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Wednesday, June 28, 2017

Big Toe Injury from Fall: Email Advice

Hi Dr. Blake,
 
I realize you must get absolutely tons of emails from desperate foot patients humbly looking for advice--and, yes, I'm one of them as well.

First off, I am very grateful that you take so much time out of your day to work on your blog and also respond to perfect strangers. I'm glad I found it, since there is SO much helpful advice and perspective! (and I'm long overdue for making a donation, since I think I've read just about every single post at least twice). Since you are so generous in offering general opinions online, I'm hoping you may be able to advise on my situation (sesamoid-related, surprise surprise! I think you may be one of the best DPMs in the country for this issue). I'm on an HMO in DC, so it'd be challenging to see you for a proper visit, but I would be more than willing to pay a fee for you to give second-opinion correspondence from long-distance.
 
Long-Winded Nickel Tour:
I had a fall-injury in early March which impacted mostly the ball of my foot, and hurt my medial sesamoid (MRI report indicated "stress reaction"). I went in a boot right away, since the pain was awful. I also almost immediately developed CRPS symptoms (no swelling, but horrible pain and purplish discoloration). I have a history of the OTHER foot having a plantar injury with CRPS from 8 years ago, so I knew the signs and how to deal with it (get a pain management doctor, get on gabapentin immediately, keep the foot moving as much as possible, etc.) Fortunately, with a lot of daily work, the CRPS symptoms have slowly abated a lot in the past 4 months.
 
However, I think my bigger problem is the sesamoid (my podiatrist calls it a "deep bruise") that does NOT seem to be healing. I've had a total of 3 MRIs  in 4 months; here are the impression notes:

 MRI in March:
"Moderate edema within the medial hallux sesamoid with adjacent plantar subcutaneous soft tissue edema. Findings may be seen with a stress reaction or sesamoiditis. No acute fracture identified. Mild hallux metatarsophalangeal joint effusion with mild osseous marrow edema and subchondral cyst formation at the hallux metatarsal head. Findings most consistent with stress reaction or early osteoarthritis."
Dr Blake's comment: This is normal for a stress fracture (no fracture line seen) although the impact of the sesamoid may have irritated and damaged the metatarsal also (where they come together, seen in impact activities). Sources of pain at this point are nerve hypersensitivity from CRPS, inflammatory bone and soft tissue, sesamoid, and first metatarsal.     
MRI in May:
"Interval improving marrow edema along the medial hallux sesamoid and the head of first metatarsal. Subchondral cystic changes along the head of the first metatarsal along the plantar aspect of the dorsal aspect with resolving mild marrow edema"
Dr Blake's comment: Good improvement in 2 months. I tend to wait 6 months, so this is fun to read. 
MRI in June:
"Minimal interval improvement in marrow edema within the medial hallux sesamoid. Stable degenerative changes in the first metatarsal head at the crista" (not sure if "minimal" means "the radiologist can't really see a difference…")
Dr Blake's comment: The first change was probably just the decrease in overall swelling and inflammation. I would never expect any reliable change in a month. Do not get another MRI until October or December even. 
 
I went and looked at the images myself--to my (admittedly untrained) eye, the marrow edema doesn't look like it's changed at all in 4 months' time!
Dr Blake's comment: Probably right, but a very indirect reflection on healing. The bone is getting stronger, but the remoldeling phase causes the bone to have more water than it should. It could be healing just fine. Also, have you been icing twice daily and doing contrast bathes each evening to help control the deep swelling. Also, as you bear more normal weight the swelling gets pushed out more normally. The bone mineralization process needs this period anyway. With no fracture line, you do not have to be overly concerned about the bone healing. You have to flush, insure you have good bone health, create your 0-2 pain level yet increase your activity (this is why we need to experiment with orthotics, dancer's padding, Cluffy wedges, rocker shoes, spica taping, etch.
 
I'm on my second DPM (first was a nightmare who didn't seem to even believe in CRPS), and I'm limited in choice by my HMO unfortunately--the second DPM has 30+ years experience, but doesn't see many sesamoid injuries, nor does any other doctor in the HMO--I think it's maybe because they serve general population and therefore not as many athletic types.  He said he doesn't read MRIs, so can't take a second look at the "progress" of the bone. He originally wanted to cast the foot for a period in the beginning, but I objected because of the CRPS symptoms (immobility=very bad). DPM has now advised to wean out of the boot with J-pad orthotics and Hokas/Altras, but I can't maintain 0-2 pain level (per your advice) in the sesamoid area for more than several steps--and I've experimented with dozens of shoes/orthotics/dancer pads/adhesive felt/jerry-rigged orthotics combinations, to try and offload the bone without upsetting the rest of the foot. No dice there.  I’m having a custom one made, but I'm not expecting miracles or even a better solution than what I've already constructed.
Dr Blake's comment: Sometimes you have to really work with the inflammation and nerve hypersensitivity alot, before the mechanical support gives you 0-2 pain level. Typically a good arch support, a metatarsal support and 1/4 inch dancer's padding, cluffy wedge, and spica taping will give you level 2. What level does it give you? If more than 2, try to work with anti-inflammatories, contrasts, ice, gentle massage and range of motion to bring the pain down. If you touch your skin, and the skin is sensitive, then there is a lot of nerve hypersensitivity. Work with bio feedback like mirroring to get the toe working. Any thing that increases normal touch or motion will tell the nerves all is fine, so stop hurting. People have to neural floss or use Neuro-Eze to relax the nerves. Some need an oral med, like Elavil or Lyrica, to at least calm the nerves while you sleep. 
 
