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Wednesday, March 14, 2012

Sesamoid Injury vs Hallux Limitus/Rigidus: Important Pre-surgical Decision-Making

Mark's Sesamoids and First Metatarsal Heads

Hello Dr. Blake,

Long-term reader, first time writer. I'm impressed you appear to take the occasional email and offer up your opinion, with the usual disclaimers, but at least you've got an opinion. I'd like to see if you can offer me some advice, a 'tie-breaker' of sorts.

I have two surgical opinions, they differ but both have merit. Both seem plausible but the Doctor won't' be sure until 'We're in the foot and have a look.." No guarantees.
Dr Blake's comment: I love MRIs, but I have seen too many cases where the MRI did not show the full extent of the damage, or showed more damage apparently under healthy cartilage that was not appreciated at the time of surgery. And the last thing you want to do in surgery is dig up good cartilage in search of something bad.  So, for many cases, as we will see in Mark's case here, there may have to be some decision making at the time of surgery. Never my first choice, but quite necessary at times.

Male 50, right foot seasmoid pain (fibular).
Dr Blake's comment: Sesamoid pain is very tricky since generalized swelling in the tissue under big toe joint can cause localized sesamoid pain when the sesamoids are fine. I have been convinced it was the fibular sesamoid (the one closest to the 2nd toe), when all the testing showed it to be the tibial sesamoid was misbehaving. The foot tends to humble foot care providers daily. 

Over-pronater, a few pounds over weight, good health otherwise.
Dr Blake's comment: Over pronation is deadly for big toe joints. As you over-pronate, body weight at pushoff jams the big toe joint against the ground, at a time it should be relatively free to plantarflex and push off the ground. As it is jammed into the ground, this is called functional hallux limitus. It is functionally taking too much pressure, which makes it hard to do it's normal job. This, over time, and Mark is over 50, can gradually break down the joint. Stopping this over pronation, not all pronation needed for shock absorption, is crucial for orthotics, and shoe design in athletes. 

No known trauma - unless you count cumulative stress from playing the game 'kick the can' as a kid...

Conservative treatment over 14 years has been, NSAIDs, orthotics, walking shoes and cortisone shots. I'm not a big fan of needles but the one day I crawled into the Podiatrist office, I did beg him to shoot me, it was that bad.
Dr Blake's comment: If you are designing orthotic devices for the big toe joint, you must have orthotics and shoes that together as a team place your weight at push off through the center of your foot (more 2nd and 3rd metatarsals). I try to ask my patients this important observation when dispense the orthoses, and try to get them to do one foot at a time, and walking vs running. Sometimes, totally different orthotic devices are needed for running vs walking to achieve this effect. Sometimes, a lot more correction is needed in one foot vs the other. Sometimes, it is not the foot you are treating for pain and needs the most attention. But, it is important to make the good foot as good as possible. All of this is best to experiment with before surgery than afterwards. All of the treatment modalities you learn will help if eventually you do have surgery. So, Mark, please analyze the orthotic devices for this criteria.

Dr Blake's comment: Cortisone into joints are used to delay surgery, but rarely to prevent them. If you have had cortisone that made a significant improvement, when done in a joint, it is always at a risk of possible masking of pain long enough to speed up the need for surgery. Cortisone is wonderful, and some patients have done well with cortisone shots for years, and some patients never seem to need surgery, but it is a strong warning on the Cortisone label. Avoid unless forced into the corner like you were. Hopefully that doc didn't just give you a shot, but talked to you about some of this stuff. 

Early tests were -

Nuclear bone scan revealed some 'hot spots'. Nothing alarming.
Dr Blake's comment: Nuclear bone scans have been a crucial part of the differientation of sesamoid fractures vs bipartite (normally in 2 pieces) sesamoids for 3 decades. I always tell the radiologist that if they find hot spots in the area of injury to make me blow up images. Mark do you know where the hot spots were? Were they in the joint, in the sesamoids, both, etc? This can be very important.

Bone tomograpny revealed bipartite seasamoid. Nothing unusual.
Dr Blake's comment: This is 3D images of just bone and should tell bipartite from true fracture. However, a healthy bipartite sesamoid functions as one bone. When a bipartite sesamoid is injured, the weakest link in the chain is the ligament between the 2 pieces, so that gets injured. Now the 2 pieces are functioning differently with their rigid ligament bond injured. This can produce just as much pain as a broken sesamoid. Even worse, there is no chance of healing the ligament, and all the tests show that their is no broken bone. No one know what to do but remove the bipartite sesamoid or try all the conservative treatments used for sesamoid fractures. A sticky wicket I'm afraid. 

