, “Does the pain radiate anywhere?” Bobby shook his head no. “How long has the toe been out of alignment?” I asked Bobby. He replied that it had been that way for as long as he could remember, but the pain was something new. “You know, Doc, my mom had the same feet. She spent most of her time in an old pair of house shoes with the part over the bump cut out. I’m working in a freezing cold meat locker, so wearing house shoes is not an option. Besides, do you know what would happen if I dropped a side of beef on my foot if I was wearing house shoes? Not an option.” I asked Bobby about any fever, chills, or other constitutional symptoms such as weight loss or night sweats, and he shook his head no. He denied any other joint, musculoskeletal, or systemic symptoms, or bowel or bladder symptoms.

On physical examination, Bobby was afebrile. His respirations were 18, his pulse was 72 and regular, and his blood pressure was 124/76. Bobby’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his thyroid exam. Auscultation of his carotids revealed no bruits, and the pulses in all four extremities were normal. He had a regular rhythm without ectopy. His cardiac exam was otherwise unremarkable. His abdominal examination revealed no abnormal mass or organomegaly. There was no peripheral edema. His low back examination was unremarkable. There was no costovertebral angle (CVA) tenderness. I did a rectal exam, which revealed a completely normal prostate. Visual inspection of the right toe revealed the classic deformity of a bunion: hallux valgus (see Fig. 9.1 ). There was no evidence of ecchymosis of the skin overlying the bunion. Deep palpation of the bunion elicited pain, as did any effort to straighten the toe. There was no other obvious bony deformity (e.g., hammertoe, which can accompany hallux valgus). The left foot examination was completely normal, as was examination of Bobby’s other joints. A careful neurologic examination of both lower extremities was within normal limits. Deep tendon reflexes were physiologic throughout.

Key Clinical Points—What’s Important and What’s Not

The History

■

History of right great toe pain and deformity
■

The gradual increase in pain in the great toe
■

The pain is localized to the great toe and affects no other joints
■

Standing can exacerbate the pain
■

There is significant sleep disturbance
■

No fever or chills

The Physical Examination

■

Patient is afebrile
■

Classic findings of hallux valgus (bunion) of the right great toe
■

Marked tenderness to palpation of the right great toe
■

Marked pain with any attempt to straighten deformity of the right great toe
■

Normal neurologic examination, specifically no signs of tarsal tunnel syndrome