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Wednesday, August 8, 2012

Sesamoid Injury: Email Correspondance

Dear Dr. Blake,

I ran across your blog, particularly your entry from September 2010 to the patient with a sesamoid fracture, while I was researching removal of a sesamoid.  I am hoping you can provide me with sound advice regarding my current situation.  For your reference, I am active duty military, in my mid-30s and am required to work out regularly and have been limited in my ability to do so since all this began.  Because this has been going on for over 7 years with little relief, I have pain just about any time I walk or become active.  I realize the history I am about to give you is long but I feel that unless you have all the information you may not be able to answer my questions.

I have had pain in my foot, specifically where the big toe meets the foot, for about 7 years now.  It started when I fell down some stairs.  I jammed my big toe and shins into the step as I fell forward.  The good news was that I stopped but the bad news was that I immediately developed pain in the joint where the big toe meets the foot.  Initially I figured I sprained it and didn't do anything aside from minimize activity.

 After a couple months with no change I went to the doctor and they did an x-ray, which they said was negative for fractures.  I was already seeing a podiatrist for pain at the underside of my foot where the second toe meets the foot.  This initial problem gradually got worse and would swell to the point where my second toe would shift to the side, away from the big toe.  After I was told the x-ray on the big toe was negative I brought it up to the podiatrist and they began working both issues.  They tried to find the source of the pain in each joint (both the big toe and the one next to it) and apparently all tests were negative including a bone scan and x-rays.

 Steroid shots into the second toe joint did help with pain and swelling, but both would come back with a vengeance after approximately three months.  They also tried inserts which seemed to help a little bit but again didn't seem to totally fix the problem.  Specifically, any time I started to resume activity the pain and swelling would return immediately.  Push-ups seemed to make it worse.  After several years' worth of bad diagnoses and unsuccessful attempts to alleviate the pain in both joints, the doctor planned an exploratory surgery to explore the joint that had the original problem.  While they couldn't explain why the big toe joint would be fine prior to the fall then suddenly become painful afterwards, they said there was a bunion on x-ray and that if they did a bunionectomy while they did the exploratory surgery they should be able to address and correct both issues.
Dr Blake's comment: Pain from impact in the big toe joint is a stress fracture or sprain until proven otherwise. Since the bone scan was negative, and health plan not cover MRI, the diagnosis now has to be a sprain. 

During the exploratory surgery (August 2008) the doctor discovered dead synovial tissue and a small bone fragment in the second toe joint.  He removed the bone and cleared out the dead tissue.  He also shaved down the side of the first metatarsal for the bunionectomy.
Dr Blake's comment: The first surgery on this big toe joint did nothing to help or identify the source of your pain. Did the surgeon say anything after looking into the joint about what you injured? We would expect from this description that the surgery did not help you in the least. 

Almost immediately upon resumption of activity following the surgery (to include simple walking) I noticed two things: 1) the pain in the second joint appeared to be gone and 2) the pain in the big toe joint was the exact same as it was prior to surgery.  I told my doctor and he told me to give it time to finish healing.

 Over the course of the next several years, I was sent from podiatrist to podiatrist to figure out why it was still painful.  They tried various forms of physical therapy, to include steroid infusions (with the electrolysis pads) and laser therapy.  Nothing helped.  I was still using inserts in my shoes and icing it regularly.  After my doctor exhausted all his expertise, he referred me to yet another podiatrist.  That doctor (at Walter Reed Medical Center) suspected it was torn cartilage on the head of the bone and said my case was almost exactly the same as two previous patients, who had the same mechanism of injury and symptoms.  Unfortunately I came up on orders to move and my doctor didn't want to stop it so she told me to proceed with the move and have my next podiatrist do the surgery.
Dr Blake's comment: The torn cartilage theory does not hold water due to a negative bone scan. However, I have seen many bone scans where the images of the foot were too small to make an accurate read. Images from bone scans on the foot can be so small that they are read as negative when the dye does not seem to highlight any one particular area. This is a false negative. And can be devastating since it misses the true reason for the pain.  On a bone scan I try to remember to ask for blow up views of any suspicious area to delineate the exact location of the increase dye uptake. Increase dye uptake into bone means that there is a healing process going on. Golden Rule of Foot: As long as you have a pulse, your bone, or cartilage, if injured will try to heal and the bone scan will be positive. 

