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Wednesday, October 9, 2013

Sesamoiditis: Email Advice

Dear Dr Blake,

I am contacting you from Australia as I have been suffering from a particularly persistent case of sesamoiditis for the past 4 months. I read your blog and was hoping you may be able to help as I'm desperate for answers. 

I have tried all methods of conservative treatment, including custom orthodics, 2 cortisone injections (FHL tendon sheath guided by ultrasound) and 1 MTP joint capsule. I had a negative reaction to the second injection, with increasing swelling pain in the 1 MTP. My orthopaedic sports surgeon, decided it was best to have a investigative synovectomy with biopsy carried out to eliminate any potential infection/underlying inflammatory condition that was not appearing on blood tests or MRI. The biopsy yielded no results.

I have also been in a cam walker for almost 3 months, with 2 weeks of crutches included in there post surgery. I have been training in professional football. I am desperate to heal this condition and am reaching out to you for help as I feel my options here in Australia are limited, with little success this far.
I am particularly interested in ESWT and the specific modalities applied so that I may be able to request from a clinic here. I would also be interested to hear your opinion on PRP injections or Augment for bone healing, even though no fractures are present in my case (just a bipartite sesamoid, confirmed via xray and 2 MRI's).
I would greatly appreciate your assistance Dr Blake as I am a very active person and this condition has severely affected my quality of life and aspirations of becoming a punter in the NFL.
Yours sincerely,

Dr Blake's comment: I am honored you have asked me. I have no experience in ESWT or PRP or Augment for this condition, but I think that there is a place for Exogen Bone Stimulation to strengthen the bone. You have been in the Immobilization Phase for typically the time you would for a broken sesamoid, so the question is how to progress you to the Restrengthening and Return To Activity Phases. I am happy to look at any MRIs that you want to send me. The Pacific Ocean is not that big. I would have to assume the length of time is either from inadequate orthotic protection, a misdiagnosed small sesamoid fracture, or pain more from soft tissue with inadequate physical therapy. If everyone is happy that the bone is not broken, find out who makes the best orthotics in town or in the biggest town near you. See if a physio can evaluate you for bone, joint, or soft tissue problems. Ice Pack the area 3 times a day for 15 minutes, and do contrast bath each evening. Buy a roll of 1/8 th inch adhesive felt from Moore Medical ( and with a tennis shoe 1 size bigger, and a good deep toe box, try to design a dancer's pad and arch support that when you walk and run there is no weight on the sesamoid (a slight overcorrection of the foot as a temporary design). Send me photos of your foot, inserts, anything and I can give you advice. Do you have swelling? Does the joint have good range of motion? When does it hurt---with joint motion, or just with pressure? Let's start analyzing. Best to comment on this post, but it you want more confidentiality, email me again. I hope this helps some. Rich

Patient's Response:

Hi Rich,

Thank you so much for your reply.  

From what I have been able to gather in my research, there are two different types of sesamoiditis.  One which is more related to a bony stress response, and the other which is more related to FHB and FHL tendon/ligament inflammation.  I think there's no doubt that initially it was a bony stress response, however I tend to think the sesamoids are now more reactive to the surrounding inflammatory soft tissue.  The MRI's reports detail tenosynovitis to FHB and FHL.
Dr Blake's comment: Tenosynovitis is an advanced, very sore, form of tendinitis and hard to get rid of. 

I was using a personal ultrasound device for a few days (ultrasound pro) which I bought over the internet, which has a low frequency setting.  I was using this around the FHL and FHB area, as well as 1st MTP.  It seemed to aggravate things for a couple of days and then settle down.
Dr Blake's comment: Ultrasound units that you can purchase are either for bone or soft tissue. The soft tissue ones are bad for bone healing, so you need to know which one you are getting. 

  So I have stopped this and am now only using the Melmak bone stimulator which my specialist recommended.  My specialist says its the same as an Exogen 4000.  Here in Australia you can't rent Exogen, you can only buy them for around $1,800.  So I am renting the Melmak for 1 month ($330) and doing 20 min per day treatment as prescribed. 
Dr Blake's comment: Definitely switch to twice a day for the same 20 minutes. 

 I was hesitant to use this as I have been told I don't have a fracture as such and was wondering how much good it will actually do for a "stress reaction" to the sesamoid.  I hope it helps rather then causes a negative reaction.  Do you think these devices help with soft tissue/ligament and tendons? What about 1st MTP swelling?  
Dr Blake's comment: I love this device for building bone strength. A bruised bone would be helped as would a broken bone. For the soft tissue, due regular PT, icing massage, spica taping to limit the motion of the FHL and FHB, and contrast bathing daily for the swelling. 

The 1st MTP is still swollen (6 weeks post synovectomy) and range of motion it limited, although it improving as I'm doing some light rehab like picking up pegs and just ROM exercises.  I'm also doing some heat treatment like hot bath soaks, sauna then swimming pool.  I still haven't had a proper answer from the doctors I have been consulting here as to why I had such a negative reaction to the cortisone injection into the 1st MTP.  I think it was administered incorrectly and have not doubt it set my recovery back significantly.  At the time, the doctor commented - "oh that's good, I got more in than usual there."  I was told he got about 1.5mls into the joint capsule, which from what I can gather was too much.  Also, if there was any bruising of the articular cartilage it can really respond badly.  Would articular bruising show on an MRI?
Dr Blake's comment: Yes, articular bruising shows on MRI. Typically, when my cortisone shots irritate things, for whatever reason, it is 2-4 weeks before we are back to square one. And, in those cases, you never get any benefit from the cortisone, which I do not understand why.

Regarding the orthodics, these have been fitted by one of the best here in Brisbane.  He is the podiatrist for our professional sporting teams, although he didn't employ casts for my high arches.  Techniques include heal cups, posts from 2 to 5, dancers pad and arch support.  I have attached pictures of my inserts for reference.
Dr Blake's comment: Do they or do they not take pressure as you walk off the sesamoid? If not, modify!!!!

I have also contacted the radiologists who took the MRI's.  They are able to set up a web site for you so you can view the images online.  For this option I need to provide them with the following - name, location, provider number, specialty etc). We would then create an account for this doctor so he can log on.  If this doesn't work I can arrange to have the pictures sent via email, although these would be still images.  Would you mind providing the details so I can have QSCAN set up an account on our end?  I will also get copies of the MRI reports to emailed across to you.
Dr Blake's comment: Great, will do in the original email.

I continue to ice each night for 20 minutes which helps.  I have also just started (this last week) getting out of the boot more and back into my trainers with orthodics around the house.  I have also been taking silica as it's supposed to help with connective tissue strengthening (i.e. ligaments and tendons).  I am also taking glucosamine, fish oil, Vit D and calcium supps, in addition to a multi.  I eat a very good diet so I don't think there is anything more I could be doing nutritionally to aid in recovery.

I am seeing my surgeon on Monday (tomorrow) for another post op review and I will request another MRI to see how things are progressing and will keep you posted.

I am happy for you to repost this email on your blog.  Feel free to modify/amend parts as you see necessary.

Thanks again,

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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.