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Sunday, April 27, 2014

Sesamoid Injury: Email Advice (General Rules to Go By)


I'm a surgery resident from Finland and I have a problem with my foot, for a little over two months now. I'm writing to you because it seems I can't get adequate advice here. I would be extremely happy with any insight. I realize though that there are tons of people writing to you every week. But if you decide you could spare me a few minutes, here is my story.

I'm 33 years old woman, and I love sports, especially road cycling. During winter it's not possible here, so I had a trainer with my (older) road cycle on it and rode it with clip-less pedals as usual, with the road cycling shoes I've had for a few years and ridden thousands of kilometres without any problems.

 Well, I did a few sessions that were a little harder and then one morning after a session I had pain in my right foot, right under the 1st MTP joint. I didn't think a lot about it, the pain subsided during the day and I forgot it. But the next morning I woke up in pain. I then began to worry and read my books and googled, and it sounded like sesamoiditis, with pain when dorsi-flexing or plantar-flexing the toe. I changed to a hard sole shoe (hiking shoe) and when I got to work, I taped my big toe and added cushioning to my shoe (shaped to unload the sesamoids). Also I iced (2-3 times per day) the area and took ibuprofein and rested.

My foot did not improve and a week later I took an x-ray, which was perfectly normal, no bipartite sesamoid or anything. Then I went to see a sports surgeon, who confirmed my diagnosis, the fibular (lateral) sesamoid seemed inflamed. He recommended orthotics for my shoes and physiotherapy. He suggested it was because when I cycle hard, I curl my toes and had overworked the sesamoids by doing this, with indoor cycling there are no natural pauses like there are when cycling outside.

 I went and bought Sidas insoles (I have a high foot arch), which made my foot stop hurting while walking in just a few days. I went full-weight bearing the whole time, no crutches, and I also have been working the whole time. The foot-specialized physical therapeut I got to see a few weeks later, he examined my foot, and said that my 1st metatarsal-tarsal ray was lower and more mobile than on the other side and did not work as normal, like when dorsiflexing my ankle, the big toe lagged behind compared to all other toes. I got exercises to correct this as well as new custom orthotics, that support the arch and try to raise the 1st metatarsal ray upwards. Both the sports doctor and the therapeut said I could cycle with the orthotics if I wanted to.

I still iced the area, did all my exercises and got a few new ones to correct the alignment of my whole leg - I seem to have my whole right foot pointing naturally slightly out. Most days the foot was quite ok, did not hurt much at all and I was able to walk normally. I went to a congress a few weeks ago, where I had to stand up and walk a lot during the day, and the toe became worse. I treated with ice and rest, and the pain subsided again.

 I started aqua-jogging to do SOMETHING (I love sports), and I've continued to go to the gym the whole time. Last week I had a good week with only a few stings of pain, and really felt I was getting better. Last weekend I was able to go cycling for a short, 10-mile ride, which did not really hurt (just felt the stupid foot being there) during or afterwards. Also I use kinesiotape, my therapeut showed me how, to "rise" up the 1st metatarsal ray (taping from under the 3rd metatarsal joint, then the tape goes across the dorsum of my foot and up the lateral aspect of the ankle), don't know if that has been helpful or not.

I was pretty hopeful that this would heal. But yesterday, when I forgot to put the tape on (don't know whether this has anything to do with it or not), it started to hurt again. No excess use - actually, I got a lumbago a few days before this and could not go to the gym either - no further trauma. Now I feel a kind of a burning sensation coming and going, extending all the way up the plantar aspect of the big toe, independent of whether at rest or standing/walking. It hurts more to walk than before. The fibular sesamoid is still a bit sore when palpated, but moving the toe does not really hurt. I've been wearing hiking shoes with very stiff, cushioned soles the whole time, and I have now Birkis shoes for work, they are also very stiff and quite thick and I use them with my orthotics. I'm losing my patience with this. I asked an orthopedic surgeon at my work about my foot, about whether to get an MRI scan, but he said that it would make no difference, that sesamoids heal notoriously slowly/badly and that he thinks surgery is a very bad idea anyway, so no help there. I found your blog, and read everything I found about sesamoiditis, and started to do the contrast bathing as well. But a lot of my questions go unanswered.

Sorry about the long story. I would like to treat this once and for all, properly, to get it healed. I'm just so tired of my foot feeling either painful or just not normal, and sometimes even I think amputation would be a great solution... Should I get a MRI scan done - what is the benefit? Is this pain relapse just a part of recovery? Can I ever cycle again - and if so, should I switch my cleat position to midfoot (road cycle shoes don't have much lee on this) or do other adjustments. Do you have any suggestions for me to promote healing? I'm desperate for help - and if I lived in the same continent, would definitely book an appointment.

