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Friday, May 26, 2017

Big Toe Joint Pain: What is it?

I’ve been reading your blog for many months and it has been comforting to know that so many others have trouble getting well after a sesamoid injury.  It seems everyone’s story – like mine – has many twists and turns and failed attempts at pain relief.  I would not be writing you if I were not at my wits end.

Let me preface my story with saying that I am extremely active and physically fit.  I regularly (at least weekly) swim 30 laps, hike 10 or more miles, bike 10 or more miles, play tennis or racquetball, take 2-3 pilates and yoga classes per week, lift weights, do yardwork/landscaping, house repairs, etc.  I am about 5’ 3”, weigh about 120-130 lbs, female, and although I am currently in my 50’s, I can out-do any 35-year-old.  Since so much of my life revolves around an active lifestyle, you can imagine how devastating it is to have my whole world changed by a foot injury.  I have never had any foot or leg injuries before, and am in good health, take vitamins (Calcium, D, multi, fish oil, baby aspirin, etc.), and take no prescription medications other than an estrogen patch (for hormone replacement post-menopause).
Dr Blake's comment: You are a great example of cross training to vary stresses we put on our bodies. 

On October 2, 2016, I was doing yardwork and had a set of long pruning shears hit my foot.  Immediately I could feel my foot (around the big toe area) swell up inside my shoes (sneakers) and I knew by the amount of pain it was bad – very bad.  Nevertheless, I had to finish the yardwork because I was getting ready to show the house the next day (in the process of selling it), so I pressed on without icing it right away.  After doing yardwork I took a hot shower, and it swelled further and became more painful.  So it was only many hours after the injury that I started icing it.  I thought it was a broken toe and since there is nothing to do for that really, I did not seek professional help.  A week later, when I still could not walk in a regular shoe, I made an appointment with a podiatrist, but the first opening was not until October 17, so I had been walking on my foot for 15 days before I had an x-ray which showed a broken sesamoid bone. He put me in a walking boot which came up to my knee and showed me how to make the “L” shaped pad to affix to my foot underneath.  After a week, my ankle began to swell and the walking boot became uncomfortable, requiring I have my leg elevated most of the day. He prescribed compression stockings.  The compression stockings increased the pain, and after a week, I quit using them.
Dr Blake's comment: We call this vaso-motor insufficiency, when the protective nerves cause too much discomfort. The body rushes in fluid to heal something, but it is only the nerves screaming that is causing the pain. It is an over reaction to the injury that involves the sympathetic nervous system, but it makes the pain terrible. 

November 2016: I began using a knee walker “scooter” at work (I’m a medical writer). However, I could not use the scooter at home because of the stairs (my house was on 3-levels). I was walking in the boot (or slipper) while at home. I began working from home part-time, and due to the impending sale of my house, I was packing (requiring being on my feet a lot), and searching for a new place to live (requiring being on my feet a lot)… most of the time in the boot.  The pain was bad enough to require icing it down daily. I experimented with a small boot (that only came up to the ankle) but that was much worse.
Dr Blake's comment: I am not sure why 2 or 3 of those scooters can not be dispensed at the beginning. So many patients complain of the same thing. They need a scooter at home, at work, and one in the trunk of their car. The larger the boot, the less tight around the ankle it has to be, since it has a bigger area to grab your leg. The smaller ones only have the velcro down by the ankle to crank down on. Unfortunately, this is all usual stuff with easy cures. 

December 2016:  The foot pain was getting worse and ice no longer helped. I had a car accident which totaled by car, so now, on top of packing and moving, I also had to start car shopping and test-driving cars.  An MRI at end of December showed the bone still had not healed and there was significant bone marrow edema in the medial sesamoid.
Dr Blake's comment: The MRI is going to be hot for a year or so. I like to wait 6 months between MRIs and definitely get a comparison of the two done. At some point, the hypersensitivity of the nerves really started going. Nerves hate ice and like warmth, gentle motion, gentle massage, no prolonged stretching, etc. 

January 2017: I was moved, unpacked, lost my job, and was finally able to stay off my foot, and use the scooter in my new house (no stairs).  After 6 weeks of total rest, an x-ray showed no healing of the fracture. Indeed the pain was still as severe as it was the initial day I hurt it.  I experimented with creating home-made orthotics inside the boot. I tried applying heat (heating pad) because ice was no longer helping.
Dr Blake's comment: Xrays are poor at showing the internally healing, and you have to go mainly on the pain. In your case, that was not helping us either. 

