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Sunday, June 17, 2018

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I came across your blog while researching fractured sesamoids. Thanks for all the great information! I wanted to tell you about my experience and see if you had any additional insights int my condition or thoughts about my treatment thus far.   

I’m a 45 year old male and fairly active. I woke up in March with some pain and discomfort in my big toe. I wasn’t paying very close attention to it but my impression at the time was that I thought I had slept on it funny, maybe did something like hyperextend it in my sleep or slept with it bent back for a length of time that caused me to wake up sore. It wasn’t incredibly painful though, so I didn’t think too much of it. In fact, I sort of figured the best thing to do was to work and stretch the toe as I normally would. That day I did the orbital machine at the gym as well as some shadow boxing and weightlifting, all of which put pressure on the toe.
Dr. Blake's comment: In some ways, this is a good sign. You did something in the presiding 3-4 days that the big toe did not like, but it took several awhile for the swelling to collect enough for it to hurt when you got up. The morning is the classic time to hurt since all night long when you are still, the swelling from an injury has time to settle into the tissues. The pain is for the inflammatory part of the pain. The injury happened without you noticing it a lot, so maybe a good sign!!?? Can you think back to these 3-4 days? Did anything stress the joint out of ordinary? 

I went to bed that night and maybe an hour or two after I fell asleep, I was awoken by excruciating pain. Throbbing, sensitivity etc.. I took some anti-inflammatories and iced it but could barely sleep. I hobbled to work the next day and taped my toe to restrict the movement of the joint for, what seemed to me, maybe some sort of turf toe but I did not see a doctor at that time. The taping helped and the pain subsided over the next few weeks. I was able to do yoga and box and was in a little discomfort but not bad pain.
Dr. Blake's comment: Again, good sign!! Most joint flares, if arthritic, occur over 4 days to 2 weeks if you are treating the flare-ups. They can last longer if you choose to ignore or to select inadequate treatments. We do not know what you did, but this pain is still inflammatory and not the injury itself. Inflammation is the response of the body to heal. You are trying to heal something? Perhaps it is gout or arthritis? Have you had recent uric acid levels? 

Maybe 5 or 6 weeks after that episode ( after 2 long intense bike rides which definitely put pressure on the toe and another intense workout) the toe pain came back and I was again having trouble walking. At this point, I found a podiatrist and went in for an appointment.
He took an X-ray which didn’t show anything and said his hunch was that it was gout, but that he would send me for both a blood test and an MRI. I also was given a 5 or 6-day pack of prednisone anti-inflammatory steroid.
Dr. Blake's comment: The thought was good. You do not want to take prednisone, even NSAIDs if you are suspicious for bone injury. Do not make this your way of handling bone/joint injuries in the future. 

The steroid cleared the pain up very quickly. I was hopping around barefoot and everything seemed good. The blood test came back before I could schedule an MRI and the uric acid read 8.1 which all seemed to point to a gout attack.
Dr. Blake's comment: First, do you know what the range is of normal for this lab. Please send. Gout attacks can occur with high uric acid when trauma occurs. So, just because there was a possible gout attack, you still could have a stress fracture that caused inflammation that sparked the gout attack. A twofer!!

When the course of prednisone was over, the pain came back with a little swelling. I was then able to get the MRI, which showed a comminuted fracture on the medial sesamoid. 
My podiatrist put me in a darco low top shoe with a few cutouts to isolate the sesamoid and told me I’d be in that shoe for 4 weeks. From everything I read that seemed optimistic and sure enough, I'm at the 5-week mark now and after an appointment yesterday, the doctor suggested 2 more weeks based on the fact that the area was sensitive to the touch yesterday. He says that progress is really just based on clinical diagnosis of comfort. The problem with that is, the more I try to give the area with attention, massaging and movement, the more sensitive it is after. 
Dr. Blake's comment: Here I will comment on the some of the images you sent me. First of all, when you use Prednisone, you should ice for 10 minutes three times a day after for the next 2 weeks. This helps to make the effects of the Prednisone last longer. 

Noting the inflammation in the first metatarsal above the sesamoid

When you push down, the sesamoid can push up against the first metatarsal causing injury. The arrow points to the darkened or inflamed first met head. This is a stress reaction, bone bruise, or stress fracture of the first metatarsal head. The stress fracture can actually heal much faster than the others!!

