#397 Is cortisone good or bad for hallux rigidus? - DOC

#397 Is cortisone good or bad for hallux rigidus?

Today on the Doc On The Run podcast, we’re talking about whether or not cortisone injections are good or bad for hallux rigidus.

This question came up during a recent telemedicine visit I was doing with a runner who has hallux rigidus. He wanted to know whether or not it was a good idea or a bad idea to inject the big toe joint with cortisone to treat his hallux rigidus.

Now, there is nothing free in medicine. For every good thing, there’s a bad thing. For every risk, there is a benefit. And everything in medicine, the doctor is basically looking at your circumstances, trying to figure out what you really want short-term and long-term, and then figuring out whether or not that treatment is actually appropriate and really best for you given your circumstances, given your condition, and your goals.

In the case of hallux rigidus, what you have is a joint that’s stiff and it’s not moving appropriately. We presume that the cartilage is getting damaged, but oftentimes you can get inflammation not just of the cartilage, but the soft tissue that actually lines the inside of the joint and makes the fluid that lubricates that joint. Now that fluid is called synovial fluid and the little soft squishy tissue on the inside of the walls of the joint capsule that makes that fluid is called synovial tissue.

When your toe gets inflamed, it gets swollen, and because it can’t swell outward, it swells inward. When it swells inward that synovial tissue can actually get pinched when you move your toes. So when you run and you bring your heel up off of the ground and it basically bends the foot upward and your toe is sitting on the ground, it jams the big toe joint. If you have inflamed soft squishy synovial tissue and it’s swollen and it gets pinched, then that causes a lot of pain.

Sometimes the doctors will recommend a cortisone injection to reduce that inflammation in the tissue and shrink it back down so it’s not getting pinched. Now that is very, very helpful, particularly if you’re in the course of training and you’re having a lot of pain that’s interfering with your training.

Let’s talk about the bad stuff. Again, there is nothing that is risk-free in medicine. So when you have a cortisone injection in the big toe joint for hallux rigidus, what’s happening is you’re doing the corticosteroid injection to reduce the inflammation. It’s very effective at that. Corticosteroids, however, are also very effective at breaking up collagen bonds.

So if you have scarring in the big toe joint and we’re trying to break up some scar tissue, then the cortisone injection is very effective and helpful for that. But if you don’t have scarring and you’re just reducing the inflammation, well, that’s great, but at the same time you have to remember that the cartilage in the joint, the articular surface that covers the ends of the bones and cushions those bones when your joint moves, it’s all made of collagen. Now it’s very compact, very finely woven, very highly organized collagen, but it’s still collagen.

So if you have hallux rigidus and you’ve really been jamming the joint for a long time and it’s already damaged and you have a little tear or flap in the cartilage that’s already kind of loose, well, sometimes the corticosteroid injection or the cortisone injection can actually make that worse because it makes the collagen weaker. So that’s one of the reasons that doctors want to talk to you about your short-term goals versus your long-term goals.

Now, let’s say you’ve been training for the Boston Marathon and you finally qualified and then you do some pushups or something that aggravates the big toe joint and it gets inflamed right before the race. Well, if I know that that goal is very, very important to you and you know that it’s very important to you and you’ve been trying to qualify for 10 years, I think it’s reasonable to inject the joint, knowing that there’s some risk that you could actually damage the cartilage, but it’d be totally worth it because you’re going to have a good race at a race that you’ve been trying for a decade to qualify for. But if you don’t have that issue, it might be better to do some other things to try to reduce the inflammation that are not so risky to the cartilage. It just depends on your circumstances.

So you’ve really got to think carefully about what your most important goals are, about what you’re really trying to achieve both short-term and long-term to see what’s most important for you and what’s most appropriate for you. You’ve got to figure that out and you’ve got to think about that stuff before you do your telemedicine consult or before you go to the doctor’s office so you can make sure you get the best advice.

Now, if you want to learn a little bit more about hallux rigidus and what hallux rigidus means to runners and some strategies around what to do, you can go to the website doconrun.com/halluxrigidus and I have a video there for you. You can get it, it’s free, but it just shows you the worst exercises to do if you’re a runner and you have hallux rigidus. So go check it out. It’d be really helpful because with hallux rigidus, you can go for a long time without any trouble, but you have to be diligent about avoiding the exercises that actually will predictably cause trouble.

To get the video for free, just go to docontherun.com/halluxrigidus and you can find it there. By the way, it’s spelled H-A-L-L-U-X R-I-G-I-D-U-S. Go check it out.