Reasoning GP · Algorithm · 1-page summary
Toe pain in adults
For: adults with toe or forefoot pain in primary care, with or without diabetes. Not for: children and young people (seek specialist advice; use the limping child algorithm); nail changes without pain (use the nail disorders protocol).
Core rule: the first acute hot great toe is usually gout, but in a person with diabetes, or with systemic upset, exclude septic arthritis and the diabetic foot first. A toe can be ischaemic despite a palpable proximal pulse.
0Stop — call 999 now
- Cold, pale, pulseless, painful or numb toe of acute onset (acute limb or digital ischaemia) → 999 vascular emergency. No compression; do not delay for routine investigations.
- Hot swollen great toe + fever + rapidly spreading redness (septic arthritis, necrotising fasciitis) → 999 if signs of sepsis, septic shock or suspected necrotising fasciitis; otherwise Same-day hospital.
- Diabetic foot with sepsis, limb ischaemia, gangrene or suspected deep soft-tissue or bone infection → Immediate hospital and inform the multidisciplinary foot service. Start antibiotics as soon as infection is suspected.
1Triage — diabetes and neuropathy first
| Finding | Route |
|---|---|
| Diabetes + active foot problem | Ulcer, local infection without systemic instability, suspected osteomyelitis while systemically well → multidisciplinary foot service ≤1 working day |
| Neuropathy + hot swollen foot | Suspected acute Charcot, even if painless → stop weight-bearing, offload, foot service ≤1 working day; weight-bearing X-ray foot and ankle |
| Acute hot 1st MTP, well | Gout likely once septic arthritis is considered; aspirate if the diagnosis is uncertain or infection is possible |
| Gradual, mechanical | Structural or nail cause → block 4 |
2Screen — serious causes
- Deep ulcer, visible bone or positive probe-to-bone → Immediate hospital assessment.
- Absent pulses or suspected ischaemia in a diabetic foot → Urgent vascular or diabetic foot assessment (toe pressures or Doppler).
- Widening pigmented band in a toenail + Hutchinson's sign (subungual melanoma) → Suspected cancer pathway dermatology.
- Bone erosion on X-ray + weight loss + known or suspected cancer (metastasis) → Suspected cancer pathway orthopaedic oncology.
- High-risk foot with a painful ingrown toenail or pressure lesion → foot service ≤1 working day.
3Assess
☐ DP and PT pulses, capillary refill, temperature, colour, sensation, movement ☐ 10 g monofilament + 128 Hz vibration ☐ Skin: callus, ulcer, cellulitis; nails ☐ Joints, alignment, dorsiflexion, Mulder's click ☐ Urate (may be <360 µmol/L in a flare: repeat ≥2 weeks after); HbA1c, eGFR ☐ Weight-bearing X-ray for deformity, arthritis, fracture
Not routine: imaging for typical Morton's, metatarsalgia, hallux valgus or uncomplicated gout. ABPI can be falsely reassuring in diabetes.
4Classify — only if blocks 0–2 are negative
- Gout (podagra) — nocturnal onset, hot, red, very tender 1st MTP; clinical diagnosis.
- Hallux valgus / rigidus — medial MTP prominence; or stiff toe, restricted dorsiflexion, pain on push-off.
- Morton's neuroma — burning between 3rd/4th toes, "walking on a pebble"; Mulder's click supports, not diagnostic alone.
- Metatarsalgia / sesamoiditis — pain under metatarsal heads or 1st MTP on weight-bearing.
- Ingrown toenail / paronychia — nail fold pain, swelling, granulation.
- Uncertain → X-ray; MRI for suspected osteomyelitis, Charcot, stress fracture or avascular necrosis.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Gout (septic arthritis considered): NSAID with PPI, colchicine or short oral steroid by renal, GI and CV risk. Avoid colchicine with clarithromycin or strong CYP3A4 inhibitors, or seek advice.
- Diabetic foot infection: antibiotics now, oral if stable, per NG19 and local guidance; ≥7 days, up to 6 weeks for osteomyelitis.
- Ingrown toenail, low risk: salt soaks ± cotton wick (not in diabetes, neuropathy or PAD without podiatry advice); antibiotics only for clear infection.
- Structural: wide toe-box, low-heel footwear; metatarsal pad placed proximal to the metatarsal heads.
6Refer routinely and review
- Podiatry: ingrown toenail stage 3 or recurrent; onychogryphosis; painful callus in a high-risk foot.
- Orthopaedics: hallux valgus with pain and functional limitation (no fixed conservative trial needed); severe hallux rigidus; hammer/claw toe with ulceration; persistent Morton's.
- Gout: urate ≥2 weeks after the flare + renal function; offer ULT per NG219 with colchicine prophylaxis; target <360 µmol/L.
- Diabetic foot review (NG19): low risk annual; moderate 3–6 months; high 1–2 months.
7Never reassure by
- A palpable proximal pulse — the toe can still be ischaemic.
- "It's just gout" in a diabetic or unwell patient — septic arthritis mimics podagra.
- No pain in a hot swollen neuropathic foot — Charcot can be painless.
- "Cellulitis" not improving on antibiotics in a neuropathic foot — think Charcot.
- Normal markers, X-ray or probe-to-bone — osteomyelitis is not excluded.
- A normal urate during a flare, or a normal ABPI in diabetes.
8Safety-net — say it, then document it
999 “Call 999 if your toe or foot suddenly turns cold, pale or blue, numb or very painful, or you feel very unwell.”
Same day: “Contact us or NHS 111 the same day for a fever with a hot swollen joint, spreading redness, or any new wound, blister, swelling or colour change on a diabetic foot. Contact us if the pain worsens or is not settling.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Pulses, capillary refill and sensation recorded
Diabetes and neuropathy status checked
Septic arthritis considered before calling it gout
Review date and safety-net given and documented
Summary of the full Reasoning GP toe pain algorithm, which holds the history, differential, nail procedures, footwear advice and evidence. Sources: NICE NG19 (diabetic foot), NG219 (gout), NG12 (updated April 2026), NG253 (suspected sepsis), EULAR gout recommendations and SPCs. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.