This image shows that the bone edema of the first metatarsal head is the most significant injury, not the sesamoid. 

This is not a fracture, but a bipartite sesamoid with a smaller piece nearest the toe. It looks a little inflamed in this view. What is also interesting to me is that the joint is not really inflamed. Gout usually shows intense inflammation, another reason to get the MRI when things are still inflamed (not being drugged up!!)

I wear the darco shoe whenever I’m outside but mainly I’m trying to stay off my feet and not walk a lot as the darco alters my gait enough that it’s uncomfortable for other parts of my feet, knees, etc...
Dr. Blake's comment: As long as you have something with a dancer's pad to off weight the sesamoid area, various the stresses with stiff soled mountain bike shoes, anklizer removable boots, Hoka One One shoes, stiff hiking boots. You must maintain the pain at 0-2. You should spica tape and cluffy wedge. You should get an Exogen bone stimulator for the next 9 months for the first metatarsal, not the sesamoid.

I still go to the gym but am doing the stationary bike in a way that puts no pressure on the upper foot or other exercises that do not involve the foot. When I'm home I’m barefoot but I walk on my heel and side of my foot and don't ever let the sesamoid hit the ground. 
I also got an exogen bone stim and am using that twice a day along with calcium supplements. 
Dr. Blake's comment: At home, try the Oofos sandals as house slippers. Hopefully, you can put down more normal weight. It is okay to put a dancer's pad in the oofos. Get your Vit D levels. Any osteoporosis run in the family? Bone health may be the issue in any bone injury. Consider a bone density screen if your diet is irregular, or chronically low Vitamin D, etc. 

I am trying to massage the area a bit and introduce a little motion to the joint but the times give done that, there is pain and more swelling the next day. My thought is that it should be ok to bend the big toe down but that I should not flex it up as that would pull the tendon tighter against the healing bone. Is that right? Yes

I’ve read about people in casts and much more restrictive boots for a fractured sesamoid. Is the darco shoe not conservative enough? I will say that I do not put pressure on the sesamoid nor do I flex the big toe when I’m walking. 
Dr. Blake's comment: You have to do whatever to create the most normal gait with a 0-2 pain level. I love also having three possibilities for shoe gear to alternate because you never really know if something is working if you are only trying one. See my comments above. The bike shoes and anklizer are both about $50 each (if you look around). 

Any insight or suggestions you have would be really appreciated! I'm a little unsure of my podiatrist's ability to provide nuanced advice based on what I’ve experienced thus far and if I don't get this healed properly I won't be able to work. I’m also unsure of his approach in taking additional x rays to monitor progress when an x-ray did not find the fracture in the first place.
Dr. Blake's comment: Definitely, you can go on symptoms, and then repeat the MRI if needed in 6 months. Hopefully, you do not need to. Follow up xrays could be taken once, and if it shows no change, it verifies that it is not the sesamoid. Also, if your symptoms keep flaring, consider the CT Scan which just looks at the bone to see if the bone injury is subtle or more involved. However, if it shows a change, then the sesamoid is more involved. Good luck. Rich

thanks a lot

I'm attaching some frames form the MRI as well as the report form that MRI:

"There is nondisplaced probably comminuted fracture involving the medial sesamoid with associated diffuse bone marrow edema within the and focal edema within the articulating plantar metatarsal head. There is trace focal edema within the plantar aspect of the lateral/!fibular sesamoid. The intersesamoid ligament and bilateral sesamoid phalangeal ligaments are intact. There are thickening and heterogeneity with a linear increased T2 signal at the origin of the medial collateral ligament (series 6, image 11). The joint spaces and alignment are maintained. The articular surfaces are intact. There is no aggressive osseous destruction. There is no joint effusion or synovitis. 
Tendons: The visualized extensor/#exor tendons and ligaments are intact. 
Miscellaneous: Ill-de!ned soft tissue like signal intensity within the second intermetatarsal web space possibly represent small neuroma. Plantar plates are intact. There is no abnormal signal in the musculature to suggest atrophy or denervation. The subcutaneous tissues are unremarkable. "

Dr. Blake's initial response:
     Thanks for reaching out. I will work on my comments over the next several days. I would definitely get a CT scan since the bottom of the first metatarsal looks injured above the sesamoid. Rich

The Patient's Response: 
Hi Dr Blake,

Thanks for the response on your blog. Here are my responses to your questions :

I can't recall anything specific that I did to the toe in the days immediately before the first symptoms but I suspect that I sometimes exert a lot of pressure on that toe area when I ride a bike so perhaps that is related. I had definitely ridden that week. I will be mindful of my technique in the future and perhaps get different shoes for riding.  

