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Monday, March 14, 2016

Post Sesamoid Removal and Neuroma Care: Email Advice

Thank you for inviting me to email you about my foot trouble.  

     In the middle of February 2015, I was in a car accident in which someone pulled out from a side street across my line of traffic.  I slammed on the brake and tried to swerve but ended up hitting him in the rear driver's side. My left knee got jammed into the dash and by that evening my right foot had started swelling up and got quite painful. 

     I went to walk in clinic to get checked out and they xrayed my foot. (Dr Blake's comment: x rays do not show small fractures ever or it can take up to 4 weeks).  She said she did not think there was a break.  A few days later I followed up with my primary who went by the urgent care's report and said it was sprain so ice and rest it and take a lot of advil.  I did, it was getting no better.  I went back to my primary a week later because both my neck and foot were not getting better so she sent me to PT.  My neck got better, my foot had no improvement.  It was hurting so bad it was waking me up several times a night

     After several weeks my PT said he thought it must be broken so  I went back to my primary who finally sent me to a podiatrist.  The podiatrist sent me for an MRI which showed the tibial sesamoid was indeed broken.  The podiatrist said that Urgent Care missed the break because they did not take the xray at the right angle. Now the pain I was experiencing was a sharp pain in the big toe joint area.  Driving was excruciating.  I also had pain between the 2nd and 3rd toes.  It felt as if there was a baseball under that joint, which changed to feeling like there was cotton stuck under there.  Sometimes it felt like it was burning. (Dr Blake's comment: This is nerve hypersensitivity kicking in. It is pain generating more pain by making the nerves hypersensitive inorder to protect you, tell you to get off it). 

    My podiatrist did not really address that concern but regarding the sesamoid he said that my options were to be completely non weight bearing for 2 months but that may not even work, or get the surgery (keeping in mind  by this point it has been about 2 months since the accident).  So on May 5, 2015 I had the tibial sesamoid removed.  After the surgery the doctor told me that not only was it broken but the cartilage between that bone and the joint above was blown out so he had to clean that up a bit. 
Dr Blake's comment: This was good news so you know the surgery was 100% necessary to avoid further injury to the metatarsal. 

    I went back to PT but stopped since it did not seem to be helping.  Last October I went back to the podiatrist because the big toe joint was still really hurting and the neuroma was still really bothering me.  He scanned my feet to make orthotics and gave me 2 cortisone shots at the big toe joint.  At first he was saying the pain was due to a bunion, but after the shot and after the difficult time he had administering the shot due to scar tissue he said the pain could be from the scar tissue.  He still did not address the neuroma.  The cortisone helped some for the pain.  I think it was late December before he gave me the orthotics.
Dr Blake's comment: I love to get orthotics to patients right after surgery, if they do not have them already, since I want them walking with sesamoid area protection. 

     In January, I went back because I just could not take the neuroma and at first he just wanted to pass it off as being because of a bunion but then he actually looked at my xrays and said that no that did not look to be the case so he gave me a cortisone shot between the 2nd and 3rd toe.  It helped take away some of the burning pain I was getting.
Dr Blake's comment: This doctor is just slow at doing good things!!!

     I wear the orthotics consistently in well fitting athletic shoes, but they don't seem to make much a difference. Actually the orthotics are so hard (and I did put a thin cushion on them) that when I get home I want to take my shoes off, but I don't because the doctor said not to go barefoot. My job keeps me on my feet alot on concrete floors.  I do have some antifatigue mats around and use them whenever possible.  But I find that if I have to stand or walk on those floors for even a half hour I can feel that neuroma and it feels like my foot is blowing up like a balloon. 
Dr Blake's comment: It is common to need up to 3 shots to calm a neuroma down. See if you can get the second one soon. 

     The big toe is becoming again painful (a sharp pain on the underside and side), but not all the time.
Dr Blake's comment: The surgery for a damaged sesamoid and undersurface metatarsal bruising can take up to 2 years to feel great. Typically a PT will be the most help getting the range of motion better, reduce the scar tissue, and get the muscles strong. I am assuming you are doing met doming exercises and simple self mobilization. Does spica taping help you?

     I went for a second opinion who said he had very little time, just said he recommended a couple more cortisone shots at that neuroma. 
Dr Blake's comment: What a comment!!! I apologize for the sacred profession of medicine. 

 I would like to get back to a normal life but if I try to walk too much, or run I pay dearly.  And I am not sure what to do.  Any suggestions would be greatly appreciated.  I can send you xrays if that helps.  Thank you so much for your time!
Dr Blake's comment: So, I would have the doc do at least one more neuroma shot with cortisone. Read on my blog about neuomas to see if there are other suggestions, like metatarsal pads. Get referred to a PT known in your area for feet and see what they say about the big toe joint and the neuromas. Keep me in the loop. Get a new MRI 2 weeks after you next shot. I would be happy to see the images. Just email me them by taking photos of each frame. What shoes or qualities in shoes have you found helped the most. 

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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.