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Monday, August 15, 2016

Big Toe Joint Pain: Email Advice

Hi Dr. Blake,

I'm writing to you to get your insights and hopefully share my journey with the other folks out there. I never want to join the sesamoiditis club but through your blog I really felt less alone. I now can pontificate for hours on sesamoids and feet (and why it's critical to have a good podiatrist) and it's a wonder I still have any friends left!
I am 30 and an avid ballroom dancer (so dancing in heels on releve a lot!). Not overweight, and relatively healthy. I first started feeling pain in front of my right foot in late April, and I'd ice my feet and go back to dancing. But it wasn't getting better (I was probably at a 3 or 4 pain level at the worst - but I'm a baby about my feet), so I got an X-Ray and an MRI in May. No evidence of fractured sesamoids, but I did have a Grade 3 tear on the lateral sesamoid ligament. And now it appears I have bad arthritis in my big toe joint (from 2nd MRI - report at end of this email).

After the first MRI in mid-May, I immediately went into an Aircast - I was 100% in boot any time my foot had weight-bearing for 6 weeks, and then I started easing out. It was still painful so I went back into the boot for 3.5 more weeks, with 1-2 hours then 4-5 hours after work in supportive Hoka shoes with padding (Dancer's pad and arch support). I'd also tape my arches for the first 8 weeks I was in the boot. I was able to achieve 0-2 pain levels for basically all of the 11 weeks since this "journey" started. I did 1 full month of 1x-2x day contrast baths, and now I do a warm soak in ginger water every night (my mom is a nurse who also studied traditional Chinese medicine, and she said ginger can help inflammation. In any case, I figured it can't hurt!).
Dr Blake's comment: You have been doing everything great, limiting the bend at the big toe joint, and creating a great 0-2 pain level. Good job so far!!! And thank you for the humor!! 

I see a super wonderful podiatrist every 2-4 weeks since this started in May. I am taking glucosamine supplements, vitamin D, fish oil, and calcium chews. I never go barefoot. I've been out of the boot for a week at this point and I'm probably at a 0-2 pain level even with the padding. But I've read your post on good vs. bad pain, and I'm not limping, and I do have pain-free periods. I do metatarsal doming exercises 5x a week, and I am starting to go see a PT 2x a week starting next week. I am easing back into dancing - I have suede soles put on a pair of Hokas and I am doing some walking to music starting this week. In my Hokas, I can go up on a very slight releve without any pain.
I am also getting a bone stimulator because my doctor said it might help with a bone cyst in my foot - in any case, it should not hurt, right? 
Dr Blake's comment: I love the idea of a bone stim for the cyst. Could you send a photo of the Hokas with suede sole!!! Everyone, this person really wants to get better, and is doing everything very smartly. 

It'd be amazing if you can help me calibrate the MRI report - i.e. should I be freaked out, very freaked out, extremely freaked out? :-/  "severe degenerative changes" sound horrible and I plan on living and dancing for at least 40 more years..
Dr Blake's comment: If you can take a photo of the xray or MRI that shows this severe condition, that would be great. You are only thirty, and I assume you have never had any problems with this joint before. May be an over read. If you can get me the MRI CD before Friday 8/26, I would be happy to look at. Mail to: Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. If you bend the right and left big toe joints upward, can you tell the injured side is alot more limited. That is one of the definitions of degenerative big toe joints (aka Hallux Rigidus). Perhaps someone could also measure your joint range of motion like in the video below. 
https://youtu.be/Z21MtkhW7e0



Also,
1. Is there ANYTHING else I can be doing to heal this faster and make sure I don't get injured again?
Dr Blake's comment: You have created the activity pain level balance. Gradually increase your activity over the next few months. Do not set any goals to perform. Ice pack 10 minutes twice daily, and contrast bathing each evening. Met doming, single leg balancing, and calf stretches crucial (once a day except the calf stretches 3 times a day). 

2. I have nightmares that I secretly have a fracture and it just haven't showed up yet - can you reassure me? 
Dr Blake's comment: No, unfortunately, I would have to see some imaging. Sorry!!

3. Should I get a bone density test?
Dr Blake's comment: I hope everyone is reading this. Great question. Yes, degenerative changes in a 30 year old could point to bone problems. I bone density test is a wonderful idea. If they find a problem, you have many years to right the proverbial ship. 

4. How should I assess when I can start going back into heels for dancing? I imagine it'll be at least a few more months so I can be patient...
Dr Blake's comment: You need to change one variable at a time, and then level off activity when you add the next variable. I would gradually increase your dance next several months, then slightly lower intensity levels as you gradually introduce the heels first 5 minutes, then 10, etc etc. 

5. When can I start working on PT barefoot (like standing on a mat, etc.), and when can I go on releve? Is it all based on being able to do so with 0-2 pain? 
Dr Blake's comment: You definitely will need to maintain the 0-2 levels. Typically you see a PT once a week and they add more and more stress to the sesamoid area, like barefoot, like releves, like turns, etc. 

Thank you so much! I've never heard of sesamoids before this and now they consume 90% of my thoughts. 

2nd MRI - 8/1/2016

Impressions:
1. Scarred but intact lateral sesamoid-phalangeal ligament in continuity between the lateral sesamoid and the proximal halanx of the first ray as determined on thin section sagittal images (1st MRI showed Grade 3 tear in ligament)
2. Moderate to severe degenerative changes across the lateral sesamoid-metatarsal head articulation with chondral degeneration and degenerative marrow edema along the distal aspect of the lateral sesamoid.
3. Mild degenerative changes across the  medial sesamoid-metatarsal head articulation. 
4. Non-specific inflammation / effacement of subcutaneous fat along the plantar aspect of the fifth digit in an area 13.8mm medial to lateral and 6.7mm superior to inferior (at the leave of the fifth metatarsal head)

Stable proximal retraction of the lateral seamoid. The abductor pollicis tendon is intact. Mild degenerative changes across the  medial sesamoid-metatarsal head articulation. Cystic changes are more clearly seen at this articulation. 

Redemonstration of mild increased sclerosis of the medial hallux sesamoid.
Moderate tendinosis of the abductor hallucis tendon and mild edema of the flexor hallucs brevis muscles (unchanged since 1st MRI). Intact plantar plate, flexor, and extensor tendons. Callus formation plantar to the second MTP joint.
Minimal fluid in the first through third intermetatarsal space. No evidence of Morton neuroma.
Dr Blake's comment: When I read all this, it says to me that you have been beating up on this joint for awhile. I hope you can say that it has served you well up to now. I would go slow but steady back to dance over the next 6 months keeping the pain level between 0-2. No rush. 6 months from now, after probably an up and down course, you should get another MRI to compare 2 to 3. I would be happy to help you then also. Go slow. Listen to your body. I have treated Olympic athletes with worse looking MRIs but doing well. Because they are smart, and alot is on the line. 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.