Pre-Dislocation Syndrome: Email Advice

Dear Dr. Blake,

I was diagnosed with pre-dislocation syndrome in my right foot 9 months ago. 

Dr Blake's comment: This normally refers to the 2nd metatarsal phalangeal joint where the toe begins to develop a hammertoe and begins to dislocate off its normal position on the metatarsal.

 I limited my activity, wore a flat post-op shoe for 3 weeks, and got custom orthotics.  Not only did the pain not get better, I developed sesamoidits in both feet, but worse in the right.

Dr Blake's comment: Pre dislocation syndrome of the 2nd MPJ is treated with metatarsal pads ( higher the better), budin splints when needed to control toe position or pain or both, icing 2 times per day, and metatarsal doming/arcing exercises. Orthotics are only for long term stabilization, not when the acute symptoms begin. If you have pain in the 2nd joint, every orthotic made will try to put weight on the first and off of the second. This weight transfer could be the reason for the sesamoid pain under the first metatarsal head (ball of the foot). 

Got orthotics adjusted.  Started icing and NSAIDS every day.  Right foot swelled up massive and was so tender I couldn't bear to have heavy covers over my feet at night or to put any pressure on the right foot. 

Dr Blake's comment: So, your initial injury now becomes a secondary war zone that must be calmed down. This acute phase must be turned into a subacute or chronic state with Immobilization. 

Okay, so then we tried 3 weeks on crutches (got marginally better, but still swollen and painful), 1 cortisone shot, 8 weeks with tall camwalker and a donut pad around sesamoid.  The latter resulted in 1 good day, 2 agonizing days, 1 good day, 3 agonizing days, 2 good days, 1 agonizing day, etc.  Still massively swollen and painful much of the time.

Dr Blake's comment: When the primary injury has such an acute phase, with swelling out of control, you must begin treatment of nerve hypersensitivity. A pain management specialist should be called into to help. The initial protocol is like the treatment for Complex Regional Pain Syndrome even if you have not been labelled as such. Also, non weight bearing on crutches typically does not get rid of swelling, since it is weight bearing that is needed to move the fluid out of the area. 

 X-rays do not suggest that it is fractured--just high arches.  I'm not running or hiking or anything else I used to do on a daily basis.  I can barely walk to the restroom without pain hence barely moving.  The next step might be a plaster cast all the way past my toes for a month or more.  I have a pretty demanding job and I'm not sure how I could do this and keep my job--they've already put up with a lot--so I am hesitant unless it is absolutely necessary.
Dr Blake's comment: In this scenario, immobilization in any form should be avoided. Even non-weight bearing on crutches makes the swelling worse, since weight bearing removes swelling if it can be done with little to no pain in a protected fashion. 

  Any advice on the whole idea of complete immobilization?  Could orthotics for the pre-dislocation syndrome have made me get sesamoiditis? I'm obviously now afraid of any more treatments since everything seems to have made it worse, although maybe that was just going to happen on its own, not sure.

Thanks!

Dr Blake's comment: Thank you again for emailing and I am sorry for your problem. These are the things I think you should be doing, but your doctors have the last say since they can see you. 

1. Immediately begin to see a pain management specialist to help control the pain symptoms, and pervent this going forward towards CRPS. 
2. Use the crutches with the cam walker and sesamoid pads to allow as much healthy weight bearing as tolerated. 
3. Purchase some OTC Neuro-Eze online and massage into the tissues 3 times per day.
4. See if your body can tolerate contrast bathing twice daily with the ratio of 1 hot to 1 cold water. 
5. If the orthotics do not take enough pressure off the sesamoid, go back to have them redone for you will need this soon to help wean off of the boot. 
6. See if you can find a flat hiking shoe (even if it is 1 size larger) that is stiff and limits the pain in the sesamoid area.
7. Ask your PCP for an Rx now of Lidoderm Patches. 
8. See my blog post on the CRPS checklist to look at all the areas to explore to get this under control. Good luck!!!