February, 2017:  I purchased an Exogen bone stimulator (low-intensity pulsed ultrasound) and have been using it twice per day for 20 minutes each time, beginning mid-Feb. (a total of 93 days now). Because I was in the boot for so long, I developed plantar fasciitis, which was even more painful than the sesamoid!  I also began having knee and hip/back pain due to the altered weight-bearing, and multiple bruises on my leg from using the knee walker.  I started physical therapy 2-3 times per week, with the goal to increase circulation in my foot. Since I was still non-weight-bearing, the exercises I could do were limited: ankle and toe calisthenics. Although the exercises hurt at first, I did them and gained excellent flexibility and range of motion.  The physical therapist also used deep tissue ultrasound and taping for my plantar fasciitis. I had a custom orthotic made (they took a mold of my foot), but it was many weeks before I received it due to insurance snafus. After being totally away from all exercise since my injury, I began swimming again, and worked up to my “usual” 30 laps each week.  Initially, it was hard, with lots of foot cramps and stopping, but it got progressively better.  In an effort to find some reason why the bone was not healing, I had a bone density scan to rule out osteoporosis, and a Vitamin D3 test, which both came back normal.
Dr Blake's comment: You are doing all the right things. The pain can intensify with limited weight bearing due to fluid buildup  and nerve hypersensitivity. I hope the sesamoid is hurting because of that and not lack of healing. 

I came across an article (https://www.ncbi.nlm.nih.gov/pubmed/12463658) that described inserting a screw into the sesamoid (to hold the broken pieces together) which obtained excellent results, and I sought about trying to find someone who does this procedure.  I consulted with 3 different doctors, and all said no one in the U.S. does this procedure (the research for the article had been done in Australia). I was told about one orthopedic surgeon in NC who tried an open (not percutaneous) screw fixation procedure years ago and had bad results, so stopped.

March, 2017: I consulted with an orthopedic surgeon who said the quicker I get into a “regular shoe” with an orthotic and out of the boot, the quicker all my plantar fasciitis, knee, hip, and back problems would improve.  He was right.  I wish this would be widely known and become the standard of care in medicine.  I feel I endured much more pain, discomfort, decreased mobility, and harm to other parts of my body needlessly.  On the advice of the orthotic maker (who also makes custom prosthetics for amputees), I purchased a pair of New Balance sneakers a size larger than normal and an extra wide width, and the orthotic was fitted to it.  The purpose of the orthotic was to push the weight to the outside of the foot and force me to walk “unnaturally” so as to alleviate pressure on the sesamoid.  A “regular” insole was put in the right shoe (good foot) so I could wear the same pair (both feet) and be level.  I returned to doing as much exercise as I could: weight-lifting, pilates, swimming.
Dr Blake's comment: I do also. And I am sorry, but old rules sometimes never die. Many readers will benefit from your wonderful descriptions. 

The orthopedic surgeon told me the objective should not be to get the two broken pieces of sesamoid bone to unite, but rather to walk without pain.  He explained that many people have a bipartite sesamoid and do just fine.  Both he and the podiatrist told me if I still cannot walk after 12 months, that they would remove the bones – both broken pieces.  I found articles on using platelet-rich plasma injections for helping to heal broken bones, and looked into that.  Unfortunately, my insurance would not cover these and they are $700 each.  Also, my podiatrist said although he has had good results with PRP for wound healing, he said the probability it would help for a broken sesamoid is extremely low.  What is your opinion on PRP?  I found a doctor who not only does PRP but also amniotic membrane injections, and injections of stem cells made from your own fat cells.  All of these things are considered experimental and so are not covered by insurance.  However, at this point I am willing to try anything!  But for what the cost of these injections would be, I could probably fly to Australia and have the screw fixation!
Dr Blake's comment: They are experimental. Patients flood my office after unsuccessful PRP or stem cell injections for another opinion, but I am sure I do not see the successes. Limited and biased experience. I totally disagree with not letting them unite!! And, I totally disagree allowing you to walk on the outside of your foot (called supination). I can name you 20 injuries or pain syndromes at least caused by this abnormal walking. You need the weight through the first and 2nd mets, evenly, not the 4th and 5th metatarsals. 