I've read every single one of your (very helpful and informative!) posts about sesamoids (along with lots of other reading/research), and am doing everything I know of to help it: Vit D and other supplements, daily warm soaks, daily stretching/intrinsic strengthening of the foot (per a physical therapist), daily stationary bike and floor exercises (trying not to atrophy too much elsewhere),  trying all the different shoe/orthotic combinations, acupuncture, more antinflammatory foods.   Have recently added icing and 2x daily contrast baths--I tried in the first 2 months, but ice/cold often makes CRPS much worse, and my foot was definitely not happy with it then, when I had to ice the sesamoid in the first few weeks! Now that CRPS has calmed down a lot, though, I'm tolerating cold therapy, so I'm religious about the contrast baths (along with everything else. I am on the extreme-compliance end of the patient spectrum).
Dr Blake's comment: Since the fall cases impact to hurt the soft tissue, sesamoid and 1st metatarsal, it was a significant injury. You could have an element of turf toe (ligamentous involvement) in there. Be kind to yourself and do not rush, because it is probably not just a sesamoid injury. I would consider getting a CT scan to work at the 3 dimensions of the bone, a nerve evaluation for possible nerve entrapment, and of course an Exogen bone stimulator for the next 9 months. 
 
 It wasn't covered by my insurance since I don't seem to have a fracture, but I got an Exogen anyway, and doing that once a day--just in case it might help. I’m very worried that the marrow edema hasn't really improved in 4 months, and that it might start to get necrotic.
 
I've also read the horror stories about people not being able to walk normally for years because of sesamoid issues (or the bone eventually going AVN after fighting for months to save it, and then necessitating surgical excision). I'm desperately trying not to become a member of that camp! I will do ANYthing to help this get better. From my other-foot injury 8 years ago (which got complicated and had me on crutches for a whole year, with several awful years of leg-atrophy rehab following), I already have an INCREDIBLY deep appreciation of walking and mobility in general, so you can imagine how this latest injury is taking a huge toll on my psyche and soul. I'm extremely depressed/grieving and afraid that I'm looking at many more months of immobility and problems. Before March, I was very active walking-wise, ~7 miles/day, and need to walk a lot for my job (and sanity). I'm fully aware of the domino-effect of injuries--and I'm also having some mild symptoms of sesamoiditis in my other foot now, presumably due to compensation.
Dr Blake's comment: First of all, you are doing what you can as a super patient (if all my patients were this good!!) Somehow you have to stay positive to keep the blood flow going. Anxiety is a vaso-constrictor to the sesamoids, and a vaso-dilalator to the quads to make you run again from danger. This is why CRPS patients in general need meditation, gentle healing music, and psychiatric help. I am so happy the CRPS is better, but some nerve hypersensitivity, the type that lingers and lingers, may be still there. Typically a skilled neuro-physical therapist can help with this (what pain to honor, what pain to push through). I can not recommend over 2, but I have had patients okay pushing themselves with 5-6 pain max. That sensitivity is not the place for this blog. 
 
I'm so grateful for all the helpful information on your blog. Is there anything additional you might advise me to do here? I have these specific questions, if you are at all able to answer them:
 
  • I now have good flexibility in my foot and joints (it doesn't hurt to flex, only to weightbear) and don't see the benefit of spica taping at this point in the injury. Should I be taping?
                            Dr Blake's comment: You can spica tape to hold your big toe down, and your sesamoid completely off the ground. We call it the ballerina walk. Give it a try to see if it helps. 
  • I've read that biophosponates *might* be helpful for stress injuries (I believe the studies are limited, though--can you speak to this as a possibility?
                           Dr Blake's comment: First get a Vitamin D level and bone density and report back. 
  • Does weightbearing on the sesamoid cause more internal bone inflammation and edema? i.e., Should I just get back in the boot full-time (sigh)? The edema doesn't seem to be going anywhere and I'm terrified that the weightbearing I'm doing may be hindering healing.
                           Dr Blake's comment: Without knowing you any better, and believing that maintaining 0-2 is safe for healing, spend the next 2-3 months in the boot and on crutches. We want some weight bearing for bone mineralization, swelling reduction, bio feedback, etc. Tell me what it takes to create the 0-2 consistently and we can go from there. That will be your July 1st benchmark, and you re-evaluate where you are August 1st. 
  • Is it possible that the internal edema hasn't really healed in 4 months because the already-tenuous blood supply to the sesamoid has been compromised or injured by the internal bruise? And if so, is the bone likely to eventually die?
                           Dr Blake's comment: Sure, anything is possible, but not likely. The CT scan now, and in 3 months, will help assess the possibility of avascular necrosis. That is a much better test in the next 6 months than another MRI. You have done way to much to get necrosis (Exogen, contrasts, some weight bearing). I worry more about turf toe which could require surgery. Have them look at the ligaments really well to see if there is any sign of sprain. 
  • Could the Exogen possibly prevent necrosis? Would you recommend upping the frequency? (I'm on once/day)
                            Dr Blake's comment: Sure, most recommend 2 times daily. It is one of the biggest factors to fight against dying bone because its purpose is to wake up those bone forming cells. And studies show that Exogen helps healing in pretty bad bone!!
  • If you cannot do a long-distance consult, is there anyone you'd recommend in the DC/Baltimore area? I'm stuck with my HMO right now, but may change it at the end of the year, or even pay out of pocket for someone who has a lot of experience with sesamoids.
                           Dr Blake's comment: I love Dr Stephen Pribut. He is wonderful. Pay for a consult and after you get the CT scan, and let me know what he says. We should start there. Good luck. 
 
