Hallux Sesamoids: Email Advice

Thanks so much for this blog with many useful bits of info.

      I am 61 yr old active woman who noted a "callous" under my mid big toe with tenderness when in hiking boots for prolonged periods about 6 months ago. I was walking and doing pilates barefoot without pain.

     I saw a podiatrist last week  who did xray and showed a rare sesamoid under the  first joint (hallux inter phalangeal) in addition to the 2 sesamoids expected at the lower joint (big toe joint). Unfortunately it was fractured into 15 pieces by his count. He fitted me for orthotics which are due in 3 weeks. However, since then i have had a major flare up with pain and swelling not previously experienced. It is so bad that I cannot bear weight, and awake with throbbing pain in am. I suspect I aggravated something by squatting barefoot on counters while I painted kitchen cabs....

     My question is with this new onset sx should I be concerned about injury to tendons or joint now caused by the bony fragments? Since this sesamoid is rare, looking for info on what can go wrong and if treatment  is much different from other sesamoid fx. I read NSAIDs can interfere with bone healing, but wondered about a tendinitis as the culprit. Is the treatment of extra sesamoid fx pretty much the same as described in previous posts re non wt bearing? thanks.

Regards,

Dr Blake's response: 

     First of all, you have co-existed for 50+ years with these sesamoid flakes/fragments, without any problem so I think you will co-exist another 50 years or so (God willing!!) with them. When squatting you placed too much pressure on the area, and something (sesamoids, joint, tendons, nerves, ligaments)  got angry at you. Even though these sesamoid bones are there, who knows if they are the problem. Since it would be rare to have to remove these, they are probably not your problem. This is an educated guess, that any one has a right to change with my blessing at any time. 

     So, first thing you have to do is create a pain free environment to allow whatever to heal. If this takes crutches, shoes, orthotics, and/or removable boot, you have to start treating the pain. Then, you work on the inflammation with icing, contrasts, PT, oral meds (okay in this case), accupuncture, topical meds, etc. Once you get your orthotics, make sure they are modified to completely protect the area as you walk, even if you have to go to a shoe size bigger for a while. 

     In terms of diagnostic tests that I do, MRI and local anesthetic injection into the joint. The injection is easy, you place 1-2 ml of local anesthetic into the joint from the top and see if all your pain is gone. If so, you know that pain comes from inside the joint. If not, the pain is not coming from the sesamoids, but the external ligaments, tendon, or nerves. 

     MRIs are not perfect for toes, so I would only get if I needed more information because I did not have a game plan I was convinced of. The reason they are not great is the slices are 3.5 mm and you can miss the area of pain. Also, all parts of the soft tissue are near the skin, and the skin can allow in too much light (artifact). 

     So, for the next few weeks, create your pain free environment, use various forms of anti-inflammatory, create an orthotic base that protects the spot, and then gradually increase your activity. I sure hope this helps. Rich