Avascular Necrosis of the Tibial Sesamoid

Dear Dr. Blake:

I recently commented on one of your blogs posts on PodiatryToday.com, before I came upon your blog. You seem to know much on the subject of sesamoids and their issues, more so than any doctor I’ve encountered.

I’m a 20-year-old college student with avascular necrosis of the right tibial sesamoid. I was diagnosed with stress fractures in my right foot 4 years ago, and when those failed to improve, I was eventually diagnosed with AVN 2 years ago by an orthopedist. He put me through conservative treatment (orthotics, carbon foot plate, Exogen bone stimulator) for a few months, but my symptoms persisted. He recommended surgery. I sought a second opinion from a podiatrist, and he recommended that I continue with whatever conservative treatment I was already doing. So here I am 2 years later still doing the Exogen bone stimulator every night and wearing orthotics in my sneakers (or dancer’s pad if I’m barefoot). I ice when there’s pain; sometimes I do a hot soak with Epson salts. I was an avid runner before I was diagnosed and have since quit because I still have pain when I run. I’ve found solace in swimming, rowing, and weight training but still sometimes get pain when rowing or going for long walks/hikes.

Long story short, my problem has steadily worsened over the past 2 years, and I was led to believe that it would continue to worsen until surgery was the only option. Reading your blog suggests otherwise though. In other emails from people with AVN of the sesamoids, you discuss treatment options that my doctors never mentioned, mainly spica taping, dry needling, contrast baths, foot mechanic evaluations, Neuro-Eze, bone density/Vitamin D screenings,  and CT scans to check for bone fragments. You also say that the chance of the injury re-occurring is very low in the case of the 14-year-old Irish step dancer, whereas my doctors told me that I would have this injury for the rest of my life with no hopes of improvement. 

But is there still hope for me, 2 years after the initial diagnosis? Is it common to have this injury for so long with gradual worsening over time? Is it still possible to reverse the effects this late in the game? I know you can’t answer specific medical questions over this forum, but do you have any words of wisdom for a frustrated young athlete? 

Thank you for your time.

Sincerely,

Dr Blake's comment: Thank you so very much for reaching out. I would love to tell you some positive words, but there is so much we need you to do to find out what is really going on. I have to assume you have good bone density and overall healthy. Definitely if you want me to help you need a CT scan (your Primary can order) and a bone density screen. Also, this should be sent to me with your current MRI (within 6 months). They can be mailed to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. I do no charge for this. I hope I can help. Rich

Peroneal Tendon Taping with Leuko tape Video

https://youtu.be/QIVbAB1t0Gc

When More is Better than Less: 10 Ways via Caroline Jordan

Caroline Jordan, an incredible gift to fitness and happy living, gives us 10 guidelines to review over and over. I love routines, so change is hard. Caroline encourages this in a very positive way. 

https://youtu.be/Y3B3aoVlExg

Capsaicin: Neuropathic Pain Topical Treatment

This article brings to mind a long forgotten medication for nerve pain. I will probably start experimenting again with it. Looks like it comes as a patch also. Sweet!!

http://www.podiatrytoday.com/blogged/can-topical-capsaicin-be-treatment-alternative-neuropathic-pain

How to Evaluate a Bunion

https://youtu.be/PhVT9b4p7_s

Other bunion posts:

http://www.drblakeshealingsole.com/2012/07/how-to-conservatively-treat-bunions.html

http://www.drblakeshealingsole.com/2016/06/bunion-exercise-to-slow-progression.html

http://www.drblakeshealingsole.com/2015/06/help-for-bunions-and-hammertoes-correct.html

Dr Blake and wife Patty at recent concert!!

https://goo.gl/photos/sCJaUWrbteVyowbP7

Another Motivational Video on Healing an Injury by Caroline Jordan

Caroline is such a delight to listen to as she herself is coping with trying to heal a foot injury. I have so many patients on both sides of the coin. Some stormed on through injury, and now are trying to control the quickest rehabilitation. Some get so frustrated that they give up, or try untested treatments, or even unnecessary surgeries. I think we have to surrender to the clock, and give up some goals possibly, and live in the present only as Caroline says. We however must not forget to listen to what our bodies are saying. If we have been told to ice, but it always increases pain, we should stop. If we got orthotics to shift the weight off a sesamoid, and we don't think it is enough, speak up. If we are told we have tight achilles, and we only stretched once a week in the past, we can control this. We can stretch more, 3 times a day can be needed to gain flexibility. So, control what you can, relax in the presence, learn some new things (cross training can be wonderful), and you may find you like something more that does not hurt than the activity that does hurt. Good luck. Thanks Caroline. You are motivating as always. 

https://youtu.be/M79CoFF5uMs

Sesamoid Pain: Email Advice

Hi Dr. Blake, 

Thank you for providing so much information on your blog. It really is so kind of you to selflessly help so many people. I was hoping you could provide some thoughts on my current sesamoid issue. 