Please let me know if you'd be able to consult coast-to-coast.
 
Very warmly and appreciatively,

2 comments:

  1. The sesamoid/CRPS patientJune 29, 2017 at 7:19 PM

    Oh my gosh you are wonderful beyond words!!! I was so excited and heartened to see your thoughtful responses here, and will take your advice. I can't tell you how much it helps to have your impressions. If you can stand an addendum to the (already-long) story:

    I wasn't clear, I should clarify that I CAN now maintain 0-2 pain level easily and pretty consistently while in the boot (aside from the inflexible, locked-up feeling of being encased in the @!#! thing…). It's trying to "wean" OUT of the boot with shoes/orthotics when the sesamoid and ball area gets unhappy. So crutches sound like they might be overkill, right?

    I never had the "classic" CRPS symptom of allodynia (pain even with gentle touch. For those who think they might have CRPS, don’t let a doctor tell you you "can't have it" because you don't meet this or that "requirement." Every case is different). I’m already on a fat dose of gabapentin, which works fairly well for the burning nerve pain--not perfect, but it helps a lot and I’m almost never in discomfort when not weightbearing. However, weightbearing in shoes sets off the deep, aching pain (mostly centered in the 1st MTP joint area). That pain feels like it's "mechanical" more so than nerve-y (as a CRPS veteran I feel I can often tell the difference, but it does kind of mix together here! No doubt there is still some CRPS nerve-sensitivity in the whole region that's contributing, as you rightly indicate). So for those of us with lingering CRPS symptoms AND a soft/hard tissue injury, it's kind of hard to know what level of pain with weightbearing is actually safe; it complicates trying to stay at the "0-2" target range if one isn't sure what portion of pain is neuropathic (not gonna damage anything to walk on) vs nociceptive (could do more damage to walk on).

    Turf Toe possibility:
    Oh dear--I would have thought this'd be noted on MRI, or my current DPM would have thought of this (he seems competent, just overloaded with patients and not as experienced with sesamoids as yourself). From the details of my last report: "There is no edema along the intersesamoid ligament.There is no femoral head collapse. There is trace fluid within the first MTP joint. The medial and lateral collateral ligaments at the first MTP joint are intact. The plantar plate is intact." Does this sound like TT could still be possible? In the first 2 months, I had problems actively flexing the farthest tip of my big toe downward, and I also had more pain in the big toe itself in the boot. Now, though, I have good flexibility of the big toe and no pain with flexion or dorsiflexion. I stretch the toes against the floor several times a day. My big toe (toe itself) does not really hurt as much anymore after a lot of walking in the boot, but could that actually be turf toe as you suggest?

    CT scans, next steps:
    I'm glad you think it's unlikely that necrosis will happen, given all that I'm now doing. Do you think I should ask for CT scan now, or wait a few months to see how things go? The last MRI was only a few weeks ago--would there be any value in getting the CT this soon?

    "Try to work with Antiinflammatories, etc…."
    Should I think about taking NSAIDs, do you mean? I've largely been staying away from ibuprofen b/c I wasn't sure if it was good for the bone healing. I asked my DPM if he thought NSAIDs would help with marrow edema, and he said he didn't know (honesty always appreciated!) Do you think it would help?

    I really appreciate the name of that DC doc; judging by his webpage he sounds awesome! I will get my ducks in row with going to see him soon for an outside looksee.

    That is all--no more questions.
    A MILLION THANKS!

    ReplyDelete
  2. Sesamoid/CRPS patientJune 29, 2017 at 7:20 PM

    p.s. Everyone reading this blog...please contribute a few bucks! This is the only site think I've EVER seen where a doctor takes time to educate non-doctors on specific cases, and give impressions and advice. We want him to stick around and keep helping lots of people get back on our feet!

    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.