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Sunday, September 2, 2018

Sesamoid Pain post injury: email advice

Hello Dr. Blake
I am a 30-year old woman suffering from sesamoid complications in both feet. I came across your blog while desperately searching the internet for some help. My situation is somewhat unique and I would greatly welcome your advice.

On June 20th, 2018, I rolled my right ankle while doing yard work and obtained a mild eversion sprain.
 This was the 5th time in my life I have sprained that ankle so I am fairly familiar with the proper treatment.
 I rested as much as I could for three days and used ice and compression.
 There was no bruising and very minimal swelling. 
After three days, I did contrast baths once a day for a week and started range of motion,
 theraband, and balance exercises. I did not wear a brace (kicking myself for that now).
 I remember having some mild discomfort in the ball of my foot under the big toe at that point,
 but nothing that seemed too far out of the ordinary. I visited a podiatrist at 3 weeks post-injury
 and he was satisfied with my strength and range of motion and told me to keep doing what I was doing.

Fast forward a month to the end of July 2018 - I was still unable to walk normally 
and was now experiencing a lot of pain in the ball of my right foot, under the big toe. 
My podiatrist put me in a CAM walker boot on an as needed basis.
 I wore this out of the house for about two weeks but found that the stiff angle put pressure 
on the ball of my foot, and I was worried about losing flexibility in my ankle.
 During the time in the boot, I started feeling some intermittent pain in the ball of my left foot.

On August 18th, the pain was present and consistent in the balls of both of my feet (2 weeks ago).
 I do not have any relief while resting or elevating my feet, and I also am experiencing tingling 
and tightness in the painful spots and throughout the arches of both of my feet.
 I also have fasciculations in both arches while resting.
 Doctor ordered an MRI of the right ankle and an MRI of the forefoot - both came back showing mild
 inflammation. He decided to put me on a 12-day prednisone taper (60 mg to start) and 
I have one day of 10 mg left. I do not think the prednisone helped at all. 

I have started physical therapy since this all seemed to spring up after the acute ankle injury. 
I have never had issues with my feet before. The physical therapy team assessed me 
and decided that my hip strength is to blame. Basically, they are saying that my weak hips 
cause my feet and ankles to turn outwards and splay all over the place while I'm walking,
 causing an unsteady gait and thus the pain in the feet. I am working on hip strengthening, 
calf stretches, and some mild nerve flossing exercises. They also instructed me to walk with 
my stomach tight and focus on keeping my hips in a straight line. 
I've only had two physical therapy sessions so far.

The doctor also recommended Hoka running shoes for me because of the rocker forefoot. 
After wearing those for 2 days, I started feeling and hearing a popping sensation in my left ankle
 (the good ankle!) and I can feel what I think is a peroneal tendon moving over the ankle bone
 when I invert my foot. I also have an extremely sore spot on my lateral leg
 above the ankle now. I exchanged the Hokas for Altras two days ago and
 the popping is less consistent. The physical therapist said that should resolve itself,
 but if not I will have to see the doctor for this new injury as well. I am particularly worried about this. 

I am desperate to get some relief. Do you have any suggestions for me? 
I am particularly concerned by the constant nerve pain I seem to be having and am unsure 
what medications or course of treatment might be best for me. 
I'm functioning at 20% of my normal capacity and I'm basically at my wits end.

Thank you,
Linda (name changed due to witness protection)

Dr. Blake's comment: These are not that abnormal symptoms post injury to raise any warning flags 
of something serious. You got injured, your body compensated, other things hurt, and you will get 
better. You did not injure your sesamoids when you sprained your ankle, but your biomechanics change 
and stress is placed on other body parts. This sucks, I know, but you will work through it. The MRIs showing 
only mild inflammation, and the prednisone not helping, really points to your back (or nerves). The treatment 
should be activity modification to maintain 0-2 pain level, nerve flossing, neuro-eze OTC medication 
online, contrast bathing, real focus on normal gait (no favoring), ankle brace if you feel unstable (I doubt it), 
some sesamoid protection with dancers padding and arch support, sciatic nerve evaluation (what is you back 
history?). Keep me in the loop. Rich


  1. Dr. Blake,

    This is the original poster again. Thank you so much for your quick response. It is hard to feel like I will ever recover from this but you are helping me feel hopeful today!

    I do not have any history of back or sciatic nerve issues. The physical therapist evaluated me slightly for that, by moving my leg up and down and asking me questions about how it felt while I moved my head, etc. Similar to the techniques you talk about in your nerve flossing videos. My podiatrist wants to send me to a rheumatologist but I don't think that's necessary. Should I ask to be referred to a neurologist instead for a more comprehensive nerve evaluation?

    My biggest question right now is how to get the pain to a constant 0-2 level if I'm experiencing it in both feet. Getting a walker boot for both feet seems counterproductive since it would surely alter my gait negatively. Walking around actually isn't too painful - it's just while sitting (either in a normal position or elevated) that things really start to act up. Also, my feet swell during the day right now which has never been an issue for me.

    Lastly, do you recommend heat or ice? I have been using ice before bed as it's the only thing that offers some relief but I'm not sure if that is harmful to the nerves.

  2. Definitely see a neurologist since an anti-inflammatory approach did not help. If you can walk with the pain levels not escalating above 0-2, then you do not need boots. Sitting is stressful on the nerves, as is lying in bed some times. The swelling is called vasomotor insufficiency, where the body is trying to help but the nerve hypersensitivity makes it difficult. Is there discoloration in your feet, or only swelling? Is the swelling always better the next day when you first get out of bed? Ice for 5-10 minutes is okay for nerves, but contrast bathing is a better way of soothing the nerves and getting the swelling out of there. Hope this helps some. Rich

  3. Yes, this is very helpful. The swelling goes down overnight and there is no discoloration. They look like normal feet!

    I can definitely walk at that pain level so I will keep focusing on walking normally. Planning to try contrast baths again tonight and I ordered the neuro-eze. I will call tomorrow for a neurologist referral. Advil seems to help slightly so I’m taking that for now.

    Finally, is it worth seeing a chiropractor? I know there are mixed opinions on that topic.


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.