I started feeling pain in the ball of my left foot around the beginning of 2016. I didn't go to a podiatrist until December 2016, as I ignorantly thought the pain would eventually go away. The pain was always a dull ache. I continued to run, do plyometrics, and perform lunges and push ups during this time. 

The podiatrist in December 2016 took xrays (attached both right and left to this email) and determined I had a fracture. As the injury had been there for a long time, he said it probably was already partially healed so directed me to stop running for 6-8 weeks and put padding in my sneakers. I follow his direction but did not see any improvement.

2 Views left tibial sesamoid December 2016

 I continued with this non-impact activity and padding method until mid-april when I came across your blog and started wearing a boot with a dancers pad for three months. I iced twice a day and contrast bathed at night. I also was weight training and cycled on a stationary bike in a surgical shoe during this time.  The pain level was definitely within 0-2 so I thought it could be healing. After three months, I decided to try to get an MRI so I visited a doctor recommended by you, Dr. Dan Altchuler in Santa Monica. He took xrays (attached), thought potentially I could be feeling pain because my sesamoid was slightly pointed and suggested potentially performing a sesamoid planing to shave off the point. He was surprised that it didn't hurt me more when he was putting pressure on my foot and moving my toes in certain ways so he directed me to stop wearing the boot and padding. to see how it felt without anything. 

Recent Xray showing left tibial sesamoid irregularity July 2017

My foot definitely felt weaker from non-use and I had to force myself to put weight through the full foot, as I previously had inadvertently been putting weight on my outer foot. I didn't feel any pain while walking unless I went up on my tippy toes but I did feel a dull ache at the end of the day. I starting wearing padding again which has helped. I told Dr. Altchuler that I wanted to get an MRI, especially before any surgery. I have the CD and have taken a few images (the program doesn't have set images but instead I use a slider to change the image so I don't know if I'm using it correctly but I tried to screenshot images that appear most clear). I also just got the report today. I will try to scan tomorrow and sent it to you. I have an appointment with Dr. Altchuler tomorrow and will update you on what he thinks. 

MRI showing intense inflammation/bone edema in tibial sesamoid

I completely understand if you don't have time to review the attached images or the report I will send tomorrow, but I would greatly appreciate if you could share any thoughts you may have!!

Thank you so much!!

Dr Blake's comment: Thanks for sending me the views. Since I am not a surgeon, I am not sure about the planing procedure. The pain right now from the August MRI is the intense inflammation still present in the tibial sesamoid. It is trying to heal!!As you put weight down, that sesamoid pushes against the first metatarsal and gives pain. You have been in a boot long enough, but no Exogen. That could be a wonderful new chapter. You have to commit to a year of activity modification to continue the 0-2 level, 9 months of Exogen twice daily, icing and contrast bathes, orthotics with dancer's padding or just dancer's padding if the 0-2 pain level can be attained, repeat MRI in one year. You could get a CT scan to get a clearer view of the sesamoid for avascular necrosis, which could speed up the decision making. We need you to weight bear for mineralization, but not to crank up the pain. Hard, but doable. You were doing a great job on creating the healing environment. The bones can desensitize so doing surgery in the next year makes sense only if you are frustrated too much. No one would blame you, but I would just recommend taking the whole sesamoid out, and not risk not doing enough surgery. Again, I am not a surgeon. I am assuming you can do alot, and continue in a 0-2 pain level now, while adding the Exogen bone stimulator. With the hot MRI, you do not know if the sesamoid hurts because it is still partially fractured, or it is just very sensitive due to bone inflammation. I hope this makes sense. What are your thoughts and I will put them below? 

