Turf Toe with AVN Sesamoid: Email Correspondence

     I have had a 2 plus month relationship with this patient after she first contacted me around January 3rd, 2020. I have given her advice and had her send her images on a CD to me. Below in red is a note I sent her in February. The original injury was early September 2019 playing ultimate frisbee in cleats. No acute incident happened. Late October 2019 X-ray which was negative except bi-partite fibular sesamoid. Late November 2019 MRI documenting AVN fibular sesamoid, intersesamoid ligament tear and lateral collateral ligament suspected tear. Podiatrist at that time wanted to do surgery, but she wanted another option. Shockwave for the sesamoid flared her up with significant swelling. She went on crutches, and started reading my blog early December for advice. She was able to calm it down with the crutches, contrast bathing, etc. 

Thanks for the update. Just went down and had a wonderful discussion with one of our radiologists who went over the joint with a fine tooth comb for me. Most of this we know, but she added a twist. Her findings were:

• Fractured fibular sesamoid with AVN 
• Stretched or torn ligament from the sesamoids to the base of the toe (places the sesamoids in the wrong position)
• Torn and partially healed ligament between the sesamoids (moving the fibular sesamoid laterally too far)
• Partially torn lateral collateral ligament with adhesions to the base of the first metatarsal causing chronic irritation (this is the part I did not appreciate)

So basically the sesamoid lost its blood supply (which we are trying to bring back with contrasts and bone stim), but it is also stuck down in the wrong position so motion of the joint is painful. 

Time will heal the ligaments more, so that part of the course is fine.

The questions are will the AVN come back (only another MRI in 6-8 months will tell us if our direction is solid). But even if it comes back, will it be stuck down (like a frozen shoulder is stuck in the wrong position and people can not comb their hair) too much, that PT will not be able to rehab? Alot of unknowns. I will help you with them. Watch my video on self mobilization for hallux rigidus on you tube under drblakeshealingsole self mob and start doing that twice daily. Rich

https://youtu.be/FBTeWbdGrzs

The Patient's Response today March 23rd, 2020.
Hi Richard,

It's been a month, and I wanted to give you an update on my situation! I apologize for not getting back sooner, but things have been completely crazy with the coronavirus situation. I'm adjusting to this new life. I hope you are doing well and that your business is not too impacted by the current situation! I imagine that your hospital is bracing for impact...

Dr. Blake's comment: Thanks for the good thoughts. I am in an outpatient clinic within the hospital so we are completely shut down and it may be for a long time. Trying to learn Zoom video so I can use Telemedicine some. Hard to give my patients orthotics and adjust them via the internet however. LOL. Hope you are well and practicing good social distancing!

So, here goes on the update - as a reminder, I'm the girl with the case of turf toe + AVN of the medial sesamoid. :-)

• Overall, I've been experiencing an incredible improvement that began towards the last week of February. The last 3-4 weeks have truly been a blessing and I'm starting to get my life back. It's strange that this would happen at a time where many are losing their lives, but that is the cruelty of life sometimes, I guess.
• I got off crutches and started to be able to walk for 10-15 minutes mid-February or so. Following that, I've been improving every day.
• I attribute a lot of my improvement to having gone to Physical Therapy over the last 3 weeks. He has truly helped me in actually pushing me to do a little more than what I thought I could. We do massages to decrease the swelling, but also strengthening barefoot on the ground and I even have graduated to doing small heel raises barefoot, which I am coping with very well!
• I have been able to take walks for longer and longer, (cluffy wedges have helped my toe mobility and gave me a further boost). I've finally managed to get back on my road bike using my clip-on shoes, which is just amazing. I used to swim a lot, but the pools have closed for the moment.
• I'm continuing the Exogen Bone Stimulator, along with PT, and revving up my walking and exercising. 

Dr. Blake's comment: I am so happy for you. By creating the 0-2 pain level, and gradually adding stress to the tissue, it sounds like it is responding well. So many of my patients need a PT which sees them at least once a week to gently but progressively move them along. Rich

My questions are quite straightforward at this point:

1. How slow or fast should my recovery go at this point? Am I doing too much? I'm trying to be really, really, careful, but I find that doing just a little more than what I'm used to helps bring me to the next threshold of recovery. Like, I need to feel a bit of pain, but not too much. Dr. Blake's comment: 0-2 pain which is very healthy is still pain. Yes, you will have pain as you do something that you think you are ready for but was not. You should take 2 steps forward, 1/2 step back at times. Each month should show improvement (sounds like you are much better than last month February). Just go with the rehabilitation gradually, do not think about time tables.
2. Is it possible that I am improving so much but that my bone is still dying? I will get a second MRI in May (at the 6-month mark) - what if my bone is still suffering from AVN? Will I need it removed even if my symptoms are almost none at that point?Dr. Blake's comment: The MRI is for some judgement of how the healing is going. Surgery must be matched up with disability. There is no reason to consider surgery if you have a non painful AVN. I am hoping the bone recovers. You made need another MRI summer of 2021. Your pain has always been from the injury, the inflammation, and probably nerve hypersensitivity. You are working on everything which needs gradual stress applied week by week. No more than 10% more each week, and you should be on the 48 hour recovery between the highest stresses. 

Thanks so much for all your help.

Kind regards and good luck with the current situation. My thoughts and prayers to you and your family. Stay safe and healthy! And you!