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Saturday, April 16, 2016

Sesamoiditis: Email Advice

Hi Dr. Blake, 

I have had sesamoiditis confirmed via MRI for 3 months now. I went to a podiatrist 2 weeks after I woke up with intense pain in my left big toe. She gave me a cortisone shot and sent me on my way. 4 weeks later the pain came back (not as intense as the initial pain) but was still limiting my ability to walk very far without pain. 
Dr Blake's comment: With sesamoiditis, one cortisone shot is fine, but I would stay away from long acting cortisone as a treatment option. It can slow down bone healing, and I think sesamoiditis can be a small stress fracture in disguise. What did you do the day before that made your sesamoid scream so much?? When treating this problem, you need an off weighting orthotic for the sesamoid and an understanding of how to make your own dancer's pads. 



Here is a dancer's pad made of insole material cut up. You can purchase from www.mooremedical.com 1/8th inch adhesive felt, with emphasis on the adhesive part. In this way you can add dancer's padding to off weight the big toe joint area in any shoe, or on any insert. The goal is to try to get less pressure on the sesamoid as you roll through you foot. 

For 2 months I've been in a surgical boot with offloading padding (new podiatrist). On most days my pain level is 0-2 but if I walk alot I end up really sore at the end of the day. My new podiatrist made custom orthotics and wants me to transition to orthotics in a neutral athletic shoe since my pain level has remained at a 0-2. I've also been icing 1x/day. 

It's now been 3 months and I haven't seen much improvement from 2 months ago when I put the boot on. 
Dr Blake's comment: Sounds like you are doing the best you can. Keeping the pain level between 0-2 and getting out of the hideous boot has been crucial. And typically 2-3 months of immobilization is just incase there was a small stress reactions. I have been following these sesamoids for years and at times the bone edema which makes everything very sore, is hard to resolve. So, you can email a photo from the original MRI that has the same view as the one below. If it looks like this one, I would definitely do a 6 month bone stimulator from Exogen (probably have to self pay). You have to wait 6 months at least between MRIs to see the percentage of healing. I have had them go out 3 years before the bone toughens up in the worse case scenario. We can do a new post alone on the image you send if you remind me. 


Questions:

1. How long is the recovery typically for sesamoiditis?

Dr Blake' s comment: Weeks to years. Sorry. Why would it take a long time? Perhaps foot alignment that puts too much pressure on the sesamoid. Poor or compromised bone health (like Vit D deficiency). The type of activity the patient does that may be high stress to the sesamoid. Inadequate treatment somewhere down the line. Too much immobilization that weakens the bone. The development of nerve hypersensitivity mimicking poor bone healing due to high pain levels. Etc Etc.

2. How would you recommend transitioning from boot to orthotics to ensure I continue to heal?

Dr Blake's comment: Typically keeping the pain level between 0-2, with an occasional sharp stab that lasts seconds and no residual. You want to transition when you can be in control of what you do, and can get off foot, or put boot right back on, so start after work going one hour for every days, then 2 hours, etc. Once you are fully weaned out for day to day activities, start weaning at work with one hour, then two, then three, etc etc.

3. Is there anything else I can be doing to speed up the healing process?

Dr Blake's comment: Vitamin D blood levels, possible bone density test, health diet (2 four ounces of red meat if you are a vegetarian per week), perfect the orthotics, get the dancer's pad material, ice for 10 minutes twice daily and do an evening flush of contrast bathing.

https://youtu.be/rRt5hC24Afg
4. I've had tingling in the ball of my left foot recently and my podiatrist says that means I'm healing, but I always thought tingling meant nerve damage. Thoughts?

Dr Blake's comment: Nerve Hypersensitivity is common, and presents in many ways like this. Get online some NeuroEze gel and begin to apply 3 times a day for 2 minutes into the injured area. 

5. Can I never wear heels again? I have high arches. 

Dr Blake's commment: Yes!!! Maybe with a small dancer's pad for good luck? When I watch people walk in heels (in San Francisco it is both sexes LOL), you can see that some heels work better than flats at getting the weight to the lateral side of the foot (4/5 toes). You have to try on many of the same heel height and see where the pressures go. Good luck. Rich

Thank you in advance for your time. Your blog has been very helpful. 

In good health, 

2 comments:

  1. How long should someone use the Neuro Eze for hypersensitivity?

    ReplyDelete
    Replies
    1. Typically for one month to see if it is helpful, and then one month longer than you need to eliminate the symptoms. So if it takes 3 months to feel completely better, go one more month. Rich

      Delete

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.