Neural Flossing or Gliding: Dr Blake's Video

Nerve pain in the foot goes right to the brain on a super highway called peripheral nerves and gives up the most significant pain a podiatrist will treat. Any time a patient says that they have level 6 pain or higher, I will always look for a nerve component to their pain. It is common for a podiatrist to treat nerve entrapments, Morton's or Joplin's neuromas, tarsal tunnel syndrome, but there are alot of chronic problems that develop a hypersensitivity from nerve overload that needs to be treated. Neural flossing is a wonderful part of any nerve treatment. Here my wife Pat demonstrates neural flossing, aka neural gliding, with several provocations. You are trying to get the nerve to break its pain cycle but gently stimulating it in some way. Warmth and painfree massage, acupuncture, transcutaneous nerve stimulation, Calmare, etc, and other ways to keep reset the nerves to generate less and hopefully no pain. 

https://youtu.be/g94F8g_jzGg

Nerve Innervation Foot: Great Review of Local Nerves and Low Back Innervation

Nerve pain, also called neuropathic, is one of three common causes of pain in the foot. This is a wonderful review of this innervation. Any pain can have one, two, or three causes: mechanical, inflammatory, and neuropathic. Each aspect can be simple or complex to treat or even recognize. So many of my patients start with mechanical pain (for example, the sesamoid hits the ground too hard in a work out), develop chronic inflammatory pain as the body unsuccessfully tries to heal it, and then nerve pain sets in making the pain intolerable as the body tries to protect itself. It does not take long for an injury to have all 3 types of pain going on, each needing its own treatment. For example, the same sore sesamoid bone may need mechanical off loading, a daily dose of ice and contrasts, and neural flossing, Neuro-Eze, gentle but deep massage to get at the nerve pain. 

https://youtu.be/cpOTXT_Zd0g

Rehabbing a Sesamoid Injury!! Some Great Thoughts!

Wonderful empowering video to help us stay very strong and still recover from a sesamoid injury. Thank you Caroline and Shawn. 

https://youtu.be/b6ZZ1Vb6dOY

Big toe joint pain: Email Advice

Dear Dr. Blake,

I'm a relatively new fan of your blog, and am grateful for all of the information you provide - it's a godsend!

I'm writing this email as I contrast-bathe my right foot (multi-tasking!). I'll cut to the chase with my question, and then provide details below: what is the timeframe for reducing the inflammation that causes hallux limitus - is it a matter of weeks, months, years?

Here's my case: I'm a 53 yo woman, in otherwise excellent health. I developed pain along with a big "bump" on top of my foot, just at the base of my right big toe - this was over several months (probably last fall into spring). Not sure how it started.

I finally saw a podiatrist May 31 2017. From the examination, and subsequent xrays, he diagnosed hallux limitus (the xray result reads: "Moderate MTP arthrosis of great toe is present. No malalignment can be seen. Findings would be suggestive of hallux limitus or hallux rigidus. No other specific abnormality of the right foot can be seen.") He told me to take 500mg ibuprofen 2x/day for 10 days to see if that would reduce the inflammation; I could continue that for an additional 10 days before returning to get a cortisone injection. He also suggested that I use warm moist heat for 20 minutes several times a day.

I did about 15 days of high dose ibuprofen, and in the meantime discovered your blog. I'm not keen on getting a cortisone injection, and long term use of ibuprofen at that level seemed unadvisable, so around mid-June I began to follow your "top ten" list for hallux limitus: I started contrast bathing religiously (at least once daily, sometimes 3x a day); I started applying Voltaren 2x a day; I spica taped; I got some dancer's pads (although this caused me discomfort in my ankle and made me limp, so I discontinued that); I only wear comfortable, flat, soft shoes; I do the joint mobilization gently every day; and in general my pain level is 0-2 most of the time (unless I do a lot of walking - but if I soak my foot in an ice bath right after that brings the pain right down again).

It's been about 6 weeks of this regime, and while my pain level is way down, I still have a big old bump on top of my foot, and I still have very limited ROM (I can point my toe, but not flex it back).

How long can/should it take for the inflammation to start to subside?

Dr Blake's comment: Sounds like you have done a fine job with the inflammation. If you have the 0-2 pain level, you can gradually increase activities, but try to avoid excessive toe bend for the next 6 months. You may have entered a new phase of the hallux limitus and your joint will be somewhat more restricted. You can walk up tall mountains without bending that toe. Get some 1/4 inch adhesive felt from www.mooremedical.com. Use it to place a small pad behind the bump, and relace some shoes so there is minimal pressure on the bump. You can thin the 1/4 in half and make better dancer's padding. My blog is full of examples for this stuff. If we take the pressure away from the bump, and avoid excessive toe bending, and you ice massage the bump area twice a day for 5 minutes, we have to see what you can and can not do and still keep in the 0-2 pain level.

