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Tuesday, August 20, 2013

Fractured Sesamoid with Surgical Complications: Email Advice

Hi Dr. Blake,

I have been reading emails after emails on your site trying to find a similar situation to mine. I have been through 6 doctors in the last 5 years and I have hit a wall. I will tell you I am only 26 years old.

I fractured my  lateral sesamoid in 2008 of my left foot. I was casted multiple times,placed in a boot, fitted for orthotics, and had many cortisone shots. After 3 doctors I had my Lateral sesamoid removed in 2011. I got pregnant in between so I had to wait the year. My foot didn't hurt when I was pregnant but the moment my foot unswelled it was back.  The doctor who removed my sesamoid used porcine graph without my permission, I was allergic and it caused a HUGE mess. The doctor vanished on me. I found another doctor and she went in and cleaned out what the prior guy did 1 month later. My incision was infected, I had a hole in my foot. I got it cleaned out and now there is a thin layer between my bone of the foot and skin on the side from incisions. You can literally feel the bone. They say if i every get cut there it would be directly on the bone.  If anything touches it, it hurts right away and even makes my nerves crazy sending shocking sensations up my toe. That is the least of my problems.
Dr Blake's comment: I am so sorry.

Since that seaamoid was removed the pain had not improved. I was still unable to walk correctly or pain free. Over the course of 1 year my big toe starting turning in and the pain was increasing.
Dr Blake's comment: It is hard sometimes to know if the pain is coming from the sesamoid which is in the joint vs some other arthritic process within the joint like Hallux Rigidus (although you are quite young for that). 

My doctor suggested transferring the tendon and fusing my big toe. She said this would alleviate all my problems. I had that surgery in Jan-13. I have had nothing but more problems. Pain in my arch, above my toe joint, ball of my foot and now my toe hurts from the screw. I got orthotics and more cortisone shots. The shots no longer work.  Her next step is to lengthen the tendon. I would rather not have surgery on my foot again so I decided to get another opinion and changed doctors.
Dr Blake's comment: When they fuse the big toe joint, they typically fuse for a slight heel. The bend in the toe produced forces more pressure on the sesamoid area underneath. 
My new doctor did an MRI and x-rays. My medial seasmoid is fractured now and I have fluid in my tendon as well as chronic edema and arthritis in the joint.  This doctor casted me for 2 weeks after finding that out. If anything, this increased the ball of my foot pain drastically but the pain directly over the sesamoid is gone. I had NO pain when I was casted. With every step now I hear a cracking noise. This doctor says the tendon is not healing around the sesamoid. (That entire tendon hurts all the way up my calf, ankle. I saw a physical therapist and she had me in tears just from barely pushing on it). He is out of options on what to do other than remove the remaining sesamoid. He feels a Plasma Rich Platelet injection may do the job and heal everything in my foot. Well, my insurance denied that and I can't afford it right now. I am frustrated and extremely upset that I will never be able to walk normally without having pain. I can't hold a job that requires standing or walking. I can hardly go grocery shopping. The zoo? Mall? no way! I am in tears in the middle of it and at the end my foot is very swollen and I can not bear weight, it feels like my entire foot is broke. I am out of options and do not know what to do. I have been rubbing the essential oil lemongrass on the ball of my foot and arch and toe for 4 days now hoping it will work. Please help me! What can I do? What is your advice or opinion on this situation?

Thank You!

Dr Blake's comment: 
     Thank you so very much for your email, and I am so sorry for the problems. I have more questions, then answers, so while we try to get some direction, place yourself into as pain free environment as possible. This is probably with a removable boot with accommodative floating of the big toe joint with an EvenUp on the other side. 
Sesamoid fractures take minimum of 3 months of casting and the cam walker should do that. We need to protect the other sesamoid as well as possible. I am sorry that I have no experience with PRP to help you with that decision.
     The fusion should have taken care of 2 of the 3 sources of pain in a bad big toe joint: the pain produced by pressure in the joint and the bend produced by bending the joint. This leaves the 3rd source or the pain produced by weight bearing on the area. This is where temporarily (2-3 years with your problem) you need to off weight the area with various forms of arch support and dancer's pads.
     If you are working on the mechanical aspects of pain, you have 2 other areas to deal with: inflammatory pain and neurological (neuro-pathic) pain. For the inflammation I would be icing every several hours for 10 minutes placing an ice pack on the bottom of your foot. For the neuropathic pain, I would see a pain specialist. It can take you 2 or 3 to find one that really gets it for you. But, I would start working on that right now. 
     The nerve person, pain specialist, will have topicals, patches, oral meds, and other tricks. If you read some of my posts on "Complex Regional Pain Syndrome" you can get a feel for what that speciality has to offer. You will also read that is it important to be touching the area gently AMAP as long as it does not hurt to desensitize the area. 
     I am sure hope this starts pointing you in the right direction. You may have to have the metal removed, since that could be a source of irritation and only needed until the joint fuses at 12-15 weeks post surgery. Typically, they wait 1 year to let the area calm down after surgery before removing the hardware. Rich 