Ten years later, yes, ten years, I'm conservative in my treatment, I get an MRI and X-ray. X-ray shows some arthritis and MRI shows some edema, early bone defect. Probably explains why now it feels like it throbs at night and keeps me up. That's something relatively new. The usual sensation is one of a 'hot knitting needle jabbing my ball of foot'. Or running my foot over hot oiled ball bearings, that's a typical sensation for years. But nothing broken, more wear and tear stuff I'm told. I walk with some pain and limp, some days better than others.
Dr Blake's comment: The bone edema is under the first metatarsal and more over the tibial sesamoid on the images which are at the end of this post. The symptoms of throbbing is general inflammation, so definitely things at present are out of control. This does not mean they are getting worse, only means the joint has been irritated and is now in the Immobilization/Anti-Inflammatory Phase of Rehabilitation. It can be calmed down with ice three times daily, removable boot with EvenUp, and activity modification. Also, accupuncture and PT can be very helpful along with spica taping to restrict big toe joint range of motion. The symptoms of "hot knitting needle jabbing my ball of foot" and " running my foot over hot oiled ball bearings" are classic nerve symptoms. Cartilage is a pillow protecting the bone. Cartilage has no nerve endings, whereas bone is full of ripe juicy nerve fibres. When the cartilage is damaged, even slightly, it can not longer protect the bone as well. The nerve fibres sense more stress and complain is very descriptive phrases that you used. Nerve pain gives me the most exciting symptoms of any other source of pain. I remember one patient describing her pain as hot lava pouring onto her foot. We got her better by appropriately dealing with the source of her nerve pain.

Both docs said I've run the course for conservative treatment for ten years, it'll only get worse with age.
Dr Blake's comment: Do you think this is true? Do your orthotics need improvement to take more pressure off the big toe joint? Do this now, not after surgery. Do you have a good physical therapist that will help your post op that you trust? If not, find one, and perhaps she or he can help you with exercises, taping, gait training, etc. Have you learned to spica tape? Are you in a removable cast right now, and does it take all of the pressure off your big toe joint where you have no pain? If not, best to do it now, so when you go into it post operatively you will already be set. Get an EvenUp for the other shoe, all guys definitely need one to balance the spine.

 Doc 1 suggests some big toe top bone shaving of sorts - theory being it's more hallux ragidus. Says my foot bone needs to be scoped and scrapped like a bum knee. Well, it is a little limited in flex and makes some sense.
Dr Blake's comment: A little limited does not normally mean Hallux Limitus/Rigidus. As the joint really gets limited, normally the pain increases. This sounds like a mild part of your syndrome of big toe joint pain, not the primary concern for surgery. I am sure you have some Hallux Limitus, and that you do have some Hallux Limitus symptoms, but I am unsure if this is the part of your problem that needs surgery. I can only listen to what you tell, and Doc 1 does not make sense in light of your chronic persistent localized sesamoid pain. 

 Doc 2 says, "Sure, that could be a part of it but your patient complaint and tests reveal a likely sesamoid problem. When I palpate your fibular sesamoid it's very localized and pain inducing. I'll know when I excise but that's my read."
Dr Blake's comment: Sounds more right, but presently not sure if it is the fibular sesamoid, tibial sesamoid, or the undersurface of the metatarsal head adjacent to one of the sesamoids. Let's not take out the wrong bone shall we?

Hmmm, later Doc is highly rated foot surgeon, so I went with his opinion and surgery date is set for late March.

But it is nagging me, what if there's a hallux variable, what if the sesamoid is some referred pain and I'll be laid up for the wrong reason? Hence, I'm kind of fishing for a third opinion, hoping someone points and goes, "See Mark, that spot there is no good, we take it out, you feel all better…." Ok, asking too much, huh?

I do have MRI report and a CD disk of images, that's about it, would you care to look at it? Or have I done enough due diligence that now, as a patient, I make the best informed decision and move forward?
Dr Blake's comment: Mark has since this email sent me selective images from his MRI that are following this post.

Regards, Mark

P.S. After a year or so of reading your blog, the sesamoid section is, obviously, my favorite. You've hit on a number of issues and this response seems to sum up my blight - (this is from a previous blog post)
Dr Blake's note: Significant Arthritic Changes mean Hallux Limitus or Rigidus, which is a totally different animal. Read some of my posts on this. Make sure if this is the cause of your pain, and you are going to have surgery, that you attempt to treat that condition appropriately before surgery. I am still confused about the MRI showing only bipartite sesamoid, and somewhere you being told you have significant arithitic changes?? Isn't this fun. Now you have 3 possibilities of your pain: 1) Sprained bipartite sesamoid with excessive motion between the pieces on weight bearing causing pain (this is where the surgeon may be going when he talks about removing a piece), 2) nerve trauma and chronic nerve pain, and 3) hallux limitus/rigidus with severe arthritic pain. Unfortunately, all 3 of these conditions may need surgery. Fortunately, all 3 of these conditions can respond to conservative treatments, if we know which one to treat. At least, the surgeon, who probably knows all this, will get a good laugh out of this. Surgeons do like to be black and white in their approach.