Thank you a lot anyway, if you got this far in my long e-mail...

Dr Blake's response:

     Yes, I made it through. You explain everything very well. And, I think you are doing well for what we know. You have to treat the worse case scenario without the benefit of a MRI and CT scan. X rays are notoriously poor for diagnosis of sesamoid injuries. The worse case scenario, and definitely my diagnosis of choice, a sesamoid stress fracture. I love MRIs as a baseline of image, so push for that, and if we can see the images, it may change some of my thoughts. 

So, what do we know about sesamoid injuries that may help? Here are my top 20 plus pointers when teaching about sesamoid fractures. 

  1. They rarely do not heal (and never need amputation!!!)
  2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
  3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
  4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
  5. Followup MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.
  6. The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis (self pay MRIs of this area are $500 in the San Francisco Bay Area).
  7. Since we are dealing with bone, we must look at diet, Vit D3 levels, calcium/zinc/magnesium, and bone density.
  8. Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Restrengthening, and Return to Activity. 
  9. When the patient is in the Immobilization phase, the treatment should be thinking about the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, cardio. 
  10. Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase). 
  11. One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.
  12. As treatment starts, the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc) that maintains 0-2 pain level.
  13. The initial goal is too create this pain free environment for 3 months by whatever means it takes.
  14. Non weight bearing (crutches or RollaBouts) always increases swelling, so protected weight bearing is crucial. 
  15. The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed. 
  16. If you are basing treatment on x-rays alone, you may be way off base.
  17. Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques.
  18. Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. See the foot strengthening exercises all over the blog. Keep the joint/foot flexible and strong.
  19. Patients with sesamoid injuries are prone for set backs so do not get discouraged. 
  20. If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months, some not. Self pay for Exogen Bone Stimulator is around $500. 
I hope this helps you. Rich

Patient's response: 
Hello again!

Thank you so much for the previous answer. I hope you could be so kind to answer a few more questions.

I went and got a MRI taken today and watched it through with the radiologist right away. It appears I have fractured the medial sesamoid (and I thought the pain was in the lateral one, oh well...). The fracture is a simple one, so the bone is broken in two (diagonally), and it appears that it might already be healed from one side (one third of length of the fracture). No other problems were found. So, you were right, and thank you for that, now I know what I'm facing. I'm attaching an image from the MRI here for you to see.

The bone swelling in the fractured medial sesamoid appears white in this image

The medial sesamoid is seen with a crack line running diagonal. 

So it has been 11 weeks now since I supposedly injured the sesamoid. I haven't known what I have had so I probably have been treating myself wrong and been treated and adviced wrong. The whole time I've been to work and wearing stiff, thick-soled hiking shoes with orthotics. I can walk for short distances, slower than usual though, without pain. But if I walk too much, or stand for too long, the pain comes back (of course I try to avoid this), but the pain isn't too bad, I haven't been needing painkillers. From your posts, I see that I should be in immobilization phase? Is what I'm doing enough, or should I get a walking cast or something?
Dr Blake's comment: Yes get the boot, you are in a delicate time right now for healing. I would wear the removable boot with an EvenUp on the other side for the next 6 weeks as much as possible to insure the fragile fracture has a good chance of complete healing. You must side on conservative. Put your custom orthotics in the boot. 

I'm icing twice a day, and also contrast bathing every evening. Fortunately I can move my toe without pain, so I've been doing strenghtening exercises for the foot and the joint isn't stiffening. I eat a lot of dairy, and also take calcium, vitamin D and magnesium supplements. I go to the gym, to mainly do upper body exercises and core, and do aquajogging as cardio.
Dr Blake's comment: Sounds great. The next 6 weeks will bring you a more healed sesamoid, a less inflamed joint, a stronger foot and maintain your cardio. 

What can I expect? Do you think I'm progressing right with the foot? When could I go to Return to activity-phase and try to start cycling, or walking longer distances, and how? The radiologist suggested that a CT scan shows bone healing much better, so later on I might be going to get one. I'm also going to enquire whether I could get a bone stimulator (Exogen).
Dr Blake's comment: Definitely you want the 6 months of bone stimulator. I like the CT scan, but you could wait on that for now, since you are subjectively doing very well. Remind with the cycling the injury could have been produced by pushing down on the big toe joint too forcefully, so I would wait for at least another six months. You could do a stationary bike with the pedal in the arch now. Walking in stable shoes and orthotics, with a progression to a walk/run program, to progression to long distance running is a more controllable program from my distance with you. A physio there many look at your cycling mechanics and say you are fine to cycle, or recommend modifications to cleat/orthotic/clip, etc. Good luck. 

Thank you again so very much, you are a footsaver :)

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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.