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Wednesday, March 25, 2015

Sesamoid Pain with Compensatory Symptoms: Email Advice

Dear Dr. Blake,

I’ve been reading your blog over the past month- thanks so much for all the information!  

I wanted to ask you some questions about my foot pain, because there are a few things I am confused about.  I apologize in advance for the length of the explanation.

In mid-February(it is now mid March), I started feeling a vague pain on the ball of my foot under my big toe on my right foot.  It came and went and I was still able to wear high heels to work, workout, and walk around normally. About 10 days later, I was no longer able to wear heels and switched to flats.  A few days later, I could not walk flat on my right foot and started to walk on the outside of that foot.  A few days after that, I was limping and went to see a doctor. 
Dr Blake's comment: Sounds like a sesamoid injury. The swelling within the bone builds up over the first 4 to 14 days after the injury making the symptoms more and more painful and limiting.

I visited an orthopaedic surgeon (the type of doctor covered under my insurance plan).  He bent my toe up and down and pressed on my bones- I didn’t feel any pain.  He took an x-ray to be sure and confirmed that there was no fracture.  He told me to take it easy to reduce possible inflammation of the tendons in that area.   I started icing, elevating, and minimized walking as much as possible. 
Dr Blake's comment: For sesamoid injuries, x-rays are typically a poor indicator of the problem because they may not show stress fractures or bone contusions. 

A week later, the pain became intense and I went for a second opinion with another orthopaedic surgeon.  The pain was now in both feet, in the exact same area with the exact same symptoms.  My feet were tingling and there was a constant sensation of pins and needles and electric shocks.  Additionally, my feet were getting very cold to the touch, even when I wasn’t icing.  There was a stretching/pulling pain in the web of my first two toes. 
Dr Blake's comment: When you injure the area, there can be the mechanical (orthopedic) cause of pain, the resultant inflammatory aspect of pain, and then secondary neuropathic pain for the body protecting itself. You sound like you have all 3.  

The second surgeon did more x-rays on my right foot (but not the left one), some blood tests, and an ultrasound.  The xrays were negative, the blood tests showed slight vitamin D deficiency, and the ultrasound showed tendonitis under the right toe but not the left one.  I was given a diagnosis of sesamoiditis and started taking vitamin D3: 10,000UI daily, 5 days a week. 
Dr Blake's comment: Vitamin D3 deficiency is proving to be a be killer for runners. One of my patients that I saw yesterday has not run for 2 years due to stress fractures from low Vitamin D3.  

The pins and needles/electric shocks sensation decreased in frequency and intensity but the other symptoms remained.  The way I was walking and standing to avoid stressing the sesamoid area led to sharp pain in my heel area in the fat pad directly under the heels (both feet but more on the right) and Achilles/calf pain in my right leg.  I started with a physiotherapist in mid-March to learn how to walk properly.  He found my symptoms tricky for the following reasons:
Dr Blake's comment: Glad the nerve hypersensitivity is calming, because that can become a problem on it's own. You typically have one injury and a bunch of secondary compensatory symptoms (tendinitis, nerve irritability, achilles tightness, etc. It is important to address these issues, but not to lose sight of the original issue. 

1)      There is absolutely no pain when my flexor tendon (the one supposedly affected by the sesamoiditis) is stretched or pushed in any direction
Dr Blake's comment: I am sure any flexor tendon problems is just secondary pain, not a true injury. 

2)      The pain is in both feet (which seems to be a rare occurrence) but it is not always in both feet at the same time
Dr Blake's comment: I have some many patients with sesamoid pain in both sides, knee pain both sides, achilles both sides, etc. It really depends on your weak spots.

3)      When walking, I feel like there are pebbles under my first metatarsals but when the area of the sesamoid bones is poked by hand, I don’t feel pain
Dr Blake's comment: This is highly usual for stress fracture, so sesamoiditis may be right. 

4)       Sometimes it feels like my foot is tightening up (possibly from swelling) and moving the foot upwards (without bending toes) causes pain that radiates from just below the web of the first two toes on the sole of my foot and ends just behind the ball of the foot under the sesamoids
Dr Blake's comment: This is definitely neuropathic pain with neural tension. See my blog posts on neural flossing and Neuro-Eze. 
5)      Laying flat on my back and moving my leg upwards in a straight line reproduces the pain described in #4 but only when the foot feels tight- when it doesn’t feel that tightness, nothing can reproduce that pain
Dr Blake's comment: The sesamoid injury can cause swelling, the swelling irritates the local nerves, the swelling can come and go due to anytime that affect swelling like the foods we eat, how hydrated we are, the temperature and humidity, etc. 
6)      I sometimes feel the whole ball of the foot swell up- but there is no pain to touch
Dr Blake's comment: Swelling means your body is trying to heal something. But, swelling itself is a bell shaped curve. Some people swell alot and others little with the same injury. It is hard to judge, and if you swell, the swelling shoud be treated on a daily basis. But, you may be swelling long after you are completely healed. 

After 2 sessions of physiotherapy, my feet feel much better when I take my first steps in the morning but are much worse when the burning starts (this is the only time there is pain when touching).  The pain I currently feel under the sesamoids is burning/stinging, sometimes very intense (the skin is not hot to the touch), tightness, and pebbles or ball under my feet when I walk along with a bruised feeling on the outside of the first metatarsal. 
Dr Blake's comment: These are all nerve hypersensitivity, protection, symptoms. They are real and are not treated by typical mechanical or anti-inflammatory measures. Try neural flossing, Neuro-Eze, tylenol, warm compresses. Review all the treatments on my blog for nerve pain including medication (started only at bedtime for these symptoms. 

 These symptoms come and go, sometimes there is more than one symptom, sometimes all of them, sometimes none.  
Dr Blake's comment: This is how compensatory pain goes, not the pain from an injure that is there from start to finish until the injury heals. 

The pain in my heels gets better with rest but comes back with pressure and standing/walking (but heels feel ok in shoes like Birkenstocks). The Achilles pain gets better with rest. I will go back to the doctor to try and get an MRI approved, maybe more blood tests to rule out any infections, and maybe take some time off work so that I can fully rest my feet.  At this point, I am reaching out for any advice and am hoping you can help- does this seem like sesamoiditis in both feet or might there be something else I need to look into?  
Dr Blake's comment: So, remember to not lose sight of the primary injury. You injured your sesamoid. You need to treat the mechanics with dancer's pads, possibly orthotics, spica taping, icing, an MRI, creating a protected weight bearing environment. Good luck. Rich

Thanks for taking the time to read this.

Name Removed due to Witness Protection


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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.