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Sunday, July 21, 2013

Big Toe Joint Injury and Severe Pain: Email Advice

Dear Dr. Blake,

I am 51 years old and recently found your terrific blog.  It’s my hope you can help provide me with insight and guidance on an injury I sustained to my left first metatarsal and sesamoid bones on July 17, 2011 while trail running.  I apologize in advance for the length of the email, but my history is extensive and symptoms chronic.

A month or two before the July 17th injury, I had stubbed my left big toe walking down stairs at my house.  To my surprise it did not swell or hurt and I continued to run approximately 10 to 12 miles per week.  The day before my injury I experienced a uniform pain throughout my left big toe after finishing a run.  It completely resolved about an hour or two later.

The next morning, during a five mile run I felt an explosion of pain under the ball of my left toe.  My foot was swollen and painful after the run.  A day or two later I had plain x-rays ordered by my podiatrist.  They were normal.  Initially I was placed in a surgical shoe for walking.  After a few days with no improvement in pain or swelling I went into a walking boot, which I wore for the next eight weeks without significant improvement in pain or swelling.  During the eight weeks I also was examined by a foot and ankle orthopedist who felt the walking boot was the proper treatment.

Dr Blake's comment: Symptoms like this are stress fractures until proven otherwise by MRI or Bone Scans. Many times stress fractures start as stress reactions which have mild transitory symptoms before the final straw is drawn. 
After eight weeks in a walking boot, I was given a cortisone injection in the ball of the foot and placed on crutches for four weeks.  There was no improvement in pain or swelling.  I then went to a well regarded foot and ankle orthopedist in Philadelphia.  He suspected CRPS.  He casted me for two weeks.  There was improvement in temperature and color of the foot and some reduction in the pain.  He casted me for another three weeks.  My pain and swelling improved, but continued at about a 4 or 5.

Dr Blake's comment: CRPS is made much worse typically with immobilization. So, by your improvement with this modality, you may just have an orthopedic injury with some sympathetic overload. If the cortisone shot was into the big toe joint where the sesamoids are, and there is no improvement of symptoms, it points more to the flexor tendons or another structure outside the joint. 
Between July, 2011 and October, 2011 I had three MRI studies.  The first was on 07/22/11.  It showed a bone bruise pattern of the undersurface of the distal first metatarsal across from the tibial sesamoid.  The sesamoid showed no fracture.  Synovitis of the first metatarso-phalangeal joint and flexor tendinopathy between the sesamoids and just distal to them without tendon tear.

Dr Blake's comment: Now we are getting somewhere. Bone contusion sub first metatarsal head with resultant tendinitis and synovitis makes sense from how you did this. However these bone contusions can take several years to get better and have to be followed by serial MRIs. The sudden onset of pain from the bone contusion probably meant it was a stress fracture of the first metatarsal head. Stress fractures occur in the first metatarsal head if the sesamoid is stronger. Ground reaction force pushes the sesamoid up into the first metatarsal head. Normally, everything is fine. However, if one of those two bones is weak, it may break. 

The second was on 10/06/11 with contrast.  It showed mild edema of the intrinsic musculature of the foot as well as the dorsal subcutaneous soft tissues….mild edema of the soft tissues of the second and third tarsal phalangeal regions, flexor and extensor tendon intact.  There was a small focus of subcortical cyst formation involving the plantar margin of the lateral cuneiform…no drainable fluid collections…first metatarsal-phalangeal arthropathy with sub chondral cyst formation of the metatarsal head and a mild bunion deformity…no evidence of fracture….Intrinsic muscle edema of the foot appears slightly more prominent than on prior examination.

Dr Blake's comment: Most of this is probably secondary to the pain and swelling and length of time and immobilization. The first metatarsal phalangeal joint arthropathy (joint problem) is probably what you have as the actual injury. With the month of injury July 2011, you would expect gradual response to treatment progressively until July 2013 (now!!).

The third MRI was on 11/30/11.  Impression was hallux valgus with first metatarsophalangeal and hallux-sesamoid osteoarthirits and low grade strain of flexor hallucis brevis and third dorsal interosseous muscles.

On December 6, 2011, my orthopedist said he couldn’t do anything more for me after reading the third MRI and discharged me to physical therapy and pain management for CRPS.

