Joint stiffness after osteotomy

by Susan
(San Jose, California USA)

Hi---

I had toe surgery four and a half months ago. I had a bone spur removed on the top of my first metatarsal joint area, cadaver cartilage put in my joint and my big toe broken and realigned.
I am still experiencing some swelling and pain off and on, but my biggest concern is my joint stiffness. I have been bending and moving it with my hand per the podiatrists request.
It moves a little more when I do that, but after awhile it becomes stiff again. I have been going to PT for almost three months now (first twice a week and now once a week) The podiatrist now wants to give me a cortisone injection into my joint. Do you feel that would be beneficial? What do you think is causing my stiffness? I have been back to work for about a month and a half now and constantly on my feet. Please let me know your thoughts. Thanks.

RESPONSE

Hi Susan

To start, joint stiffness in the great toe joint is a common problem associated with remodeling of the first metatarsal phalangeal joint.

I can actually say it is rare that a patient has more motion after surgery. What is different after the surgery is the lack of pain that the patient will experience in the joint.

What you (probably) had prior to surgery was pain when the big toe attempted to bend upwards. The base of the toe bone, or even a bone spur was jamming into the bone spur on the head of the first metatarsal bone. Depending on your level of activity there was probably times when the toe hurt more then at other times.

By removing the bone spur on the first metatarsal bone, you should no longer be getting the jamming effect of two bones and thus a reduction in pain.

The reason the toe does not move more then you would expect is two-fold. The first is the shape of the head of the first metatarsal bone. If it is more square then rounded, that would limit the range of motion and secondly, perhaps more important is the position of the first metatarsal bone relative to the toe bone.

Most people exhibit what is known as a dorsiflexed first metatarsal, meaning if you look at an x-ray of your foot from a side view, you will note that the metatarsal bone is elevated relative to the toe. This is something you have had your whole life and probably caused your bone spur in the first place.

If the first metatarsal is elevated, it makes it difficult for the toe to bend up over the bone and you get a jamming. Earlier in your life that was not an issue, but over the years, the constant jamming caused the bone spurs to form and then the pain began.

So now your foot structure is essentially back to before the days of the bone spurs. Once all the healing has occurred and it can take upwards of a year for bone to heal, you hopefully will be at a point where there is no pain but also a limitation of motion.

In most surgeon's way of thinking, it is resolution of pain that is their primary goal in any surgery of this type. And yes, you should have no pain even though the toe does not bend as much as you had hoped.

Now, the only caveat here is if you expected, as a result of this surgery, to go back to wearing high spiked heels. That might be a problem.

If you were only looking for resolution of pain then hopefully your expectations will be met.

As far as the cortisone injection goes, if you are not really having any substantial pain, I would forego it for now.

If you are experiencing substantial pain at four months post op, then a cortisone shot might be very helpful

Marc Mitnick DPM
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