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Tuesday, July 30, 2013

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I've been following your blog since January, and I see that you have a lot of great advice on how to deal with sesamoid injuries. I've been following the advice you provide to people in their posts, but I'm very frustrated because I have yet been able to heal my injury completely. I believe my situation is somewhat unique so I would be so very grateful if you would consider reading about my situation?? I apologize if its so long!!! (feel free to cut stuff out if you want to post it on your site)

About a year ago I had a job where I was doing a lot of walking, which is what I believe caused my injury. I remember one day coming home and not even being able to put any weight on both my sesamoids. I resorted to just walking on the sides of my feet. However, it went away for the most part after a couple days of rest. And although it continued to bother me intermittently, it seemed as if it was just a temporary condition that would heal with rest. Soon after, I got another job that didn't require much walking, so during daily activities I just remained mindful to wear shoes that were comfortable. 

But then 6 months later (December of 2012) the pain in my feet increased to the point where I was regularly having trouble walking pain free. I finally saw a podiatrist and was diagnosed with sesamoiditis. I resolved to rest, rest, rest. I started doing contrast baths, and I made several versions of dancer's pads which I wore in brook's addiction shoes and wore with custom made orthotics. I found your blog and followed your advice on icing. However after a couple months of resting and contrast baths, I failed to see any improvement. In fact, it felt like it was just getting worse. I finally got an MRI of my right foot since that one was the more painful one. The MRI showed that the sesamoid was inflamed and it was either bipartite or fractured. The thing is that although it was the sesamoid itself that was inflamed on the MRI, I also have just overall pain and stiffness on that whole metatarsal region of the foot and my big toe. The pain sort of moves from one region to the other, and doesn't always remain localized in one spot. Sometimes it feels like its the bone that hurts, other times, a fleshy part and maybe a tendon.  I was previously diagnosed with Reynaud's phenomenon, so my feet are very sensitive to cold and I made sure to soak them in hot water on the regular in order to maintain good circulation.

 However, the condition of my feet began to decline, and in May I decided to quit my job because I felt like the stress from work, and the fast paced life I was living were causing increased stress to my feet. I wanted to make my feet my #1 priority. At that time, my doctor had told me to wear a boot on the right foot for a month, but by the end of the month, my foot didn't feel better. In fact, I was having new pain in different parts of my feet. Especially along the outside edge of my right foot, including the baby toe. Along with this I developed weird tingly sensations all over my foot but especially in these painful parts. By this time I was really fed up, and feeling very hopeless about my situation. I'm only 24 years old and having to deal with this for the rest of my life is not at all something I want.

After I got my boot off in mid June, I went out and bought new shoes by this company called Alegria  These shoes really seemed ideal because of how rigid the sole was. I paired these shoes with some insoles by a company called barefoot science which are supposed to strengthen your feet. I also proceeded to do strengthening activities by balancing and using latex bands. I started walking more and being more active which really helped encourage the circulation throughout my body, and in turn my feet.  I believe that wearing these stiff soled shoes really allowed me to carry out all these activities that were previously very intolerable. With these shoes I've been able to do more than I have in the past 7 months. Earlier this week I was actually able to do bikram (hot) yoga. (What I've noticed about my feet is that they are very temperature sensitive. And being in a warm, or hot environment seems to make them feel better. Especially being able to walk around and be active to encourage the blood flow.)

However, regardless of this improvement I am still struggling with just walking. Something about the movement in my feet while I'm walking causes more discomfort than standing and doing crazy balancing poses in yoga. When walking, I will sometimes still feel pain or stiffness in the Alegria shoes, but when I do, it is not quite as debilitating (like a 1-3). However, if I take these shoes off and try to wear other shoes (Even Brook's Addiction) or walk barefoot, my feet feel just as they did before. Walking barefoot a little doesn't cause immediate pain, but if I do it for longer than a minute, then my feet will hurt more for the next couple of days. I'm conflicted because although these shoes have provided a tremendous amount of relief, I'm starting to think that all they're doing is just covering up an issue that is clearly still a problem. It just seems weird to me that after wearing them for over a month that I still can't even step out of them to walk comfortably. A lot of my improvement has come from me being more active, so I'm starting to wonder that maybe I should ditch the shoes and push through the pain, in order to ultimately strengthen my feet and increase blood flow ( I don't really know how to tell the difference between good pain and bad pain. Its all bad pain for me). I've just already delayed a lot of things in my life because of this injury, and I'm feeling really impatient and eager to get back to doing all the same activities I used to do. Do you think that by continuing to just wear these shoes and avoid being barefoot, I will likely see improvement with my feet? Am I just being impatient, or do you think that resting may not be the best solution? 

I'd love to hear whatever thoughts you may have. Thank you so much for your time. And sorry again that this email is so long!!!!

Dr Blake's comment: Wow, where do we go from here? Reynaud's Phenomenon surely complicates things since you can not ice, like the rest of ice, so you need medications more to reduce inflammation. Most NSAIDS can slow bone healing, so you want to be cautious. I would still take 2 Advil 3 times daily to reduce inflammation and stay away from the warm water soaks (which may be allowing your body to hold on to the fluid). By my calculations, the MRI was in Feb/March, so any time you can get a repeat MRI to compare with the old one and see if any sign of healing is occurring. I will try to look into this shoe more, which sounds great, and weight bearing pain free is always better than non weight bearing. Sesamoiditis, even complicated with bi partite sesamoids, does not present like this so we are probably dealing with a fractured sesamoid. When a bone fracture seems slow to heal, then we have to think about bone health. What is your bone density? What is your Vit D3? Definitely your doc should be getting a bone stim. I like Exogen's ultrasound unit. 

     You need to create a pain free environment for the next 3 months. If that is with partial weight bearing with crutches, or with full time use of Alegria shoes, do it!! We need some weight bearing or the bones demineralize too much and there is problems. 

     Remember, anyone with a sesamoid fracture (diagnosed with MRI and bone scan) is a candidate for surgery. You do not have to suffer. Surgery is done when conservative treatment fails. Each patient is there own judge when enough is enough of conservative management. Just make sure at this point that your inserts/orthotics truly off weight the sore area, since it is crucial to avoiding surgery, but also crucial if you and your doc decides surgery is necessary. I hope this helps some. 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.