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Wednesday, March 21, 2018

Sesamoiditis: Email Advice

Hello,

I wanted to share some info on my foot injury and get some get feedback.

In the summer of 2017, I was walking at work, in my steel toe metatarsal boots, and I felt a nerve-type feeling in my right foot.  It was as I rolled my foot up and pressure from my boots was applied to the back side of the ball my big toe.  The nerve feeling seemed to go back toward my arch.  I repeated this a number of times once I first felt it.  The boots I was wearing were fairly tight and narrow on my feet and I had worn them for 6-7 months without any pain until that one step where I triggered something.  I immediately got new boots that were much roomier, the back side of the ball of my big toe began to hurt when I rolled up my foot while walking and pressure applied.  The pain wasn't severe, and I figured it would go away on its own.

In November 2017, it got worse.  I believe this was from wearing tight boots while walking outside in the woods.  The arch of my foot experienced a lot of pain, I had trouble placing weight on the bottom of the ball of my big toe, and the pain was starting to go into my big toe.

I went to a podiatrist at the end of November, was diagnosed with sesamoiditis.  The doctor checked for range of motion, pushed on the sesamoids, but could not replicate the pain and there was no stiffness in the big toe joint.  I then was given a prescribed anti-inflammatory, was told to offload the area and received custom orthotics. I also had an x-ray and MRI, which didn't reveal anything alarming.  After taking the anti-inflammatory, the pain under my big toe went away and I stretch the arch of my foot in the morning for a few days and the pain went away.  The pain in my big toe also went away.  After returning for my follow up visit on December 22, I was basically released.
Dr. Blake's comment: Good drug!!

Then, a few days later, I wore my tight boots in the front of my yard for 10 minutes, and the back side of the ball of my big toe became very painful.  For the next 3 weeks, I experienced a lot of pain.  I hurt to walk up and down stairs.  The first few steps I would take after sitting for an hour.  Very soft surfaces (like gymnastics mats for my daughter, of very soft running shoes) would hurt more than walking barefoot.  I had a lot of tenderness on the backside of the ball of the big toe, and it would not tolerate much pressure.

In the middle of January 2018, I decided to call a foot and ankle orthopedic surgeon but had to wait over 3 weeks to get in.  During this time, I went to work and tried not to aggravate my foot.  And, in the evenings at home, I elevated my foot and iced.  By the time I got into the orthopedic surgeon, I felt a little better.  The tenderness went away and was able to walk around in my orthotics place in running shoes with minimal pain.  But, my steel toe boots at work still hurt my foot.

When I saw the surgeon, they also diagnosed me with sesamoiditis. The doctor showed me on the MRI where my sesamoid was inflamed.  They also pushed all over my foot, but could not generate pain.  They placed me in a walking boot for 5 weeks and gave me a prescription for the anti-inflammatory.  And, another MRI and cortisone shot are the next steps.

After 12 days in the boot, I not sure if I'm making any improvement.  I experience burning feeling and dull aches when I'm sitting around, or in the middle of the night when I'm sleeping.  And, I'll get a sudden pain if I lean/turn a certain way.  And, these pain are on the back side of the ball of my big toe.  Toward the outer side.  And, a couple times, I put on my shoe just for a few steps (to put gas in the car), and there is a lot of pain in the tendon as wraps from the back toward the bottom of the ball of the big toe.  But, that slowly went away as I was standing and took a few more steps.

My questions are:

Do you feel the doctors are on the right path with the diagnosis? Dr. Blake's comment: First of all, I am sorry for my delay in corresponding. I am having trouble shaking this cold/flu bug completely since Thanksgiving. I think the doctors are doing okay. They have ordered the right tests. You have some inflammation, some nerve irritability, some tension in the tendons in the area. You have to figure out how to not trigger this for the next 6 months: looser shoes, 100% wearing of orthotics with dancer's padding, icing for 10 minutes twice daily, every other day a full contrast bath. Perhaps the walking boot for the next several months when you are not working to relax the tissue. 

Are these treatment correct for the injury?
Dr. Blake's comment: The treatment of sesamoiditis is threefold: mechanical support to off weight, anti-inflammatory to cool the itis down, and neuropathic when the nerves are too irritable (wide shoes since nerve hate tightness, pain-free massage into the tissues to tell the brain that everything is fine, etc)

Is there anything I can be doing to help with recovering?
Dr. Blake's comment: Look back on all the times you irritated it, and try to not do that for 3 months. And, at the same time, constantly attack the inflammation and relax the nerves. Stay away from long-acting cortisone which can delay healing and mask pain. I am never sure 100% when the bone is inflamed and when it is has a stress fracture. I think they look the same on MRI. The first is a bruise, and off-weighting mechanically should solve. The second being a type of fracture may need more Vit D screening, bone density workup, even an Exogen bone stim. Try the Hoka One One shoes to see if they help you. You put your orthotics in the shoes and walk around the store. Good luck. Tell me if you still have questions or other comments. Rich


Thank you

The Patient's response: 

Thank you for the response.

I came out of the boot a few days ago.  Things are going a little better.  The nerves are calling down, but the tendons on the back and outer side of the tibial sesamoid seem inflamed but do not hurt to the touch.  The sesamoid bone doesn't hurt either, even if I take a couple steps on it.

I was recently given a topical anti-inflammatory, which seems to take the edge away.  I'm also using a graphite insert with cut out plastazote padding to unload the sesamoid.  It's almost like the boot.  My PCP suggested this, along with rolling my foot on a frozen water bottle at night to stretch the tendons and cool the tissue. 

I've tried the contrast bath, but it seemed to inflame the tendon on the outer side of the ball of my big toe.  Even just soaking in warm water does the same thing. Dr. Blake: So, just stick to ice. Definitely, pure anti-inflammatory measures help.

The orthopedic surgeon said the next step is injections, then a removal of the bone.  Which I obviously don't want to go that route, and don't even want to do injections.

This is the most frustrating injury I've ever experienced.  From what I've read on your blog, this can take a long time to heal.
Dr. Blake's comment: Yes, please send me the CD or images via WeTransfer if you would like for another look. Keep figuring out how not to overload the next 6 months, while reducing the inflammation and reducing the nerve irritability. You are going in the right direction. Time tables are tough, but benchmarks are important. What you can do in April should be more than March, and on and on. Rich

Thanks

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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.