And: at what point might I want to go back and accept the offer of the cortisone injection (if at all)?

Dr Blake's comment: I would do a cortisone shot if the MRI shows no bone edema. It rarely shows that, so cortisone is rarely given. Your icing, voltaren patches, activity modification, shoe adjustments with cortisone masking the pain will be done better. We will make decisions better with a cortisone shot working. The cortisone is temporary if there is joint damage. If the joint got all jammed up, and there is no damage, the cortisone may be a miracle to get the joint in better shape. Basically, we do not know enough.

What signs of healing can I look for? And what might be signs that I should return to the dr for a re-diagnosis?

Dr Blake's comment: Consider an MRI to know what we are dealing with. Based on the MRI, which is usually the first of a few over the next year, we can really appreciate healing. With no MRI, we can still go by accomplishments, or benchmarks. Each month you should be able to do more. If not, the joint needs to be re-assessed. What could you do, and at what pain level, May first, then June first, then July, August, Sept. Are we reaching a plateau? Are we making steady progress? Do we have to make changes to get us back to 0-2? Is my activities improving? This is where the doc or PT can help move you along. Sure hopes this helps. Rich

I'm willing and ready to do rehab for a long haul, I just want to have a better sense of what I'm in for, and when/whether I should go back for additional medical intervention. (Esp since my podiatrist gave me the impression that 10 days on ibuprofen might do the trick...)

Thank you!

Hallux Limitus/Rigidus: Email Advice

Hi Doctor Blake,

I'm  desperate to find some pain relief for my big toes and your website offered such excellent advice to others I'd thought I'd seek your advice. I work in the movement field as a Pilates instructor and it's been devastating to be hobbled like this. I'm assuming I have hallux limitus since I have lost a lot of range of motion in my big toes in the last 2 years although if I think back, my feet started showing signs of what I though were bunions at least 5 years ago or more.When that happened I started wearing toe spacers religiously and trying to strengthen my big toe abductors. That didn't stop the progression of what was to come.

2 years ago both big toes suddenly seized up and were unable to extend at all! I have no idea what set this off-perhaps the fact I was doing a lot of walking in minimalist shoes at the time (which I tried because all my old shoes such as Keens were hurting my feet and only the flexible minimalist soles were comfortable! ) Maybe because I was doing a lot of exercises  kneeling on my shins with my toes tucked under (I can't even imagine doing that now!)  

I had to wear closed Birkenstock clogs to even walk to the subway when the toes first seized up. I used to walk easily 2 hours  a day to get to work and back. And suddenly I could barely walk-when this first started I even had to wear Birkenstock sandals indoors but since then luckily I can walk indoors in bare feet with small steps. The pain is both with toe extension at push off in walking (a tiny bit of pain in passive extension but not much)  but there is also a feeling like I'm walking over a hard lump on the bottom of the ball of the big toe. In fact at first I thought I had done something to my sesamoids.

I recently was so desperate that I even bought expensive Finn rocker shoes and those don't seem to help-I can still feel the right big  toe at pushoff.  I've bought an infrared light to reduce the inflammation, take Epsom salt baths which help somewhat, I pull gently on the big toes with the movements you've shown in one of your videos, and I take the toe passively through extension (which oddly doesn't hurt-it's painful mainly in weight bearing). All in all, a full time job. 

I also suspect that the way I walk has exasperated or even caused this issue since I walk with my big toe extensors being excessively active and I always poked holes in the tops of my shoes with my toes. I am willing to come to see you if necessary despite the travel.  If you have any advice I'd be so grateful since this has affected my quality of life. I fear this condition will only get worse so will do whatever it takes to improve it.

I'm including some recent xrays:

Right foot showing signs of big toe joint arthritis with spurring

Both feet showing top of the big toe joint spurring and right side sesamoid irregularity

Finding:
BOTH FEET:
INDICATION: Pain
Moderate to severe osteoarthritis of the first MTP joints is demonstrated bilaterally. No soft tissue calcification present.
IMPRESSION: Osteoarthritis.
DICTATED BUT NOT READ

Dr Blake's response: Thank you so very much for emailing. The right foot looks more painful, is it not? At least, the right side has less motion, or does it? Here is a link to my basic post on hallux limitus treatment. 

http://www.drblakeshealingsole.com/2014/12/hallux-limitusrigidus-top-10-initial.html

This is one of the original blog posts in 2014 that may help. 

