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Thursday, August 9, 2018

Sesamoid Injury Healing and Some Prolonged Sensitivity: Email Correspondance

Dear Dr. Blake,

I hope you have enjoyed the summer! I believe I am writing to you for the fourth time now in about three years. I know you must be very busy and getting a lot of emails so I would be extremely grateful for even a very short reply from you. I am writing again because I still have some issues with my left foot after injuring both my feet in July 2015, and I have not been able to find anyone in my country with your knowledge on difficult foot injuries.

I do have some very good news also! My right foot, which had injured sesamoids, some cartilage breakdown and lots of edema in the metatarsal head is now free of pain for walking in my daily life. It took about 2 1/2 years to get there, but it is a major relief.

Now my only problem is the left foot. It has never felt quite right since the injury, although up and down pain-wise. The last time I wrote to you, maybe a year ago, the pain was worst in my outside ankle (lateral?). Some tendonitis and tenosynovitis of a few tendons were confirmed on MRI, as well as a small split in the brevis tendon. This pain has gotten a lot better, and I think the tendon split probably is from an old injury and completely unrelated, as you suggested. But I suspect this ankle pain is only secondary to the sesamoid injury I got initially in 2015. As my right foot initially was so painful, I had to choose to put the weight on my "least bad foot" when on my feet. I suspect that the pain in my left foot at times also was masked by the stronger pain from the other. Therefore I, unfortunately, may have been walking with more than the 0-2 pain level that you recommend for a long period.

Anyway, I now had a flare-up of stronger pain after our national day in Norway, the 17th of May. I was walking quite a lot and even dancing that day in nice (but not so well cushioned) shoes and also had drinks. At one point I felt a sharp sting in the ball of my foot, then it did seem to go away again quickly. But I later woke up during the night with achy pain, and it didn't really seem to go away the next few days. But no real swelling of any kind. My fear is that the sesamoids didn't heal completely, and I maybe re-injured them now. So I have been trying to offload for most of the summer, hoping to make it better. Generally, the pain in my left foot has been more aching, widespread, coming and going, and difficult to pinpoint. Often worse after activity, not so much during (but sometimes). 

I had an MRI done in 2015, maybe 2 months after injury. I have now recently done both an MRI and a CT. Back In 2015, it read "sesamoiditis", and the edema is pretty clear in the pictures. But the radiologist seems to think everything looks normal again now in 2018 and found no issues. I am attaching a few screenshots from 2015 and a few recent. It would be wonderful if you could have a look and say if you agree with him. Personally, I seem to think at least the MRI of the medial sesamoid looks a bit strange now, but probably there is a good explanation for this. If you also feel that everything looks as it should, I will try to gradually get walking more again. Maybe the pain is more from hypersensitive nerves, sore tendons, not so great orthotics for a long time and so on.

I have named the pictures with the year which they were taken. The recent MRI is from early July, and CT now early August. 

Hope for a reply from you.

The reader must be aware these images are on the left foot, but since MRIs are mirror images, they look like the right. On my computer, I can flip the images horizontally when looking at them with the patient. 

Tibial Sesamoid Injury 2015 (the dark area is where the ligaments and tendons attach and is commonly mis-read as bone death (aka avascular necrosis)

Tibial Sesamoid 2015 noting some inflammation in both sesamoids

Tibial Sesamoid 2018 Slightly Irregular (the most important thing is that it is solid)

Tibial Sesamoid 2018 not Inflamed (no sign it is actively trying to heal something) with some inflammation between sesamoid and metatarsal. Another important point is not bone swelling on the under surface of the metatarsal

Tibial Sesamoid 2018 Normal Appearance (good bone marrow is seen, although the tibial and fibular sesamoids have a different look since the tibial sesamoid underwent some bone healing) The sensitivity that he is experiencing is that maybe the tibial sesamoid is more dense or harder and that irritates the first metatarsal although no sign is noted. 


Dr. Blake's response: thanks for the email and photos. The MRI and CT scans look fine. That does not mean you do not have some irregularity in the sesamoid that makes it sensitive and subject to flares. You should work hard over the next months trying to perfect the mechanical help from an orthotic device, and some of my patients are even using the 1/8 or 1/4 inch Dr. Jill's gel dancer's pads with the orthotic and permanently with any shoe or sandal they wear. They can even be worn on your foot if you are barefoot. Definitely buy a nerve cream that you massage in 3 times a day for the next month, and watch my video on neural flossing that helps relax the nerves. Thank you for sharing your story. You have a built-in hyper protection nervous system for these sesamoids, and flares can be more sensitive than for others. The 3 sources of pain management for these are mechanical changes, anti-inflammatory changes, and nerve hypersensity changes. Keep me in the loop. 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.