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Thursday, July 19, 2018

Sesamoid Injury: Email Advice

Hi Dr. Blake,

     I woke up to a swollen and painful foot in the big toe junction area at the end of February this year. Got misdiagnosed at an ortho as gout, then a strain, then a sprain as my blood work was clear of autoimmune signs and PT for the strain/sprain was helping, but slowly and then progress would recede. 

     Second opinion sought after an MRI I demanded revealed sesamoiditis and it was recommended I try to take it easy. An experienced podiatrist took X-rays and found a fractured lateral sesamoid, and indications of tendon tears in the area. Proceeded with red laser therapy weekly, non-weight-bearing and a dancers pad. Pain level kept lowering. 

     5 weeks ago 2nd ultrasound showed no change in the amount of swelling. Was placed in a cam walker boot. I feel this helps walking, but can be painful when sitting or laying. This boot was an attempt to stabilize my forefoot (high arches, flexible forefoot). Swelling is an issue bc I seem to have the family Raynaud's Syndrome. Every time I try to ice, even for just a few moments I  experience incredible pain. Even tried going 10 seconds and then into warm water for 30. 

     I just want to make sure we aren’t missing something in our diagnosis/treatment. And the swelling greatly concerns me. I’ve been doing self-massage to try to get the swelling down daily and taking a load of turmeric as the prescription anti-inflammatory was having adverse effects on my digestive tract after 1.5 months. Also had tried a steroid pack at week three with the ortho doctor. Had no effect but I was still on my feet. 

     Your input would be GREATLY appreciated!!!

Dr. Blake's comment: Sorry for the long road, but it sounds like you are finally in the Immobilization phase of rehabilitation (Phase 1) to allow this to heal. Typically strains do not cause swelling, so I am going to discount that diagnosis. A sprain would be related to a fall, trip, stumble, so what brought this on? If you did not have an acute incident that could have sprained the tissue, I am assuming that is also incorrect. Sesamoiditis vs stress reaction vs stress fracture of one of the sesamoids is the highest possibility and they all look essentially the same on MRI, and you have to treat them the same. A fractured sesamoid looks a lot different. These injuries are caused by walking too much, dancing too much, etc, especially if the winter brought some silent Vitamin D deficiency. With this type of injury, you go into a removable boot/cam walker and get the pain to 0-2 as quickly as you can. You can walk for bone mineralization with these injuries. Sometimes you have to stay in the boot 3-4 months, but other times you can wean into a Hoka One One shoe or Chrome Bike shoe (or something similar) with the embedded cleat even after one month. All based on achieving the 0-2 pain level consistently. 
     If you go to YouTube and type drblakeshealingsole sesamoid in the search area, you should come to all my videos on sesamoid injuries. The typical treatment has to include: contrast bathing (important for the painful swelling trapped in the sesamoid), dancer's padding and cluffy wedges (important to off weight the sesamoid slightly), an Exogen bone stimulator if it is actually broken (fractured), and non-painful massage and range of motion for nerve hypersensitivity. You can use lukewarm water with Epsom salts for 30 minutes with toe range of motion for the circulation because of the Raynaud's instead of the contrast bathing. Look at google for foods that produce inflammation, like peppers. Consider physical therapy to strengthen your foot and as an anti-inflammatory measure with all their wonderful equipment. See my post on making a sesamoid well for doing protected weight-bearing exercises like single leg balancing or achilles stretching without putting too much pressure on the sesamoids themselves. I hope this helps. Rich



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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.