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Monday, December 31, 2018

Big Toe Joint Injury Rock Climbing: Part 2

This is a follow-up post from a March 2018 rock climbing injury where the patient hung by her big toe for 45 straight minutes injuring the soft tissue and nerves. The original thought was sesamoid fracture, but there was not trauma, and the x-rays and MRI proved that they were bi-partite, with the left lateral sesamoid hot enough on MRI to call it stress fracture (probably the stress across the bipartite junction between the two fragments).  The general rule I use is that the nerves need 9 months of being good to them to heal or calm down. She started treating the nerves 3 months ago I believe.

Dr. Blake, 
Happy Holidays! It's so nice to hear from you! I'm doing really well. I'm going to PT twice a week, still using exogen daily, taking 10 mg amitriptyline daily, and I've been able to start wearing Hoka One Bondi and Dansko clogs. These have saved my life. I've been able to return to most of my daily activities. Pain comes and goes but overall is much better. I've seen another orthopedic surgeon and he agrees with everything my sports medicine doctor has been doing to treat nerve pain. He suggested I continue to protect the sesamoid with rigid sole shoes and keep weight off the toe. It was good to get that reassurance in the treatment plan; however, I'm struggling a bit with how far I should be pushing things in PT.
Dr. Blake's comment: No need to push things until June 2019 as the thought of you bending too far or jumping on it prematurely scares me. Get stronger all the way up from feet to core. Get cardio with biking and gradually increasing walking up to 2-3 hours in your Hokas. Spica tape when you need to. Experiment with gentle massage 2 times a day up to 3-5 minutes to the area to desensitize as long as it is non-painful. Do neural flossing twice daily, and you can massage with neuro-eze or neuro-one both sold on Amazon. See if they will prescribe Lidoderm patches or a prescription nerve topical gel as long as it is covered by your insurance (they can be expensive if not). Try massage after a warm face cloth is applied under saran wrap to heat the area for 5 minutes.

PT has definitely helped and the therapists broke up a lot of scar tissue in the big toe joint that seems to have really helped mobilization of the toe joint. I still tend to get most of my pain in the areas the areas point to below.

The arrows are pointing to the front of the ligament (called joint capsule) before it attaches to the big toe itself. This is definitely more Turf Toe symptoms.

The Physical therapist doesn't know why my pain is here. I'm assuming this is still part of the nerve damage. I still feel a lot of scar tissue too. Could there be another problem related to the scar tissue? Dr. Blake's comment: Yes, the scar tissue from the ligament injury from prolonged tension is the body's way of trying to heal and make itself stronger. Try doing the self mobilization from the video below. Typically scar tissue starts to naturally thin out 9-12 months post injury or surgery anyway.

The doctor and the physical therapist want me to get back into more flexible shoes soon and their goal is to get me back to walking barefoot and back to all activity. Ultimately that's my goal too but I don't want to rush it. However, I still don't feel much pain from the actual sesamoid bipartite area. That seems to maybe have stabilized.  Dr. Blake's comment: First try barefoot walking on a grass field or shag carpet with the toe spica taped for 15 minutes to see how it feels. Try the OOFOS sandals with the Dr. Jill's dancer's pad to longer and longer periods also.

How would you suggest I progress with returning to activity? I'm afraid to upset the sesamoid but if the nerve pain I'm still having could be reduced by starting to flex the joint and start walking. They have suggested I walk in the pool starting chest deep to see how that feels and eventually move to shallower and shallower water. I have not yet tried this but will soon.  I've been doing more and more balancing activities which cause pain in the areas pointed out above when my weight shifts there. 
Dr. Blake's comment: Try the balancing with the toe spica taped and some off weighting of the sesamoid. You can be doing high level activity by the end of next year, but still need some off weighting and spica taping at times. I find walking in a pool is great for hip and knee rehabilitation, but not good for feet. The foot takes all the stress of balancing and pushing off in any height of water, the deeper the harder for the foot. Increase walking with the protection mentioned above, increase biking, increase strengthening the core and lower extremity, increase poses with protection like Yoga and Tai Chi and single leg balancing. Go 9 months with the Exogen. I hope this helps. Rich

I tried Tens unit but it seems to aggravate the nerve more so I stopped. 

Any additional advice you can give would be helpful! 

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.