Today on the Doc On The Run podcast, we’re talking about the good and bad of cortizone injections for sesamoiditis in runners.
Just today I received an interesting question from Victoria, who has been suffering with a bad case of sesamoiditis which has been keeping her from running.
She saw an orthopedic surgeon who who thinks there is scar tissue around the sesamoid bone restricting the range of motion and causing the pain under the big toe joint.
The doctor explained to her that one other conservative option, which might help her avoid sesamoid surgery would be a corticosteroid injection which is sometimes also called a Cortizone injection.
So her question was:
“How exactly do steroid injections help? Do they break up scar tissue?
The orthopedic surgeon told me to be cautious about doing steroid injections, but I never got a clear explanation as to why.”
The sesamoid bones underneath the ball of the foot at the base of the big toe are just like two tiny little kneecaps. And because they are only about the size of kidney beans there’s a lot of pressure on those two little bones. When one of them becomes inflamed or injured it can started to degenerate and develop arthritis.
If your arthritis in the sesamoid bone advances, or the bone starts to break and then becomes painful because it doesn’t heal, your doctor might recommend surgery to remove the damaged sesamoid bone.
But as I have said many times before, surgery should always be the very last option.
When you have pain in the sesamoid bones, the aching can be caused by variety of different reasons. And arthritis is not the only reason. You can also have inflammation of the tissue that lines the joint. You can have a stress fracture in the sesamoid bone. You could even have a pathologic fracture where the bone is broken into little bitty pieces.
Any and all of these circumstances affecting sesamoid bones can cause pain under the big toe joint when you run.
There are lots of different conservative treatments, meaning nonsurgical treatments for sesamoid injuries in runners.
The one nonsurgical treatment Vicky is asking about here is an injection into the sesamoid area and big toe joint with corticosteroids. There are a couple of different ways a corticosteroid injection can help the sesamoids when they are painful and inflamed.
Corticosteroids are the best thing on the planet to stop inflammation. If you inject a solution of Cortizone into the big toe joint and around the sesamoid bones, it will reduce the inflammation. In some cases this inflammation reduction can completely resolve the symptoms. This is particularly true when inflammation in the joint is mostly painful because of an inflamed synovial lining of the joint.
The inside of your big toe joint, which helps hold the sesamoid bones in place, is lined with this soft squishy tissue that makes the synovial fluid that lubricates the joint and lubricates the cartilage on the top of the sesamoid bones. Sometimes this tissue becomes inflamed. When it’s inflamed and you move the joint, or step on the sesamoid bones, it causes pain because it’s pinching that soft squishy tissue.
So if you inject Cortizone around the sesamoid bones, and it reduces all that inflammation the sesamoiditis pain may completely calm down. If that happens, basically you’re home free and you can get back to running without any trouble.
But as I’ve said before, there is nothing free in medicine. With every potential treatment, there is a risk and a benefit.
Corticosteroids also weaken collagen bonds. If you have scar tissue that is binding the sesamoid bones and restricting their motion, it can be beneficial if you inject corticosteroids around the sesamoids to weaken the collagen in the scar tissue. If the scar tissue gets weaker, it may start to break up, and in a sense, free up the sesamoid bones so they move with less restriction and hopefully with less pain.
The risk with injecting a corticosteroid injection into the big toe joint or around the sesamoid bones is that you might weaken and break up collagen you actually don’t want to deteriorate. The articular cartilage that serves as a cushioning between the sesamoid bones and the head of your first metatarsal bone at the big toe joint is all made of highly organized collagen.
So if you have had some damage to the cartilage on one of the sesamoid bones and it started to repair itself and then you inject corticosteroids, that injection can actually undo some of the healing that has taken place.
If you had a sesamoid fracture in one of the sesamoid bones and it started to repair itself but has not completely healed, the corticosteroid injection can weaken the collagen that has formed to stabilize the two fractured pieces of the bone. In that scenario, the corticosteroid injection can actually destabilize the healing fractured sesamoid and make the condition worse.
So in short, those are both the risks and the benefits of Cortizone injections for sesamoiditis.
If you’re considering an injection for sesamoiditis you might want to try some other conservative treatments first. But if you’ve tried everything and all of the doctors you see you’re trying to convince you that you should have surgery, you may not have that much to lose. You just have to talk closely with your doctor about the available options, and probability that any of these treatments will actually help the condition, or potentially make it worse and force you to have to have surgery to remove the deteriorating sesamoid bone prematurely.
Whether you have sesamoiditis and have been using pads to take pressure off of the painful area, or if you’ve recently started thinking about getting a corticosteroid injection, you need to make sure you can track your progress to determine whether or not you’re actually improving. Obviously i you are not improving it makes it more reasonable to consider surgery.
Unfortunately I’ll talk to runners almost every day who really and truly don’t have a clear picture of whether they’re getting better or worse, or just staying the same because they haven’t kept
track of their pain. So before you begin any new treatment in your quest to get back to running, if you need to print out a copy of the pain journal and start keeping track of your symptoms on a daily basis.
You need to get your pain journal started today. Go to docontherun.com, go to the podcast tab, go to this episode of the Doc On the Run Podcast, and at the bottom of this episode in the show notes, you will see the pain journal, it’s a PDF. I made it for you. You don’t have to create it yourself. You just print it out, it’s free. Go get it and it’ll help you really make some decisions based on data rather than just a guess. So you can get back to running as quickly as possible.
Pain is the best tool to help an injured runner decide when run. You don’t have to figure out what to write down. We made a simple Pain Journal PDF for you.
If you have a question that you would like answered as a future addition of the Doc On The Run Podcast, send it to me PodcastQuestion@docontherun.com. And then make sure you join me for the next edition of the Doc On The Run Podcast!