  Hallux Rigidus means severe wear and tear on the big toe joint. The cartilage is tired, beat-up, and aggravated. The normal motion of the joint is significantly restricted, so attempts to move the joint normally can produce mild to severe pain. There is a lesser version of this called Hallux Limitus, which has significantly more motion, and a different treatment protocol.

     Hallux Rigidus develops over many years, with sometimes smoldering pain episodes, and may never really bother the patient. The joint is actually self-fusing, and getting less vulnerable. I had a great runner as a patient once that was having smoldering symptoms with severe advanced Hallux Rigidus. Luckily he ignored the surgeons, following simple conservative advice, and then proceeded to set a Guiness World Record for 6 marathons in 6 months all under 2 hours and 20 minutes!!

     But, some patients with Hallux Rigidus are not so charmed. They do something, quite ordinary usually, that develops moderate to severe pain. And they have trouble turning off that pain with self methods, x rays taken by the first doctor show the severe arthritis, and surgery is recommended. I maintain that Hallux Rigidus should be treated as a sore joint and nothing else. How do you get a sore joint calmed down? Usually, immobilization to rest the joint, shoes and orthotic devices to limit the big toe joint motion, taping to limit the toe motion, and then pile on the anti-inflammatory measures---icing, contrasts, meds, physical therapy, flector patches, topicals, accupuncture, and injections.

     The treatment of Hallux Rigidus is then divided into 2 columns--immobilization and anti-inflammatory. I challenge the doctors, physical therapists, and other health care providers to do all you can to calm the joint down and get it comfortable, even if this means 3 months in a removable cast (last resort). Once the joint is calmed down, and pain is gone, gradually increase activities pain free. See what it takes to stay pain free. See if there is any disability the patient does not want to live with, that you can guarantee with reasonable degree, would be removed if you did surgery.

     Let us say that you get the joint calmed down, but every time you try to run, the joint flares up. And you want to run, too young to give it up and you are willing to consider surgery. Xrays will show a bad joint with many bone spurs. There is no good surgery with Hallux Rigidus, so if I needed it, I would follow the KISS principle (see separate post). I follow the same thought process as with knees--cleanup with meniscus tears, more cleanup, a third cleanout when needed, a parital knee replacement when needed, and a total knee replacement when needed, and hopefully every surgery is the last surgery. So, with Hallux Rigidus, I recommend a joint cleanout (called arthroplasty or cheilectomy--try pronouncing those), perhaps another joint cleanout, a total replacement, another total replacement, and then a lot of deep thought before joint fusion is considered. Golden Rule of Foot: With Hallux Rigidus, Joint Fusion should be the last resort. 

So, if we make you a checklist for right now:

1. You need to create that 0-2 pain level by removable boot, hike and bike shoe, Hoka One One with orthotic/dancer's padding/spica taping and some daily anti-inflammatory measures.
2. This is so devastating that getting an MRI at least on the worst side, and you could send me a copy. 
3. Find out if you have any bone issues (get bone density test and Vit D blood level).

Hope this gets us started!! Rich

Sever's Disease: No Difference Noted in Various Treatments

If your son or daughter gets heel pain, nagging or very acute, between ages of 8 and 14, they may have an irritation of their growth plate. This is called Sever's disease or calcaneal apophysitis. The article documents that you can use physical therapy, orthotics, or a just wait and see attitude, and they probably will get better. But why not do it all? Find an insert that transfers the weight to the arch, home physical therapy with ice baths 20 minutes twice a day, formal physical therapy with electro-galvanic stimulation to ease the bone swelling, and some activity modification to not continue injuring it. Non-painful stretching of the achilles is also great 3-4 times a day. 

http://journals.lww.com/pedorthopaedics/Citation/2016/03000/Treatment_of_Calcaneal_Apophysitis___Wait_and_See.8.aspx

Hip Abductor Strengthening: Active Range of Motion

Although active range of motion exercises are supposedly among the easiest form of exercises to do, being consistent with these one as you fight the invisible foe of gravity will be tough. You start with 2 sets of 5 and build to 2 sets of 15 per leg. I love to teach just moving the hip up about this high, too much and you can irritate the hip joint. You can experiment as you get good by doing short motions from this high in bringing the foot forward and backward to the other leg as a reference. Stop if there is any hip or back soreness. 