April, 2017: Because the orthotic was causing me to walk unnaturally, I now developed ankle and knee issues, and had to return to the orthotic maker for revisions of the orthotic twice.  After the second revision still did not making any sustained walking possible, he suggested I purchase a pair of Hoka One One shoes (still a size larger and extra wide), which I did.  They have been a big improvement, and I noticed you also recommended them in your blog.  I continued experimenting with making my own orthotic in it.  I found that I could bike with less pain than I could walk, so I went biking when I could.  But still, the amount of walking needed to load the bike rack on the car, etc., was painful.  Keep in mind that all this time, I am still having to use the knee scooter when doing grocery shopping, and even getting in and out of the pool in the gym.  In other words, I still cannot walk more than about 3-4 steps without pain, and still having to elevate it at various times throughout the day (hurts to keep it down too long) and also still needing to ice it down occasionally (especially after bike riding!).

May, 2017: After 93 days of using the Exogen bone stimulator, I had an x-ray which showed the sesamoid looking EXACTLY the same as it did in my original x-ray from October – not the slightest bit of healing.  Up until this time, I resisted getting a steroid shot, because steroids are known to inhibit bone growth. But now I figured, it doesn’t look like the bone is ever going to grow, so I might as well. What is your opinion about steroid shots?
Dr Blake's comment: No, not in a joint that is trying, even though unsuccessfully, to heal a fracture. With the bone looking the same, impossible for a fracture due to bone remodeling, the whole cause of your pain is in question. You really do not know if this is fractured. Your original injury could have jammed a congenitally bipartite sesamoid against the ground bruising it. The 2 pieces will have look like they are coming together. Was the bottom of the metatarsal where it hits the sesamoid also injured? A repeat MRI will help. 

The podiatrist is concerned, as am I, that my pain level is way out of whack for a typical broken sesamoid, now 7 months later.  I wondered whether we were missing something, like a torn tendon or joint problem, but he said any problems like that would have shown up in the MRI and didn’t.  He suggested I may have nerve damage and should see a pain management specialist.  From what I know about nerve pain in feet, I do not have those kinds of symptoms (like tingling, numbness, “pins and needles”, etc.), so I am not convinced of that.  However, it could be that in the injury I had with the yard implement, I damaged the nerve and that was the problem all along… that perhaps the broken sesamoid was an existing condition (for example, an injury I sustained in childhood and forgot about because it was never diagnosed or treated?).  What is your opinion?  Would you treat this as a nerve injury at this point?  What types of therapies or diagnostic measures would you recommend?  I am afraid of getting the sesamoid removed only to find out that was not the source of my pain.  Should I abandon the bone stimulator altogether? My podiatrist said I might as well stop using it because it obviously is not helping.
Dr Blake's comment: Sounds like you are on to something. And yes, typically broken sesamoids can be walked on with removable boots and dancer's pads within the first month of treatment as the inflammation goes down. Look at all the possible sources of pain. Are we sure the MRI, and you are due for a 6 month comparison one right now, did not show anything else. Limited weight bearing in a boot with a dancer's pad will not hurt your foot (and you can use crutches) and may begin to add tone and circulation back into your foot. A pain guy should be versed in nerve hypersensitivity and know what creams, pills, TENS units, etc will help the nerve. Sounds like the orthotic guy is skilled, so keep pushing him to make you something you can walk with. I would love to see a photo of an xray at least that shows, but I will be out of the office until 6/13, so I am rushing at least to get this done.  

As you can imagine, after 7 months and getting no pain relief, still unable to walk more than a couple of steps,  cannot wear “normal” shoes, and dealing with lots of crap from insurance companies (I wound up paying 100% out-of-pocket for my scooter, bone stimulator, and orthotics), I am frustrated and tired.  Any ideas, suggestions, or comments you have would be greatly appreciated and heartily welcomed.
Dr Blake's comment: I think we are ending this communication with the impression that you may not have a fracture at all, you are treating this with limited weight bearing that greatly increases pain (not decreases pain) in most people by allowing the normal weight to push abnormal fluid out of the area, and allow nerves to get hypersensitive. It is impossible for a healing fracture to look the same on xray, but what is going on. Please let me know mid June if you have found something out. 

1 comment:

  1. I had a similar situation due to sesamoid severe bruising due to road cycling. Dr. Blake's "contrast bathing" technique really helped with the pain and eventual healing. Still not 100% but the contrast bathing and orthotics really helped.

    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.