On the same day I was able to obtain a diagnostic ultrasound.  It revealed a non displaced fracture of the head of the left first metatarsal and mild tenosynovitis of the flexor hallucis brevis.
I began using an Exogen bone stimulator 1x per day and physical therapy.  Over the next six weeks I strengthened my foot and ankle and the pain subsided.  I transferred to sneakers and shoes and resumed normal activities.

For all of 2012 I functioned with no pain, but the forefoot did appear swollen and the toes were stiff.  I did not return to running, but walked five miles or more per week without pain.

Dr Blake's comment: This makes total sense. The stress fracture was healed enough to walk, but probably not run. Hopefully, you had or are getting inserts that protect the first metatarsal head area with dancer's pads and arch support. When you break a bone, you must also look into your diet. Are you getting enough Vit D3 and Calcium? What is your overall bone density? Is your diet solid? Also, a side note, you never had CRPS during this early part of your problem--July 2011 to April 2013. But, your initial injury may have not been completely healed. 

In March/April 2013 there was increased swelling across the forefoot and tenderness to palpation over the tibial sesamoid.  I went to a podiatrist who gave me a cortisone injection in the big toe and the side of my foot.  On May 3, 2013, four days after the cortisone injection I was wearing snug shoes and on my feet most of the day.  At the end of the day my left foot swelled up like a balloon and the pain was between and 8 and 9.  I have been living with persistent pain, at times 10 plus, and swelling since May 3, 2013.

Dr Blake's comment: The writing for everyone else of this email is July 2013. So, 2 + months of increase pain is now present. We do not know if the original injury is healed, and this is a new injury, or if the original injury was partially non healed, and you did something to wake it up. I suppose you were naturally gradually like all of us would increasing your activities. 
I wore a walking boot the last three weeks of May and iced two or three times a day.  There was no change in my pain or swelling.  Since the beginning of June I have been on crutches and non-weight bearing.  Again, I experienced no change in pain, although swelling varies in intensity.

Dr Blake's comment: Typically when you go non weight bearing for a bottom of the foot injury, the swelling gets worse, since it can just pool there. I always try to get at least some partial weight bearing, even if it is only on the arch or heel. 
On May 8, 2013 a diagnostic ultrasound showed irregularity of the tibial sesamoid (there was none in December, 2011) and a healed nondisplaced fracture of the head of the left first metatarsal.

On July 12, 2013 I had another MRI.  It showed progressive lateral rotation of the hallux sesamoid complex and hallux sesamoid osteoarthritis when compared to prior study.  There is now extensive osseous stress response throughout both sesamoids, with a first MTP effusion and synovitis, but no findings for osteomyelitis.  There is extensive subchondral cyst formation and at the crista of the plantar hallux.

Dr Blake's comment: The most likely scenario, without actually seeing all the images, etc, is that you injured the bottom of the first metatarsal head, and some degenerative changes (arthritic) are taking place within the joint. These changes can be progressive, but could also reflex the demineralization from non weight bearing over the last 2 months, and if you are still using the bone stimulator the bones may light up due to good bone activity. Are you still using the stimulator? If so, stop, and re MRI in 3 months. 

I have been taking Tramadol for pain, which ranges between a 5 and 10.  It does takes the edge off, but does not resolve the pain.  I have not been able to obtain any pain free environment since May 3rd and am at loss for what to do to settle my symptoms down and move forward.

The physicians I have seen are at a loss for what is happening, why it is happening and what to do about it.

I am quite desperate and don’t know where to turn.  I would appreciate your thoughts and recommendations?

With much appreciation,

John (name changed)

Dr Blake's comment: First of all, I apologize for my ramblings above, but I try to think out loud as I read these emails. The pain you are presently having is out of control. What can cause this? Stand A Lone Orthopedic Injuries do not cause this level of pain? The big 3 are Infection (may need to have the joint aspirated), Gout (what is your recent uric acid?/also joint aspiration with crystal analysis can help), and CRPS (add a pain specialist to your team who can rule in/out and also place you on a program to get your pain under control). I always worry about infection if the flareup happens after a cortisone shot--cortisone is like candy to these little bugs. Have an infectious disease specialist review your case. Please keep me in the loop, and I am hope this helps point you in the right direction. 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.