  I arrived to my next duty station and saw yet another podiatrist.  This podiatrist said they needed to re-do the bunionectomy, since the original area that was shaved had now calcified and was jagged.  She also said she wanted to cut the bone and screw it back together to lessen the angle.  Apparently the angle of the metatarsal was higher than normal so she felt this was also contributing to the problem.  She said she would explore the head of the bone while doing the other portion of the surgery.
Dr Blake's comment: Bunions do not cause this type of pain. So, correction of the bunion surgically will not help your problem. If the bone scan is negative, only a pre-operative MRI scan may show the source of the inflammation in this case. I am hoping as the story unfolds that the surgeon it not just focus on fixing the bunion, but looking for the source of pain. Which is truly the meaning of exploratory foot surgery--looking for the source of the painful problem. 

According to this doctor the second surgery went well (done in September 2011).  She said the cartilage looked fine.  X-rays showed the bone was healing very quickly and within a couple months the bone was almost completely healed.
Dr Blake's comment: So the cartilage was fine. Why do you hurt?!!? Again, the second surgery, probably done in vain, did not address your problem. I am sorry.

 After I got the all-clear, I began exercising again.  Almost immediately I noticed it started hurting again.  I figured since there was still some swelling it was just post-op recovery and would take a while.  However, I found that if I did mountain climbers (an exercise where you're in a push-up position and hop from foot to foot) or anything that required my big toe to bend and hold my body weight I could barely walk afterwards.
Dr Blake's comment: 2 surgeries to work on the bunion and explore the joint with no relief in symptoms, what does this mean? Negative X-rays and bone scan can be added to the story of investigation. Everything points to soft tissue injury. I love to give diagnostic shots of long acting local anesthetic into joints before I recommend joint exploration. The local anesthetic lasts for 5 hours and can tell us if the pain is coming from the joint or from outside the joint. It can help avoid needless surgeries like the two you had from very dedicated doctors. 

 When I returned from some training I went back to my podiatrist, as I figured she'd tell me to slow down and that this was normal.  Her response was that it was not normal and she was concerned.  She said that based on what I was telling her she suspected it was sesamoiditis.  This was the first time I'd ever heard the term and none of my previous doctors had ever mentioned it.  She ordered a bone scan that turned out to be positive.  She injected dexamethasone into the area and within a couple days my foot was completely pain free--for the first time in years.
Dr Blake's comment: Okay, now we have a doctor thinking good thoughts and probably out of the box. She tries to identify the source of pain with another bone scan (probably since the first was not around), and a short acting cortisone with local anesthetic shot. By your description, I am not sure if the shot was in the joint (where the sesamoid lies) or outside the joint. But, we are making progress. The repeat bone scan being positive, with the first one being negative, shows that the first one must have been read wrong, perhaps since blowups were not ordered. I may want you to order both sets. 

 I was so excited I even tried a little jogging, and it didn't hurt!  However, within three weeks the pain came back.  My doctor said the injection would only have lasted for a month, so given that it lasted as long as it did was a good sign.  She did another injection (mind you, I was wearing shoe inserts and limiting exercise again), and a third injection a month after that with each one lasting less time than the previous one.  She said that based on the response and bone scan, she was confident it was sesamoiditis but was out of treatment options for me.  Finally, she referred me to another podiatrist for yet another opinion.
Dr Blake's comment: I love that doctor. Very thoughtful, concerned, and willing to refer. She had made some progress for the first time in your saga. I hope she felt good about that. She should. Unfortunately, doctors tend to focus on the negatives. She probably felt she let you down, but she gave us hope. Hope that a solution could be found. I thank her! I hope you did. 

This new podiatrist has told me that my foot is the "perfect storm" to end up where it is.  I have high arches (hence the previous doctor's attempt to lower the metatarsal) yet I severely overpronate (due to physiology of my ankles, which is not what it normally should be).  He said that between those two things I put an excessive amount of stress on the sesamoids and this is probably a large part of the reason it won't heal.  He ordered an MRI, since apparently the bone scan isn't definitive with the still-healing metatarsal in it (taken about 6 months post-op).
Dr Blake's comment: Hooray, finally an MRI. I also like this doctor. Pain is the first metatarsal pain causing disability should have an MRI to see what is trying to heal. The MRI shows what tissue is normal, and what is inflamed. 