Secrets to Keep Moving: Correct timing

     We all have our secrets. But, we are obligated to let them out when others could benefit from them. This is where secrets and mere gossip separate. In my book entitled "Secrets to Keep Moving: A Guide from a Podiatrist", I try to spread some of the foot secrets out into the world. I feel that the truths spoken are only secrets because the new generation docs with high tech, short appointment times, etc, have removed anything that takes time, experimentation, low tech, apparently invented by someone old, and thrown it out the window. 

     One of the secrets we should talk about today, as I will try to weekly expand on these ideas, is timing. Yes, timing as meaning "what is the order of events that should happen for the patient to get better". This brings me to some of the Golden Rules of Foot of rehab. These would include: 

1. Create a pain-free (0-2 pain level) environment as soon as possible
2. Start some sort of strengthening exercises the day before you got hurt or very very soon
3. Weight bearing is so important for healing that there must be a great reason to non-weight bear
4. Always work on 2 causes of pain--the mechanics of the injury or getting well and the inflammatory pain
5. Always work on the 3rd cause of pain--neuropathic-- when there is nerve involvement or nerve symptoms. 
6. If the bottom of the foot is sore, try to off weight the area with padding.
7. Get xrays if the pain has been two weeks old, and someone thinks a fracture may have occurred
8. Get an MRI if the pain is over 2 months old, and not showing improvement.

I will continue going along these lines as the weeks progress. Please sign up to follow this blog and send questions to drblakeshealingsole@gmail.com. Thanks Rich

     

Sesamoid Injury: Email Advice

Hi Dr. Rich!  I am a forty year old family practice nurse writing to you from Texas, where it appears, like many of your readers, I have found myself with my very own sesamoid issue. I do not know how I injured myself, only that I developed extreme pain and swelling in my R foot mid June.

Dr Blake's note: This is 6 weeks ago for reference. 

 I am a runner, have high arches, and have run with zero arch support for years.  Unfortunately it was never an issue and I just didn’t know any better. I used to (insert sad face here) run outdoors, in the hill country, on concrete. My favorite road is VERY hilly, which I am sure all that uphill running contributed to my issues. As a side, about 3-4 days before the pain started, I was at the beach and played catch with a football for the very first time in my life with my daughter and was doing a lot of jumping up and down in the sand.

The pain started gradually for the first few days and then quickly became unbearable. I couldn’t sleep with a light blanket touching my foot, the air conditioner in my bedroom caused it to ache, and even to shower I would have to wear a sock on my foot so that the water running down by foot didn’t make the pain worse. The top of my foot, above my sesamoids, was swollen as were practically all of my toes. I saw one of the docs at my office who x-rayed it (she didn’t see any obvious fracture, and the radiologist read it as WNL)  and put me in a boot. I went to an ortho friend two days later for a second opinion who viewed my X-ray, diagnosed a R tibial sesamoid fracture, and sent me to his friend who is a foot/ankle surgeon. He concurred, told me to wear the boot, and see him back in three weeks. Lastly, there is a podiatrist who has an office directly next door to mine who I went to, he x-rayed both feet, where i was found to have a bipartite sesamoid in my R foot only. Even so, he did not think it was fractured but that it was sesamoiditis and suggested I stay in the boot. He wanted to give me a shot of cortisone at that time but I declined, unsure if it was fractured.

Dr Blake's comment: You are doing all the right things, and especially avoiding the cortisone when a fracture has not been ruled out. 

 I called the foot surgeon’s nurse and asked about an MRI, and that was ordered. The report reads:

1. Bipartite versus transverse fracture of the tibial sided hallux sesamoid with very mild edema/inflammation within the bone and mild adjacent deep soft tissue inflammation.

2. Intact adjacent plantar plates and intact adjacent lateral sesamoid.

Dr Blake's comment: When I read that report, based on your symptoms, it sounds like a bruised sesamoid, no fracture, since mild edema suggests stress not break, and a RSD type flare that was so violent. 

