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Sunday, October 9, 2011

Pain in the Ball of the Foot: Email Advice

Dr Blake,

I just came across your blog! Long story gets longer...In Dec 2008 I jumped over a large puddle on asphalt wearing tennis shoes, immediately I had a very sharp pain in the ball of my foot at the base of my big toe. I worked the rest of the day and when I got home I took some Advil and iced my foot and went to bed. The next day I could not put any weight at all on my left foot or even put on a shoe. I made an appointment and saw a podiatrist that stated with x-rays that I had a fracture at the base of my big toe joint, and a fractured 1st metatarsal. I was given an above the calf boot and crutches. The pain never subsided. It was then determined that the pain was from my bunion and bunion surgery was performed. Only to still have the same horrible pain on the bottom of my foot, numbness from the arch of my foot to the tip of my toe, and a big toe that no longer bends at the end and very minimal at the large joint at the base of my toe.

Now 3 years later... I had just come to the conclusion this was going to be how my foot would be and I was going to just have to live with it. I began to lightly walk jog. Within one week, the pain that had never really gone away was so unbearable I thought I re-broke my foot. This time I went to an orthopedic foot Dr. after reviewing all of my x-rays from previous injury and new x-rays from now, it was determined I had never broken my foot and that I had a bipartite sesamoid bone. His diagnosis has been sesamoiditits. It has been 5 months and I have tried to cut out a pad so that area of my foot is over the hole. I have also tried gel pads that sit behind the sesamoid area. The pain is now 24/7. It wakes me up in the middle of the night; I have a really hard time even being up on my feet. The orthopedic Dr. has decided that it would be beneficial to shave down the sesamoid bone and "hope" that it will reduce the pain. I’m so scared to have surgery! I already have what appears to permanent numbness and I’m very scared to have another surgery. I’m 39 years old and am terrified that my foot has been permanently injured. Do you have any suggestions?



Dawn, First of all I must put in the disclaimer that I can only speak in generalizations and can never take the place of a doctor that can look at your foot and see all the tests, etc. That being said, these are my initial thoughts.

     You probably landed hard and broke one or both of the sesamoids under the big toe joint. This is much easier to do (since they are lower to the ground) then to break the first metatarsal and big toe bone. See the image below on the anatomy.
The bottom of this image is the floor. The sesamoids are great protection for the first metatarsal and will break before it will.
Bipartite sesamoids look like fractures, fractures can look like bipartite sesamoids, bipartite sesamoids can fracture, so I am never sure on xray what is going on. A bone scan or MRI is needed to tell the difference between the 2. Let us assume you have a broken bipartite sesamoid which never healed.

Now, sesamoids are notorious for slowly healing, and some fail in that process despite appropriate treatment. So do not take anything personally. Your sesamoid was not mad at you or something like that. You need to get an MRI to verify the bone is damaged. A bipartite sesamoid has normal bone density on MRI, and a fractured sesamoid is all full of fluid.
Anatomical Skeleton of the foot showing the 2 sesamoid bones under the first metatarsal (ball of the foot).

CT image of a broken or bipartite sesamoid (looks like either to me). Turns out both sesamoids were hurt in this patient, yet both became asymptomatic with removable casting.

Sesamoid accommodation placed under the bladder in a removable boot.

Remember to wear socks like this when you stop loving your foot. It will help get the love back.

These poppies will always make me happy.
When you injure the sesamoids, there is alot of nerve pain symptoms. There are alot of nerves in this area which become hyper-sensitive to protect the area. Chronic pain in an area can also lead to more pain (pain begets pain). Chronic swelling in an injured area can produce pain as the tissue gets starved for blood flow (the same ischemic pain as in angina). Also, and one of the reasons you need to know if you have truly hurt the sesamoid, another cause of your pain could be nerve trauma pain. If you read through my blog, you will see mucho treatments for sesamoid injuries which you have not been doing. You will also see reference to treatment of nerve pain, which is rarely immobilization and allowing the pain to continue.

So Dawn, please get the MRI to decide if it was a sesamoid injury (which will probably have to be removed, but you should do great with that). If you do have a sesamoid injury, see if you can get the pain calmed down for several months (the old break the pain cycle routine!!) before considering surgery. See a nerve specialist now to make sure your nerve pain, probably initially secondary to the sesamoid injury, is now advanced to some version of complex regional pain syndrome (meaning that it is taking on a mind of its own). CRPS has its own set of treatments, and even when surgery is anticipated, surgery is normally delayed under the pain syndrome can get under control.

Thank you for your email Dawn, and I wish you luck. You can write a comment to this post any time you would like over the next few months, or years, as you learn more info, or if you have more questions. Did I answer your basic question? Rich Blake

Rich and Patty Blake gearing up early for another Halloween Party.

PS. I have never seen anyone have their sesamoid shaved.

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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.