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Saturday, May 18, 2013

First Toe, First Metatarsal, and Sesamoid Injury: Email Advice

X rays notoriously misdiagnose sesamoid injuries. I can see irregularities in her tibial sesamoid, but is that really what is causing pain? We see normal joint space in the big toe joint denoting no significant arthritis. You can see the first metatarsal head is longer than the second. It needs to be 3 mm or so shorter than the 2nd or jamming of the joint can occur. This is a major cause of big toe joint pain, and mechanical changes with arch support and dancer's pads are very important. 

Dear Dr Blake,

I have been reading your blog and have found it to be an amazing resource - and by far the best on the seemingly incredibly tricky area of sesamoid issues.

My story: I have had pain in my right forefoot ever since snowboarding in Feb 2011. Initially this centered on the distal interphalangeal joint in my big toe. I had an x-ray which purported to show a fracture on the outer extremity here and treatment to relieve the pain was a cortisone shot in August 2011.

In March 2012, the pain returned - both in my big toe joint, and now around the sesamoid region. An MRI showed edema in the sesamoid region, but no apparent reason for this. I had an ultrasound guided cortisone injection into the site of the edema. This did not relieve my pain at all.
Dr Blake's comment: Even though the pain is in the same area, this sounds like a new injury. However, long acting cortisone can mask pain for 6-9 months, and patients can be worse when the cortisone wears off. Overall, try to stay away from cortisone shots into joints for this reason. Just using cortisone, without understanding the injury mechanics/cause, can be a dangerous proposition. 

Over the months the pain worsened. After going horse riding, which placed a lot of friction on the sesamoid area, my entire joint swelled up massively. I had a further MRI in Feb 2013, diagnosis this time was sesamoiditis.
Dr Blake's comment: Sesamoiditis rarely causes massive joint swelling. There is definitely something wrong with the joint, but it is not the sesamoid.
Unhappy with this I got a 2nd opinion on my scans which has recently come back as a fractured tibial sesamoid. In April 2013 I had a further cortisone injection (bringing my total to 3 in this area!) and am now in an aircast boot.
Dr Blake's comment: Hopefully you are not getting long acting cortisone which is contra-indicated in fractures. 

My questions...

1. Given that I have gone undiagnosed for so long, I am understandably keen to confirm that I do indeed have a fractured tibial sesamoid - are you able to identify this on my attached scans?
Dr Blake's comment: Thanks for sending me all these images. You did injury your tibial sesamoid, but that seems to be doing well. You still have some major healing to occur on the first metatarsal fracture, and perhaps some mechanical treatment of the first metatarsal to help you speed up the cure, and prevent relapses.

2. The pain in my distal interphalangeal joint is now insignificant in comparison to my sesamoid pain, but I wonder if you can see anything on the scans to confirm a fracture here? Could it be that my seasmoid fracture resulted at a later date after walking differently to compensate for this pain?
Dr Blake's comment: Yes, the distal phalanx (under the toenail) was injured and is still showing inflammation. Hard to know if it all occurred at once, or were separate injuries. Has is your Vit D3 levels and overall bone density? 

3. Will the multiple cortisone shots I've received have done any irreparable damage and act to prevent my healing? I assume you would advise absolutely no further shots now a fracture has been identified.
Dr Blake's comment: Probably not, and yes try to avoid. 

4. If I sustained the sesamoid fracture so long ago in Feb 2011, is it now unlikely to heal whatever efforts I make?
Dr Blake's comment: Your sesamoid fracture with it's resultant inflammation is probably less than 5% of your overall pain right now. Most of the pain is from the inflammation within the first metatarsal head (very obvious on the MRI images below).

5. My doctor advised just 6 weeks in the aircast boot, I am assuming you would recommend much longer?
Dr Blake's comment: There is no fracture displacement necessitating casting or surgery. It is going to take a long time to have the first metatarsal feel better based on the present inflammation. You need to wait 6 months to check on the first metatarsal head inflammation process, a sign of healing. You should be creating your pain free environment with the least immobilization as possible. Right now, if the joint is swollen, contrast baths, no NSAIDS, bone stimulator if your insurance will allow, spica taping, orthotics, dancer's pads, Vit D3, Calcium, occasional boot, stiff shoe, rocker shoes, etc.

6. I am now trying to follow the advice on your blog and create a pain free environment - spica taping, icing, contrast bathing, orthotics inside my aircast boot. Yet my joint is visibly still quite swollen and I believe the aircast boot my even aggravate it from rubbing. Would you advise removing the boot whenever sedentary?
Dr Blake's comment: The swelling will be there for a long time, and immobilization makes it worse. Base your treatment on gradually increasing activity, while you protect the joint, and keep the pain level between 0-2. Do not base your treatment on swelling. Good luck my friend and so sorry for the delay in responding. Rich

The saga of my foot injury has brought me quite low. And I am quite devastated to learn after all this time that there has been a fracture lurking. I hope that by following your advice I can finally access some real healing.

Many, many thanks,

Cecilia (name changed)



On this view, like the above X-ray changes within the tibial sesamoid suggest a tibial sesamoid stress fracture. The tibial sesamoid is closest to the skin, the fibular sesamoid is closest to the 2nd metatarsal. See the dark area in the center of the first metatarsal head suggesting bone remodeling. This area is highlighted in the T2 image below which emphasizes swelling. 

This is really why you hurt. You can see that the tibial sesamoid is lighter than the fibular sesamoid suggesting some fluid retention, but healing uneventfully. The center of the first metatarsal is full of intense swelling signifying cartilage or bone injury to the metatarsal head. You will not feel a lot better until that inflammation goes down with further healing.


Here the sesamoid and the first metatarsal look fine, however injury is noted in the distal phalanx (under the toenail) with inflammation seen on this and the next image.
Normal middle of the joint from the side

You can see the center of the first metatarsal head is still remodeling. Definitely here looks like a slow healing fracture.

Here there is a suggestion of bone edema into the first metatarsal shaft away from the sesamoid area.

You can see the old tibial sesamoid stress fracture that is in one piece. You can get some symptoms, but the injury to the first metatarsal head is worse, and still has aways to go to stop giving you symptoms.

This is a hard image to read but implies normal sesamoids

This is another great image showing that the sesamoids at this stage are not your problem, but the swelling above it.

1 comment:

  1. Where are the pictures for this? Can they be re-posted? How is the patient doing now?

    ReplyDelete

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.