Dr Blake's comment: I then emailed Mark months later to apologize for not getting to his email sooner, and to send me a progress report on how things stood 3/1/12.

Greetings Dr. Blake,

Thanks for responding, still time before the surgery, March 26th. I've attached a Word file, hopefully you can open and read the MRI report and select images i copied. The pain points are indicated by lightning bolts. The first is mild, on top of first big toe joint. And, yes, mention of Hallux Rigidus and shaving was mentioned as one possible surgical option. However, Doc2 said mine was a very mild cases, he's seen many many worse. Doc2 points to the double lightning bolts - this is the decade long pain and is clearly under, or near, the fibular sesamoid. One finger tip touch to this area is all it takes to elicit major discomfort.

The one thing that has changed over the last year is a clear throbbing and burning at night (maybe during the day but I'm typically on NSAIDS…) and it's more top of big toe related. I wonder if that's simply arthritis kicking in. X-rays rule out any obvious fractures. All blood test for like gout, etc. are negative, I have good overall health, seems to be a wear and tear, or cumulative, joint problem.
Dr Blake's comment: Mark, stop taking the NSAIDs. First of all, they slow down bone healing, not a good idea. Second of all, they can mask more pain then you think, and therefore you can hurt yourself more while on them. 

Massage and physical therapy only aggravate the pain, even years later. Orthotics, dancer pad, special shoes, cortisone, nothing.
Dr Blake's comment: This is very confusing, since most the above treatments normally help either condition, at least somewhat. And if it helps somewhat, it is a clue to try to make it better. That being said, you may want to postpone surgery until you figure out how to make the joint feel at least 50% better with orthotic modifications, taping, shoes like the Specialized Tahoe, etc. Any info obtained now will help with the ease of rehab after. Does a removable boot help? You definitely should be fitted for one now to eliminate pain completely so it is ready and waiting to accept your post surgical foot. 

Finally, presuming I go with seasamoid excise, the EvenUp strap on shoe accessory seems to be a good choice to keep the hips and back even, why isn't this standard procedure? I'll ask nurse on pre-op if they offer it and then pre-order if need be. What is your experience?
Dr Blake's comment: It is a relatively new device which I think should be standard with any casts/removable boots.

Hopefully, something jumps out, or can be ruled out, by you glancing at what is a handful of data points. Many thanks and happy feet,

Mild irregular top of first metatarsal at the big toe joint. Minimal concern.

If you look closer at the bottom of the first metatarsal head (at the ball of the foot) compared with the first photo, some graying of the bone is noted indicating bone edema (some cartilage damage).

Above are 2 frontal plane cross sections through the metatarsals at slight difference. The bottom image shows some subtle changes in both the fibular and tibial sesamoids, with significant changes in the bone just above the tibial sesamoid. The image of the same foot just above shows more extensive bone changes involving bone above both sesamoids, with the most irregularities in the tibial sesamoid.

The bottom image shows the significant swelling (white area) in front of the fibular sesamoid, yet the image above shows most boney changes in the tibial not fibular sesamoid.

These images show a clear irregularity in the fibular sesamoid.

This odd image of the first metatarsal head definitely shows more irregularities in the lateral side of the first metatarsal. 
Dear Mark, Thank you for giving me the opportunity to attempt to help. As always, the disclaimer is that I can only have partial information, which could be not the right amount to make the best decision. I can only give you my gut-level educated guess. So, I apologize for this. 

That being said, your wonderful images sent do tell a nice story. I have looked over and over the photos and do want you to Fed Ex a CD so I can see them clearer. When looking at subtle bone changes, the graying of the bone when it should be white on T1 imaging is crucial. The clarity of these images is not great and I may be jumping to some wrong conclusions. Call my office at 415-353-6400 for mailing instructions. Thanks, and sorry for the inconvenience. There is no charge for this read.

