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Thursday, October 13, 2011

Followup on Sundays 10.9.11 Post: Possible Sesamoid Injury

Here is a followup to my post on 10.9.11 (it was my last one).
http://www.drblakeshealingsole.com/2011/10/pain-in-ball-of-foot-email-advice.html


Thank you for your advice. I recently had an MRI, I was told that I had a bipartite and that there was no fracture. I'm sorry I should have been more specific. I am currently waiting for a Nerve Conduction Study (NCS)

Dr Blake's Note: When there is a possibility  between bipartite sesamoid and fractured sesamoid, the MRI is usually definitive, so I am very happy that you got the MRI to rule out the fracture. Now you have to figure out what another possible source of such terrible pain, and nerve pain is a great possibility produced by the orginal trauma to the foot or a jarring to the back. Back injuries like this may never present with back pain, only pain along the distribuation of the nerve involved. Lumbar 4 nerve root goes right down into the big toe.
This past Friday I had an appointment with my Dr and came home in a non weight bearing cast to help alleviate the sesamoid pain :( other than being very inconvenient, the pain in the ball of my foot has subsided some.

Dr Blake's note: This sounds like a great move because when there is pain not improving, you must seek to create a pain free environment.

 The nerve pain and the sesamoid pain are being looked at as two separate issues. I have not been offered any medication for the nerve pain. I currently take 800mg ibuprofen regularly (yes my tummy is not happy) Although I still continue to have the nerve pain, twitching, tingling, and burning sensations in my big toe :(

Dr Blake's note: Nerve pain has its own set of meds different from anti-inflammatory. I have never know the NSAIDs to help pure nerve pain. You need pain killers like Vicodin, Neurontin, Lyrica, Nortrypline, etc.
I did ask for clarification on the surgery, because I'm very concerned since my last surgery is when the nerve symptoms began. He said he would be removing a piece of the bipartite.

Dr Blake's note: I am not a surgeon, but I have never heard of this. It may be cutting edge, experimental in my mind. Does the surgeon feel the pain is being caused by the pieces of the sesamoid moving? Sometimes the two pieces of a bipartite sesamoid are held together by loose ligaments which tear with trauma. From that point forward, the sesamoid pieces move abnormally on each other causing pain and inflammation. However, if that was the case, I would assume that the MRI would show some form of bony or joint inflammation, not just a bipartite sesamoid. Since the pieces are not adding up totally, and the fact that I think this must be a relatively new procedure, I would make sure the nerve guy treats all of the nerve pain throughly before considering surgery.

I was also told that there was significant arthritic changes to my big toe? Could that be a reason for the stiffness and pain also?

Dr Blake's note: Significant Arthritic Changes mean Hallux Limitus or Rigidus, which is a totally different animal. Read some of my posts on this. Make sure if this is the cause of your pain, and you are going to have surgery, that you attempt to treat that condition appropriately before surgery. I am still confused about the MRI showing only bipartite sesamoid, and somewhere you being total you have significant arithitic changes?? Isn't this fun. Now you have 3 possibilities of your pain: 1) Sprained bipartite sesamoid with excessive motion between the pieces on weight bearing causing pain (this is where the surgeon may be going when he talks about removing a piece), 2) nerve trauma and chronic nerve pain, and 3) hallux limitus/rigidus with severe arthritic pain. Unfortunately, all 3 of these conditions may need surgery. Fortunately, all 3 of these conditions can respond to conservative treatments, if we know which one to treat. At least, the surgeon, who probably knows all this, will get a good laugh out of this. Surgeons do like to be black and white in their approach.

Thank you for your time, and yes your reply was very helpful!!

Dr Blake's note: You are welcome.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.