I stayed in the boot for four weeks and went back to the foot surgeon, who gave me an order for a carbon fiber shoe insert with a sesamoid cut out. He directed me to try to wean myself out of the boot and into shoes gradually, and to let pain be my guide. I wasn’t thrilled with him ( I had found your blog by this point and felt he wasn’t steering me in the right direction) so last week I found a sports medicine podiatrist, at your recommendation someone who was a member of the AAPSM. I went to see him, he reviewed my MRI, and told me he didn’t think it was fractured either, and he ordered an ultrasound guided cortisone shot. I have the order for that still but have not done it yet, again unsure if the steroid is going to help or hinder my situation. I was upfront with him and told him my concerns and that I was unsure if I would be getting it. 

Dr Blake's comment: So, what is happening? 6 weeks have passed and is the pain between 0-2 in the boot on average? I agree with your decision on the shot still, sesamoiditis does not give you this reaction. 

At this point I feel like hitting my head against a wall. I am so frustrated and tired of dealing with this. I have been taking ibuprofen PRN since this whole thing started, initially 800mg TID, and have weaned myself down to two a day, and finally six days ago i stopped taking it. 

Early on I bought a pair of Hoka Bondi tennis shoes and have been wearing them on my left foot while wearing the boot. At that time I also bought some Hoka slides (a godsend!!!) and wear those to shower in or to get out of bed at night. I haven’t walked barefoot in almost two months. A week ago (after six weeks in boot) i was at a 0 pain level with no pain meds so I spent four days that I didn’t have to work in my Hoka slides 100%. I didn’t have any pain.

Dr Blake's comment: Great, but if this is sesamoiditis, with or without sympathetic over load, we still have to protect it in orthotics and dancer's padding, etc. That becomes the goal during the last 2-4 weeks of a cast, get something that will protect the sesamoid, so we can wean out of the boot. It is wonderful however about the slides. I have not actually seen them. So thank you for telling me. 

 At that time I also started doing my own PT in my pool, just lying on a float and kicking different strokes to move my foot. I started doing contrast baths along with the frequent icing i’d been doing about a week ago as well. I went back to work three days ago, and have spent the past three days in the R and L Bondi! I took the insert out of the Hoka, and cut out the section to offload/float the sesamoid. I was so happy and excited to be able to put my foot in a shoe, and walk without pain.

Dr Blake's comment: I think I know where this is going, and I try not to read ahead, funny me, but it is much safer if you have been in a boot for awhile, and you have created the 0-2 pain level, that you have to gradually wean out of the boot into shoes over a minimum 2 week, and sometimes up to 6 week period. 

 I worked for nine hours on my feet the first day (I average 3-4 miles a day at work), then 7-8 yesterday and 4-5 today. My foot has been becoming increasingly more uncomfortable each day, not painful but uncomfortable. After nine hours, I took my shoe off and my foot/toes were very swollen from mid foot down. Prior to that I hadn’t had any major swelling in weeks. I am walking in my Hokas my find that i’ve forgotten how to walk normal. My patients ask me why I’m limping. I’m paying careful attention while I walk and trying so hard to walk like I used to, but find my self over pronating on my bad foot. When I don’t i do have slight/minimal pain from the sesamoid. The only other thing I can think of that may be important to mention is the decreased ROM in my big toe. I feel like it’s becoming stuck, actually started noticing that a few weeks ago so have made it a point to keep working it. 

Dr Blake's comment: So, you have to go back in the boot until this feels fine again at least for 5 straight days, and then you have to go slower weaning out of the boot. It is common with a joint problem that was held in a boot for a while to get stiff. You definitely have some RSD symptoms, not full blown, which I call vaso motor insufficiency. You get an over reaction of the sympathetic nervous system, and the area swells so much easier. I had it in my leg after a herniated disc and needed a sympathetic block to clear it. Do contrast bathes, neural flossing, get some Neuro-Eze for 3 times daily massage. 

I really don’t know where to go from here. I would love to go to San Francisco to see you but can’t do the 12 days I read you suggested. I would love it if you could look at my MRI and please guide me where to go from here. I honestly don’t trust anyone’s opinion but yours, as crazy as that may sound. 

Dr Blake's comment: You are kind, and I am touched. I would be happy to review your MRI for sure. Send the disc to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. But, reset the boot routine, get well again, and begin to wean slower. See a pain specialist for mild CRPS symptoms to see if you should be doing something else. I hope this helps. 

Thank you for your time,