Total Pageviews



Tuesday, October 2, 2012

Hallux Limitus and Sesamoid Injury Combined: Email Advice

Dr. Blake-                                                                                                                               
                                                        Tuesday, October 22012
       Hello.  I want to express my appreciation in advance for your informative blog and for your dedication in helping so many return to health and activity.

       My foot problem started about 10 weeks ago.  I had pain one morning as I put a sandal on to go to church. One step with my left foot and I noticed a significant pain on the bottom of my foot, below my big toe.  Life went along fairly normal that week.  I did all my normal activities with some slight discomfort  on the bottom of my foot.   Six days later (on a Saturday of course!! ) the swelling and redness and warmth of that area started and I went to seek treatment at an urgent care.  

      The NP  did not feel an xray would be helpful and diagnosed cellulitis.  She did not feel my “pain” was equal to the pain of a gout attack.  (of which I have no history of)  I began 10 days of Bactrim (for possible infection) and Naproxen for the inflammation( 2- 500mg/day)   She encouraged me to follow up with a podiatrist-which I did the following Friday.

      The podiatrist took an xray- differential dx #1- fractured tibial sesamoid, (xray showed 2 bones-jagged edges)  #2- bipartite tibial sesamoid with sesamoiditis,  #3- gout    I was placed in a walking boot.  He told me to go ahead and finish my 10 days of Bactrim and Naproxen.
Dr Blake's comment: When you are started on antibiotics, you should normally finish the full 7 to 10 day course, even if you feel better within a day or two.

     Blood work for my uric acid levels came back well within normal.
Dr Blake's comment: Uric Acid is the blood indicator for gout. It always drops into the normal range after a gout attack, so it depends how normal you were to decide if gout is a possibility. At our hospital 8.7 is high normal, so any number in the 7s or 8s still means you could have had  a gout attack. 

     After four weeks in a CAM walking boot my foot was worsening. 
Dr Blake's comment: These removable boots do immobilize the joint by allowing the foot to roll through, but they do not eliminate weight bearing. That has to be done with some sort of padding to float the sore area. 

    Midway through the 4 weeks a felt pad was added to the boot, cutting out a hole for the sesamoid area to help off load the weight. This did not help. The inflammation, pain and redness was increasing. 
Dr Blake's comment: Remember it is crucial to create a Painfree environment as soon as possible, which could be permanent cast, crutches, RollABout, etc. Whatever it takes to get rid of the pain. 

   I was placed on Indomethacin.  However, I had side effects of  migraine type headaches and 7 canker sores- so after 6 days he told me to discontinue use.  An MRI and another Blood test was ordered.  Again blood test for uric acid normal (4.5)  MRI report: ”most likely”  bipartitie sesamoid with trabecular injury, possibly chronic stress response phenomenon  , degenerative changes, and tenosynovitis of the extensor halluces longus tendon. 
Dr Blake's comment: So, we know you do not have gout. What did you do to possible damage the joint (probably old wear and tear) and the sesamoid (more acute)?

     With this information the podiatrist decided to place my foot in a non-weight bearing cast for 3 weeks.  I was placed on disablitity and returned to the podiatrist office last week.  I didn’t need “DPM” behind my name to know my foot did not improve with the cast.  The redness had improved, but much swelling still present- more than just from the cast.   I was sent home in a post op shoe with crutches and slight weight bearing.  I was told if foot was worsening to go back to walking boot and crutches.  I am to go back in a week (which is three days from now) for reevaluation and podiatrist will possibly aspirate synovial fluid and/or place a cortisone shot.  Orthotics are in my future, but not until more healing has occured.
Dr Blake's comment: The course you have been on is logical, as long as changes cause less pain not more pain. Unless you told the doctors more than me, they are looking for a reason to explain this sudden onset of pain, without your physically traumatizing yourself. So, it makes sense to get a synovial fluid analysis, although only get a short acting cortisone shot. You have too much joint irregularities that the joint may break down further under the influence of a long acting shot. Hopefully, even though your pain has been more than normal, all of the rest and immobilization and protection is allowing whatever the source of pain to heal. Do not let the pain increase now that you are out of the non-weight bearing cast. 

     At this point I would say my foot has stabilized.  It is not getting worse, and the swelling in the big toe and ball of foot has improved some, but I couldn't begin to wear a normal pair of shoes or walk normally without pain.  There is still pain with palpation. Range of motion of the joint is limited and more painful when flexing upward. 
Dr Blake's comment: So, you are behaving like many of my sesamoid fracture patients. It can be something you did 2 days before the onset of pain that caused the crack in the bone. Think back. You have to be treated for the next 2 months very carefully to avoid a flareup, especially when you are apparently healing. Typically, the first 6-10 weeks are rocky, the next 4-8 weeks gradual improvement, and by 6 months after the first MRI you can get another to check overall healing. But, You have to be treated now for a stress fracture unless the other test reveals something. 

   So, I would love to hear what your thoughts are on where I should go from here.  I am impressed by your blog and your dedication to help inform others and share your knowledge and expertise.  The MRI report used some interesting terminology.  I have tried to research online “Chronic Stress Response Phenomenon” and have come up empty.  I am not even sure I understand the phrase “tibail sesamoid trabecular injury.”  What does that mean exactly?  Is the bone fractured inside?  I realize my podiatrist is just as frustrated as I am that I have not made much progress.  Could you explain to me why my podiatrist may be considering aspriating synovial fluid and/or placing a cortisone shot?  
Dr Blake's comment: Flattery will get you everywhere!! The MRI shows injury to the bone by showing that the bone is trying to heal. How does anything heal in these temples of ours? They heal by bringing in fluid to the injured area, and with that fluid are the cells and nutrients for healing. That is, if we are eating healthy, etc. So, when the radiologists see swelling within the bone, but no obvious fracture line, they can not call it a fracture for sure, so they call stress reaction, or trabecular injury (the inside architecture of bone), or bone edema. But, they really all mean the same. 
     Tell your podiatrist not to be frustrated, because you are probably only 40% healed, so have a few more months. The things I would do now are:
  1. Get good supportive orthotics made that will protect this area as you wean from the cast, and you can use in the cast as soon as they are made.
  2. Three times a day either do a 10 minute ice pack or 20 minutes contrast bath.
  3. Learn to spica tape (it takes 10 times or so to get it right. 
  4. Pat yourselves on the back for ruling out gout, infection, and starting the healing process (however rocky). 
  5. Consider sending you to a rheumatologist first before injecting the joint if a suspicion of systemic arthritis is being considered.
  6. Check out the HOKA running shoes as a possible alternative to the removable cast after 3 months of immobilization is done. 
  7. Work with your internist of making sure you have the ability to drive Calcium into your bones. 
  8. Consider a RollABout or A Leg Up for around the house or work if you are constantly irritating the joint. 
  9. Take this 2 weeks at a time.
  10. Avoid anti-inflammatories since they all slow bone healing. Ice is just as good right to the spot. 

PS-I am 56 with a history of osteoporosis diagnosed two years ago. 

(If you put this on your blog will you please change my name—call me Susan!!!   thanks)  

Susan, I sure hope this helps and I would be happy to look at the MRI if you want to send the CD. Rich

No comments:

Post a Comment

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.