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Thursday, July 12, 2012

Sesamoiditis: Email Advice

Hello Dr Blake,

      I have been dealing with sesamoiditis in my left foot for close to two years and i just would love to get some relief.

     Originally, I was placed in a walking boot for about 4 weeks, referred to PT, X-rayed and given orthodics.  I never really had relief of the pain in my foot. 

     I have also tried MAT, muscle activation technique, to help deal with the any bad habits or patterns I have with my gait. Again, nothing really helped. 

     Despite the chronic nagging pain in my foot and resting it for a long time, I started walking and running in our beautiful Redwood forest.  Wearing stiff shoes, running dirt trails and not wearing my orthodics was working for about 10 months.

     Just a month ago, I went back in to see my podiatrist because the pain was starting to get worse and I was experiencing numbness between the first two toes through to the top of my foot  with swelling.   The Dr. injected the sesamoid area and fitted me for new thinner orthodics that can fit into shoes.  The pain is not completely gone.

     The problem I face is that I am a Pilates Instructor and I cannot wear shoes all the time in our studio.  I have been wearing new shoes with my new orthodics in them, but it can get tricky.  My bare foot cannot handle standing on the floor for a very long time either, even with taping. 

      I am just at a point of frustration and feel like it will never get better. Repeat X-rays were also negative for a fracture to the bones.

     Have you seen people with this as a chronic pain?  I am wondering if PT to help identify any bad foot and ankle movement patterns would help?  Thank you for your time.

Dr Blake's comment:
     Thank you so very much for your email. I know that this can be very frustrating. Even relatively small injuries at the bottom of your foot where you place all of your weight can be very painful and very protracted. Here is my summary of what you have told me:
  • You have no confirmed diagnosis since sesamoiditis (inflammation of the small bones under the big toe joint) is as accurate a diagnosis as shin splints is. There are so many possibilities of what could be happening. MRI and diagnostic injections could narrow down the cause of your pain
  • Sounds like there was an improvement between the first and second orthotic, but what was it? More Arch? More padding? Since Pilates instructors can use ballet slippers and various forms of arch support (Hapad) and dancer's pads (adhesive felt), knowing the components of an insert that helps can help with other shoes. 
  • Soft surfaces help and hard surfaces make the condition worse. Silipsos does make slip-on padding that I have seen used in even "barefoot dance classes".
  • What helps control the pain? Cortisone shot, but try to avoid too many of these. Did the removable cast help that you used for 4 weeks? If you have bruised cartilage between the sesamoid and the first metatarsal, it can take 3-6 months in the removable cast, at least for some part of the day, to really get ahead of the symptoms and allow for the decreased stress to allow for healing. Until you have a diagnosis, wear the removable cast with the orthotics in them and with an EvenUp on the other side anytime you are not working. 
  • You are not doing enough daily to influence the swelling. Day after day of pain begins to magnify the pain response and swelling occurs. Also, not only does the swelling block the normal circulation, but nerve pain can occur vaso spasm further cutting off the normal circulation. End result, the injury gets worse, chronic, and forces you to reach out to a blogger (a little blog joke!). So everyday, ice pack the ball of the foot for 10-15 minutes twice and do one formal session of contrast bathes. 

  • Are you still better in stiff soled shoes?

In summary:
  1. Consider more definitive diagnostic tests
  2. Start wearing ballet slippers and some form of dancer's pad/arch for teaching Pilates
  3. Continue slip-on gel protection instead of barefoot (always get for both sides).
  4. Make good attempts at 3 times per day anti-inflammatory
  5. Wear the removable cast, except for when you are teaching, as long as you can get it comfortable.
  6. Definitely spica tape of teaching and ice immediately after.
  7. Start doing 1-2 foot strengthening exercises tonight (some on the blog) and every night, but not the ones that hurt the sesamoid area.
  8. If stiff soled shoes help, try to stay in them 24/7 if it gives you the exact same relief as the cast (at least they can be used when weaning from the cast in a few months). 
  9. Email me again with any other thoughts and changes over the next few months.
Sure Hope this helps.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.