Sesamoiditis: Email Advice

Hi Dr. Blake,

      It's been a while and I wanted to give you an update on my case. So last I messaged you in January I had just got the cast put on for my sesamoiditis. I had the cast removed in early April, 11 weeks with the cast on. After the removal, the doctor told me to wear the boot to walk in and gradually go into walking. I was confused as to what I was feeling, I had pain all over my foot, maybe from the cast immobilizing my foot for so long. I went back to see the doctor again, I reported to him that I'm walking with shoes, but I still have pain and that now I walk with a limp. He made custom orthotics for me.
Dr. Blake's comment: Here is the reading I did of this patient's first MRI in January when he sent it up to me. 

 I reviewed the MRI which shows you have bone edema in both the tibial and fibular sesamoids, and also the joint, and also the soft tissue. It is one unhappy joint. For mineralization of the bones, we needed protected weight bearing with orthotics, dancer's pads. You need to be doing icing twice a day and contrasts once a day. You need to see if you can get the Exogen 5000 bone stim, like Harry Potter's broom!! You need some PT to de-inflame the joint, and help with the off-weighting. No surgery since more than one thing wrong. A new MRI in 6 months to check progress. No NSAIDS or cortisone shots since they are bad for bone healing. No surgery should be needed, but it may take awhile for impact sports again. Has your overall bone health been checked? Questions? Rich

      I still had pain so I added dancers pad under the orthotics to relieve my sesamoids and help with the pain. The doctor was not very happy that I added dancers pad to the orthotics. The orthotic only relieved my sesamoids by 1/8 of an inch. After watching your videos I learned that I have plantar flexed 1st metatarsal, it's nearly 1/2 inch! I tried explaining that to my doctor and he asked where did I learn that and he immediately shut me down and told me not to look up anything on the internet. 

Dr. Blake's comment: This is the price we have to pay, but you have to create that 0-2 pain level. Did you try a cluffy wedge also? You are the one with the foot pain, but him. Doctors can be insulted by Dr. Google, but as patients, we got to try various things to get our individual situations under control. Thanks for watching my video by the way. I attached it here for the readers. 

He told me to remove the dancers pad, I did not as without it I would have pain during walking. I then went back again for another follow up. I reported again that pain and swelling continues, even after having a cast and taking work off for nearly 3 months. He pushed and pushed towards a corticosteroid shot. He said to me it's the shot or we are out of options, unless we go to surgery. I went with the shot. I was incredibly sad that I went with the shot. But me and my wife just had a baby and she needs help, so I'm out of options. The shot was painful, doctor told me he will only give me one shot and make it half the recommended dose. After nearly 2 months later, I went back, I reported that pain and swelling remained. He told me there is nothing else he can do. I told him that now I have electric pain above my 1st and 2nd toes whenever I lift my toes up and also told him that I have pain on the fat pad of the sesamoid but right where the skin folds to curl the big toe down. He said it maybe nerve irritation from the cast. He said there is nothing else he could do about it, so he sent me to a Pain Management doctor, I just went to go see this doctor last week. He put me in Meloxicam 7.5mg for pain and inflammation 2 times a day for a month, and he also put me on Gabapentin 300mg for 3 times a day for a month for nerve pain... I don't know what else to do. It seems like things are getting worse, I now walk funny, my injured foot no longer flexes up or down straight, it curves out then in while I flex up and down, now I'm having nerve pain  more and more issues. I've always been a naturalist, no drugs or meds, but now I feel that with the corticosteroid shot, and now these meds, I'm straying from my beliefs, but there is nothing else that I know of what to do. I've done so much research and it's driving me crazy the thought of not being able to walk or run pain free ever again  If you know of a specialist in southern California that you know and recommend, I would really appreciate it.

Dr. Blake's comment: I am sorry. Demand another MRI so we can compare. I think the first MRI is our baseline, with the second invaluable to know how things are healing. In Los Angeles you can try my go-to guy, Dr. Dan Altshuler, also Dr. Arnie Ross is an orthotic guru, and Dr. Doug Ritchie I know well. All podiatrists. 

PS: I sent you a picture, I know it's so hard to figure it out, but in the sesamoid region, the skin is red... when I press it to hold it and release it, the area around it returns to normal colorfast but the location where it's red does not. I explained this to my doctor he said not to worry about it, and he got on me for looking online and always looking at the color of my foot. By the way, he shot down my request for another MRI or CT Scan said no sense getting a scan if there is still inflammation. I told him a bone scan then, he said nope, we already know the condition of the bone.

Dr. Blake's comment: I know there are 2 sides of everything so I will not judge. In a separate email, you are sending me a new MRI so we can see. The redness is sympathetic nerve vasodilatation. It is a sign of nerve hypersensitivity which we called vasomotor insufficiency. The pain doctor probably knows about it. The gabapentin may have to be increased up to 2400 mg per day or mixed with other drugs. Topical nerve creams should be massaged in 3 times a day. You have to treat the nerve component as well as the mechanics and inflammatory. 

Thanks for taking the time to read this, I truly do appreciate it.

Best regards,