The doctor went over the MRI results with me and according to him the inner sesamoid shows up abnormally.  He said that it appears the inner sesamoid is now a fluid-filled cyst.  He said he can also see where the head of the metatarsal (ridge) seems to be worn down.
Dr Blake's comment: I have a patient right now with the same findings who is doing well. When you have changes in the sesamoid and first metatarsal, common in this type of injury, it takes time to get well since the injury crosses the joint. My patient SS is back running now with the same injury with no surgery. There is hope.

 He suspects that the initial fall tore the cartilage on the underside between the sesamoid and the metatarsal head.  Over time, use wore down the head of the bone and the sesamoid eventually turned into a cyst.  He also stated that this type of situation is fairly common in ankles but not so much in this area of the foot.  Based on the current state of the sesamoid and the head of the metatarsal, he suspects the cartilage is indeed torn--but it is the underside of the head of the metatarsal, not the top which was the only part originally explored.
Dr Blake's comment: This doctor is thinking real well. If you can go to the removable boot with bone stimulator for the next 3 months, you may be able to salvage the sesamoid. You could remove the sesamoid, but I would like to see the MRI first. If it was my foot, I would go into a removable boot, create a pain free environment, for the next 3 months, then spend 3 months gradually weaning out of the boot with good orthotics keeping the pain level at 0-2 day to day. During this time, you are using a bone stimulator. I have one I can lend your doctor if the Armed Forces can not afford. I can mail it anywhere that you want and the doctor in charge can talk to the rep to see how to make it work. 

This doctor had me try oral steroids which also seemed to help, but again the pain and swelling returned within a couple weeks' use.  After all this, my doctor has said that the only option left is to go in and remove the sesamoid.  He said he'll make a vertical cut into the tendon, remove the bone and stitch the tendon closed (which he said may not even be necessary if the cut is small enough).  He will also debride the torn cartilage and drill out the end of the bone to stimulate growth of scar tissue to cushion the area.
Dr Blake's comment: If you remove the sesamoid, not sure if you need to do anything with the metatarsal which will have no pressure on it. 

I have done a LOT of research on this sort of injury and procedure and still have some concerns about it.

Based on my history (and I can probably provide you with the images if you need them), can you tell me:

1)  Does this diagnosis sound correct? Yes.

2)  If the sesamoid is not broken but has turned into a cyst, is removing it the best option?  Is there any way it would heal without surgery? Yes, the cyst is just a stage of healing in my mind. You need a bone stimulator which will affect the sesamoid and first metatarsal at the same time. You need to keep the pain level to 0-2 for 6 months and then repeat the MRI to check on amount of healing.

3)  What sort of post-op prognosis should I expect if he takes the steps listed?  Should I be able to return to normal activity?  I am okay with knowing I may never be able to run regularly, as my main goal now is to simply be able to walk without pain.  I am in my mid-30s and cannot imagine living the rest of my life with this injury. Since you are so young, I am 58 and very active, give yourself the next 6 months with the above RX. If the new MRI shows improvement, you may have to go another 6 months. But, start at 6 months. If after 6 months, you have little or no change in the MRI, or you are getting worse, have the sesamoid removed. 

4)  Are there any other questions/issues I should bring up to my doctor?  We discussed everything at length but I would like another opinion before I go under the knife.  As of now my surgery should be sometime in October 2012.
Dr Blake's comment: You can have surgery to remove the sesamoid, but the joint will have to be protected forever. People do participate at a high level of activity after sesamoid removal. Even though you have had this for a while, my first choice is still conservative as suggested above. To make conservative work you must have a bone stimulator for up to 9 months, you must be able to protect the joint with orthotics for the next 2 years, you must be able to use the removable boot for the 3-6 months as suggested above, you must learn how to spica tape and use dancer's pads, and have your diet healthy with calcium and Vit D. Sometimes, this just can not work, and they have to take plan B, and remove the sesamoid. 

Thanks for your time and making yourself available!

Mary (name change for privacy)

Mary, I hope my discussion above helps. Send me the MRI  and other tests if you want. Email me for mailing instructions. No charge for this service. I hope this has helped you. 

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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.