Hi Dr. Blake,

Thank you for writing me back. I never thought about visiting a pain specialist as the pain is bearable when sitting but once I step on my foot it sky rockets and doctors pretty much just cross me off the list and are unable to help me any longer.  I guess I dont understand why my foot is unfixable. My body has automatically compensated so I walk on the side of my foot. My physical therapist says its the weirdest thing. I can only do that barefoot or in flip flops though, but being barefoot hurts as well on the side all my weight is on. When I wear a shoe it no longer allows me to walk like that, which is why the doctor gave me orthotics but those still cause pain at the ball of my foot and arch. I seriously can't wear a shoe to walk, it hurts the worst! I know its bad to wear flip flops but it is the only way I can get around. I have done a dancer pad in the past ( first sesamoid injury) and it did not heal it. I can do one this time to see if it helps again. I did read about lipstick on the ball of my foot, I will try to do that as well. I do apply ice and apply heat, I do not feel it helps. It brings down the swelling temporarily but then when I walk it swells right back up. I have been using Voltaren gel 2-3 times a day and I am unsure if that helps either. I continue using it in hopes one day it will. 
Dr Blake's comment: Orthotic devices can be designed to put your weight on the outside of your foot with some inversion force. Many orthotic lab offer various techniques to start, and then the podiatrist/physical therapist has to do some in office tinkering. But, it can be done to get you into shoes. You can also invert/varus cant the outersole of a shoe to get your to the outside of your foot. This is so much better (for the next 4-6 months) than having you have to do it with gait changes and abnormal muscle contractions. Nothing will cure this in the short term. You need to use 8-10 things that each seem to make some difference. By putting them all together, you may get at least 50-60% better. 

To be more specific my most recent surgery in January was: Hallux Interphalangeal Joint Fusion with Screw Fixation with Jones Tenosuspension of the Left Foot.  She said I had first metatarsophalangeal joint capsulitis as well.  The pain is a lot worse after this surgery than with the first. I wish I would have never got it done!
Dr Blake's comment: I am so happy they did not fuse the big toe joint, best news you told me all day!!! The Jones tenosuspension I never see, so what did they do? Please make it as clear as you can. Even a copy of that paragraph from the op report. 

My MRI findings say: Postoperative changes. Moderate osteoarthritic changes and moderate disc space narrowing involving first metatarsophalangeal joint. Mild T-2 weighted increased signal involving the lateral sesamoid at the plantar aspect of the distal first metatarsal. Flexor Hallucis longus tenosynovitis. Fluid within distal flexor hallucis longus tendon sheath
Dr Blake's comment: Definitely want you to send me a disc of the MRI so I can see. Send to Dr Rich Blake 900 Hyde Street, San Francisco, California, 94109. Sounds like some arthritis in the big toe joint which has not been addressed yet, and maybe why you continue to hurt!!?? Hope??

The MRI is my most recent diagnosis. After that I was casted and now I am still in pain unable to bear weight if not it worse after casting which he thinks is from tearing the tendon now... Did I say this already? 
Dr Blake's comment: The MRI did not talk about torn tendons, so that is good. Alot of patients hurt so much worse after casting since the immobilization allows for stiffness, weakness, fluid retention, bone demineralization,etc. Get into the removable boot with accommodation and start putting some weight on it gradually. Massage as painlessly as possible, and as often as possible. You need protected weight bearing and mobilization, and anti-inflammatory for the next 4-6 months. 

I just realized I was backwards on my sesamoids-sorry- I had the medial removed and I still have my lateral?   I just know my outer seasmoid closest to the right foot was taken out and I still have my inner sesmoid closest to the left pinky. 

Any other advice? Does that added info help you any?

Have you seen improvement in ultrasound therapy or the electronic shock therapy? My doctor also mentioned a bone growth simulator, but thinks that is a 1-5 chance of working. 
Dr Blake's comment: These toys are all about timing, and it is really hard for me to assess that right now. 

I feel like I just need cushion at the ball of my foot, can they do implants or anything of that nature? I know, that may be a crazy thought. 
Dr Blake's comment: Have your doctor look at the Hannaford orthotic design on my blog, perhaps his lab can make something similiar. Dr Suzanne Levine in New York is injecting collagen for cushion into feet. She can advise if possible in your case. 

Did I read that you suggest wearing a boot for 2-3 years? Maybe I interpreted that wrong? 
Dr Blake's comment: The goal is to create a pain free environment and then gradually wean from it. If that requires a removable boot for 2-3 years, then that is what you do. Hopefully not, for that would rack havoc on the rest of your body. 

Also I can still move my big first big toe joint which is painful at the joint and ball of the foot. I have limited motion of that joint. When I move my big toe down my entire foot shakes.  My big toe is also up like a hitchhikers toe but not as drastic.  I have used a JAS system to regain motion but it really aggravates things and makes it worse as does Physical Therapy.
Dr Blake's comment: You really sound like some arthritis is in the joint causing a severe pain syndrome. The MRI will help me understand you better. You need to move the toe, but painlessly. Get small gains very week. Only a few physical therapists can do this. See my video on Self Mob for Hallux Limitus. Thanks for all your clarifications. 

Thank you for taking the time to read this.

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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.