Big Toe Joint Pain: Email Advice Regarding Possible Surgery

This is an email I just received regarding Hallux Rigidus possible surgery.

Big Dorsal Spur seen associated with an Arthritic Big Toe Joint

http://www.drblakeshealingsole.com/2010/08/hallux-rigidus-surgery-or-no-surgery.html

Dr. Blake,
I have been recommended surgery for this condition. As long as I have good shoes on, my toe does not bother me significantly. However, I do experience some pretty severe pain at times if I've overdone it or ran around barefooted. I'm 46 and active with three young children, and the doctor recommends surgery before the condition progresses to a point of having the joint fused. I'm hesitant, not knowing how long it will be before the joint requires that. If it's going to be 30 years, I'll put it off. I guess my question is, when do you make the determination surgery is necessar? Is there truly a benefit to correcting this condition early on while things aren't so bad, or should a person wait till things grow far worse?

Dr Blake's Response:

This is a great question and I hope you will be able to read my response. What you are talking about is preventative surgery?  This would be surgery to prevent another surgery or delay another surgery. I suppose that there are a few cases of this that make sense, but not big toe joint surgery. Any surgery on the big toe joint will weaken and stiffen it. After surgery you are more reliant on orthotics, taping, icing, physical therapy, shoe gear, etc. You job now is to see what you can do to minimize/prevent the severe pain episodes. That is what will save your joint. Some, level 0-2, pain is par for the course with an arthritic joint. It is the pain from the low grade inflammation. Higher levels of pain may mean you are breaking down the joint. If you have surgery, it will not be a good joint, and you will have even more restrictions. There is no study that I know documenting the percentage of patients with an arthritic big toe, or knee, or hip, joint that go on to surgery. Do not do surgery to slow down the arthritis, since I am not sure that can happen. Have surgery if you can not control the soreness and it impacts your life (since we only have one of those for all I know). If I decided to have surgery for this, I would get a baseline MRI, and then spend 1 year rehabilitating the joint. Then I would get a comparison MRI to see if the joint is getting better, worse, or staying the same. My blog is full of information on what to do to help a painful joint. If you do not succeed, have the surgery with no regrets. But, you may get a lot better. My office has probably 500 plus patients with this problem in all different points of the progression of the disease. They have surgery only when the disability of the problem outweighs the disability and risks of the surgery.  The smarter I become on this issue, the dumber I feel. There are so many variables to deal with to help someone avoid surgery and rehabilitate after surgery. I have patients with minimal X-ray findings with severe pain, and severe X-rays findings with no pain. Analyzing disability vs function is the most important tool we have in advising patients with this problem. My job is to get as good as I can at avoiding surgery for patients, so if they need surgery, the same tools can be used to successfully rehab them. Please email again with any other comments. DrRichBlake