I do have a history of low vitamin D and had taken extra vitamin D in the past but not faithfully. in 2016 my vitamin D was 22.6 when normal range was described as 30-100. Clearly, a possible culprit here and I wish my primary physician had described the risks of low vitamin D. There is no history of osteoporosis that I know of. 
Dr. Blake's comment: This is such an epidemic, and at your age of 45, I would get the Vitamin D level, and a bone density test. These can change the course of treatment if abnormal. 

I think my podiatrist gave me prednisone because his initial thought was that it was gout. It seems like it was either was not gout or it was a secondary ( first time) gout attack brought on by the bone injury. The lab says that uric acid levels up to 8.5 falls in the normal range but elsewhere I've read that one should really keep them below 8.0. Mine was 8.1 at that time. The MRI was done about 11 days after my initial visit and 6  days after the prednisone schedule was over ( also about 7 weeks after the initial pain) and I was walking with some, but not major pain at that point. 
Dr. Blake's comment: In gout attacks, which can be brought on by trauma like breaking a bone, the uric acid levels in your bloodstream drop over 1 point. So, if you were 8.1 in a gout attack, you were really running at 9.1 to 9.6. The key now is to retake the uric acid one month later and see what is happening. If you are still 8.1 then you just run high, but if you are 8.7 or higher another gout attack is in the making. 

I realized I probably have a bipartite sesamoid but are you saying you don't see any fracture in the sesamoid?
Dr. Blake's comment: From the views I see, there is evidence of bipartite, not fracture, although the bone is bruised. The main bone problem is in the first metatarsal head, and it treated the same as a broken sesamoid. It is the sesamoid pushing on the metatarsal that causes pain. This will take a while to heal. 

Here the tibial sesamoid lights up on T2 imaging meaning it is bruised. This is not the intensity of bone inflammation you typically see in a stress fracture. The uniqueness of this situation is the bone edema in the first metatarsal head signifying arthritis or stress fracture. The sesamoid pushes up right on the inflamed first metatarsal.

I've been slightly altering where I line up the Exogen bone stimulator. Sometimes under the sesamoid pointing up and sometimes more on the side pointing toward the joint. Is there a specific place you’d recommend to address the metatarsal?
Dr. Blake's comment: Since it has a 3 inch penetration, you can place on top of the metatarsal head and then walk around and multi-task. But, where you are putting it (bottom or side) is closer and either are fine. 

How do I know when I can start flexing the toe and pronating again? I dont want to inhibit the healing process or cause any further damage but am anxious to get everything working again in a way that wont make it worse. How will I know when I can put normal weight on the sesamoid without a pad? 
Dr. Blake's comment: This is the typical rehab question for any injury as we increase activity. It is important to make one change at a time, and probably one month apart is safe. Most athletes with this stay with the mechanical supports well into their athletes, and when they have leveled out the activity, start lessening the things that helped them get there. With sesamoid injuries, you can have cluffy wedges, spica taping, rocker shoes, orthotic devices, dancer's pads, etc. You have to stop one at a time in a logical order when you are doing all your activities and feel you are healed. 

I think/hope I am almost ready to segue out of the darco boot but how will I know for sure? I had bought some hoka one one bondis last week so I will start with them with a dancers pad. 
Dr. Blake's comment: This is how us rehab people find out what people need to move forward. What does it take to achieve a 0-2 pain level while we move the patient back towards a normal existence? If I had 100 patients at one time with the same injury, they would all be slightly different in their needs. There are general rules, but each individual has to be individualized. 

I went to the gym a few days ago and made a sesamoid relief platform so that I could work on my balance and address atrophy in other areas of my foot. It felt great and contrast baths helped with the swelling afterwards.

Below are the pics of the ( very simple) workout platform and some additional MRI images just in case they show anything additional.

Thanks again!

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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.