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Tuesday, September 11, 2012

Sesamoid Injury: Email Advice

Dr. Blake,

I just found your blog yesterday and am kicking myself for not doing so sooner.  I am beginning to incorporate some of your advice (contrast soaks, exercises) to see if they help, but in the meantime I would appreciate your input on my case.  I've been dealing with what the average doc would probably wave off as mild sesamoiditis, but it has severely impacted my quality/enjoyment of life since I have yet to find any form of exercise that does not flare it somehow.  I am 30 years old (female).

To start at the beginning, in June or July of 2011 I spent an impromptu afternoon walking around a downtown art fair in less than ideal shoes and by the end of the afternoon was suffering pain in the ball of my left foot.  At the time I was running with some regularity, which I promptly stopped, and I switched to wearing more supportive athletic shoes 24/7.  I tried icing and advil for a few days, and then I just tried to rest the foot as much as I could.  After several months and significant improvement, I went for a short run and discovered that no, it wasn't all better. 

 I went to my university's clinic where a PA quickly diagnosed it as sesamoiditis and sent me for an xray, which came back negative.  He prescribed PT, and there I received weekly ultrasound and icing treatments over two months (Oct-Nov 2011) and advice to switch to a stiff soled shoe like a Dansko clog.  Before getting clogs I tried a dancers pad, but it seemed to make things worse.  They showed me how to tape my foot (a different approach than your videos show), but that also seemed to aggravate the pain.  I had reduced flexibility of the big toe joint and throughout the arches of my foot, which PT improved.    By the end of 8 sessions my pain was improved though not gone, and I found I still had to limit my amount of activity to keep the pain at a low level.  However, since I wasn't gaining any more significant improvement, PT said to just do what I was doing and it would, by the looks of it, continue to slowly improve.  They sent me on my not so merry way.

I continued wearing the clogs and over the 2011 Christmas holidays I began having pain all throughout my left foot, which I suspected was from compensating/walking funny to avoid the sesamoids.  It spread up the outside of my foot/ankle and was more debilitating than the sesamoiditis.  At this point I went back to the university clinic and requested a referral to a podiatrist hoping for a second opinion and maybe orthotics or something, anything, helpful.

  I first saw the podiatrist in January, and he quickly diagnosed the new pain as peroneal tendonitis but hearing the original xray was negative decided not to pursue any imaging for the sesamoid (which was still sore and easily flared, but overshadowed by the tendonitis).  He asked me to get motion control shoes to control my pronation, injected the tendon with cortisone, and gave me a prescription to have orthotics made.  I switched shoes as he suggested, and those and the cortisone cleared the tendonitis up quite a bit within a week.  

However, the sesamoid was still sore and still easily flared.  It took weeks to get an appointment for the orthotics at the place he sent me (based on my insurance), and my luck was when I got there the guy I saw had a chip on his shoulder about orthotics for sesamoiditis.  In my first appointment he might as well have called my podiatrist a quack and said he saw nothing wrong with my gait or feet and that more ice and strengthening exercises were in order before making me orthotics. 

 At this point I was open to just about anything if it might help, so I didn't question him as soon as I should have.  However, his exercises aggravated my foot instead of helped, and months later he was still resisting making the orthotics I was referred to him to get.  I finally put my foot down and asked the podiatrist if he could refer me ANYWHERE else.  In the meantime, the podiatrist gave me a 2nd cortisone shot for the tendonitis (which helped further) and one in the ball of my foot (which flared the pain horribly and never recovered past the point it was before the shot - I declined any further attempts). 

 I got a referral to the other place in town for orthotics where my insurance would pay, and it was a breath of fresh air.  The pedorthist said he would need to correct all 3 zones of my foot (heel, mid foot and forefoot) for pronation, to support all 3 arches, and build up the forefoot under 2-5 to compensate for the prominence of the first metatarsal area.  Overall he said he could easily see how I ended up with sesamoiditis given my foot type.  I finally had orthotics in my shoes in mid May of this year, and we spent most of the summer tweaking them, eventually cutting out more under the seasmoids and big toe to attempt to offload it as much as possible.

  I eventually plateaued again, with as much relief as I'd ever had, but with a foot that still flares if I am on my feet for any significant amount of the day.  At the same time, it gets sore if I sit still for too long at my desk (being careful to keep that foot flat on the floor).  At this point looking back I feel like the one person I saw with any good sense was the pedorthist, but he's done everything he could think of trying.  I guess my main question for you if I showed up in your office would be what, or who, do I try next?   My plan right now is to try a week of contrast soaks and icing, add in some exercises and see how that goes, and then pursue another local opinion.  However, I'm not sure who I should be seeking out - an orthopedist, sports med, a different podiatrist...?  

I'm sorry for the very long email, but any time or advice you can spare would be greatly appreciated!  Already, your blog has given me a glimmer of hope that I was beginning to think was completely lost.

Sincerely,

Susan (name changed)

Dr Blake's Response: Hey Susan if I have one strength in life it is that I first look at the Big Picture of a situation to gain perspective, then get into the details. Soooooo, what is the Big Picture here? 

First of all, you have no diagnosis!! I will go up to 2 months without a documented clear-cut everyone will agree with this diagnosis, but if the patient is struggling, stop and get one. How do you get a clear cut diagnosis with negative xrays? Order an MRI. And if the MRI is negative, then you order a  bone scan or nerve conduction study or even thermography. What ever makes sense, but you make the diagnosis!

Second of all, you must go back to square one and Create A Pain Free Environment. You have learned alot along the way on how to reduce the pain level. You must get rid of all the pain for the next 6 months to stop the pain cycle. If that requires you to get a removable boot, please do. 

Thirdly, who sees the majority of ball of the foot problems in athletes? I believe that is sports medicine podiatrists, although there are exceptions. Check the membership of the American Academy of Podiatric Sports Medicine for someone in your area. See if your local running group has a doctor that they would recommend for a chronic foot condition. It may be an orthopod. I agree not to go back to the same doc in this case, since he did not even want to get another xray. Some sesamoid fractures do not show up until several months have passed. 

Fourthly, since I am putting you back into the Immobilization/Anti-inflammatory Phase of Injury Rehabilitation, definitely 3 times per day do either ice pack or contrast bathes. Over the course of the next month, that may allow you to gradually increase what you are doing without increasing your pain. 

And lastly, keep strengthening as long as there is no pain. You can do single leg balancing on a 2 inch book with the big toe floated off the edge. You may be able to do met doming/arcing. Ride a stationary bike with the pedal in the arch, not the ball. Be creative to stay strong and fit, while you are trying to figure this out.

Now, I must go, but please keep me in the loop. Rich



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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.