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Thursday, August 3, 2017

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,

1 comment:

  1. Dr. Blake, I have a quick question for you. I have read through all of your sesamoid entries but have not read one that includes the symptoms i am experiencing (so hoping you could possibly provide some insight)

    I believe i am mostly recovered from a medial sesamoid fracture (it's been about 9 weeks). My pain is limited to the immediate area between my first & second metatarsals. This pain radiates through the big toe and down through the soft tissue area beneath the toes. It is a throbbing pain and sometimes burns. I also have a very specific sensation in this soft tissue area (in the soft tissues under the first and second metatarsal) that is very nervey and radiates electric tingling if i step a certain way or press on it in the right direction.

    I am finishing up a course of methylpredisolone but this isn't helping.

    Do you think this pain i am having is referred pain and possibly another acquired injury (i.e. torn ligament or nerve issue) or is this simple swelling?

    I would think the oral steroid would help but it has not and i am not sure where to turn next!

    Thank you in advance for your time!


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.