My take is that you have injured the articulation (joint surface) between the sesamoid and the first metatarsal. Both sesamoids could be involved, although the tibial sesamoid seems the most. True to form with many sesamoid injuries, and the pooling of inflammation between the first and second metatarsals, the fibular sesamoid may seem more involved. Slowly the joint may be developing more wear and tear, and Hallux Rigidus may be creeping in (you will know in 20 years). The radiologist read a normal fibular and bipartite sesamoid on the report. The bipartite ligament bridge may have sprained giving you that sharp nerve like sensation. These ligaments do not heal. Unless I see the other films, I would say to remove the tibial sesamoid. When the surgeon goes in from the side, they will see the entire bottom of the first metatarsal to see where the wear and tear is. If none is noted in this area, my bad, they would close up and open up laterally to remove the fibular sesamoid. When you remove the fibular sesamoid from plantar you can see the whole bottom of the metatarsal to check where there is damage. , but you have to remove the fibular sesamoid first. So, to me, if makes more sense to start from medial, look at the tibial sesamoid and as far lateral as you can go, and make the call. And before embarking on this, the surgeon and you have to agree that this is the right thing. It is one thing for me to sit here in respect of you and this process, but it is another thing to take the responsibility as a surgeon for the success of the surgery. At least you have a lot more talking to do. Email me if you are sending your films and I sure hope this helped. Rich Blake

Mark then sent me a followup email exquisitely describing some of the events following this blog interaction.
Dr. Blake,

I was thrilled with the blog posting and assessment.  This is a most generous service you provide as, I hope, your blog stats reveal - people do really Google and want to understand how a foot can be so intricate and challenging.

I had my wife read the blog, she was more frustrated, fearing I'd 'back up the cart' and start anew.  She's seen me with this condition for 15 years and it's time to get aggressive, not wait more years tweaking my gait, shoes, orthotics, ice bags, and $300 shoes.  And that's just one pair, one color.  Let alone no golf shoes.   Granted, it makes no sense being aggressive and doing the incorrect thing but I found great comfort in you confirming, "Yes, there is concern on/in/near the sesamoid and first joint."  Not like I"m making this stuff up, it hurts, I know the area, just don't no with certainty this one fix will be a cure all.  Hence, some apprehension.  

I was surprised you wanted to see more images, perhaps cases like mine read like a good mystery novel - so close to finding the culprit, yet they're just out of grasp.  I can hardly get my existing Docs to take such interest.  Remember, it took me a few years, and a couple DPMs, before they even took an x-ray, let alone an MRI.  I have good insurance, heaven help those less fortunate.  I got the impression to tape my foot, or use a Dr. Scholl pad, and to 'man up' and deal with a little ache. Apparently, they're worse cases than mine, but my pain is my pain, hence the quest to seek relief.

Anyway, you ended up printing my letter verbatim, it's another element that makes your blog a quick and appealing read - it does not read like a case study littered with footnotes and references.  And you interject where appropriate.  Plus, a sense of humor helps. 

Specific to your questions,
The nuke bone scan was done ~14 years ago, there was a handful of hot spots, in/around joints, nothing I recall.
I'm going to hold off sending the MRI CD to you until Doc2 has a chance to comment.  I'm out of town over the next week, then back  to Madison for surgery. 

I did call the assisting DPM nurse to ask about EvenUp (she had heard one patient brought it up but has no knowledge or its use or availability).  You said it was relatively new and the foot care I'm getting isn't in some third world country.  They've got a bit time sports clinic (well for star college athletes at least…), orthopedics, the full gamut of resources.  Surgeon is top dog!!

He's been great so far.  I mentioned that my 'foot was on the internet' and the nurse said, "Wow, your our first internet foot, a celebrity of sorts."  I asked if she'd think Dr. K would look at Dr. B's assessment if I provided a link.  She thought he most certainly would, he's out office, but next week for sure.  I said I didn't want interject any West Coast DPM confusion but to please consider this as another professional data point.  She thought no problem.  Plus, you had mentioned and poked fun that you offer an opinion on select data and respect and advise one to work with one's attending health care providers.   

But the nurse was unaware about EvenUp, hmmm, I'll guess I'll be mail ordering this weekend.  Don't you guys go to conferences where they show off the newest gadgets? 

So I'm leaving it at 'Please have Dr. K read this blog assessment, that I'm concerned we remove the fibular sesamoid without consideration of nearby potentially ailing structures.  I don't want to be back in in a year to tackle the tibial sesamoid." Duly noted.

I completed my pre-op physical today, all systems are go, and am looking forward to tackling the next foot chapter so to speak.

I'll be happy to update you as the next week unfolds, including any Dr. K feedback.  I told the nurse, "You've got to Google this guy, his blog, and get the word out, its a great repository of information for the lay, and maybe not so lay, person."

i'm grateful for your interest, concern, and education Rich,


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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.