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Monday, February 25, 2019

Crush Injury leading to Sesamoid Injury and CRPS

Dear Dr. Blake -

I am writing about a crush injury to my right foot 6 months ago (Aug 21 2018) when a large metal object fell from a top shelf onto my bare right foot  I’ve seen a variety of doctors and practitioners, but nothing I’ve learned has improved my condition, and I am in confusion and despair. I’ve read your blog during this time, and your recommendations always make more sense to me. I sent previous emails, but want to try one more time, because the end of my rope is near.

As a quick summary, the initial diagnosis was fractured 1st metatarsal. Second doctors found additional fracture to tibial sesamoid (also deformed), 2nd metatarsal (bottom), inflamed MTP joint, nerve sensitivity on top and bottom of foot.  

Pain has gotten worse rather than better.  Sesamoid/metatarsal area feels like shards of broken glass in my foot.  MTP joint is sensitive, and I keep my foot wrapped in sheepskin inside the boot for relief.
Dr. Blake's comment: That symptom would be intense nerve pain (neuropathic). 
During the day, pain increases the more active I am (light chores around house); better when I stay off it entirely.  During the night, pain can be worse, making it difficult to sleep. I’m still in boot, using wheelchair for total non-weightbearing, homebound from no driving.

Dec 2 MRI:
  • Bones and joints:  No dislocation.  Moderate hallux valgus alignment with mild lateral subluxation of base of 1st proximal phalanx.
  • Moderate 1st MTP osteoarthritis; severe sesamoid osteoarthritis. No joint effusions.
  • Ligaments:  Lisfranc ligament intact.  No evidence of acute injury to collateral ligaments at MTP or IP joints.
  • Tendons and muscles:  Mild edema/strain of the medial head of the abductor halluces muscle.  Mild muscle atrophy.
  • Soft tissues:  Mild soft tissue swelling, greatest along 1st to 3rd MTP joints
Dr. Blake's comment: Your symptoms are of nerve pain secondary to the crush injury to an already arthritic big toe joint. 

Dec 18: 2 Cortisone injections, which caused extreme pain, fever, disorientation. No pain relief, but some reduction in inflammation.
Dr. Blake's comment: This is diagnostic as it only addresses inflammation. Since it did not work, the neuropathic pain must be addressed. 

Physical therapist has helped flexibility/strength in foot, ankle and leg. Electrical stim and light massage reduce pain temporarily, but sometimes nothing can be done because foot is too sensitive.

My two doctors recommended 2 different courses of action, both surgery. I resisted.
  • Dr. 1:  Aggressive: remove both sesamoids, reconstruct MTP with pins, shave outside of bunion, all in one operation.
  • Dr. 2:  Conservative: remove tibial sesasmoid.  If that doesn’t work, then remove 2nd sesamoid.  If that doesn’t work, reconstruct MTP joint.
Dr. Blake's comment: No surgery should be contemplated until neuropathic pain is recognized and addressed. The treatment is not easy, so as soon as you can have the neuropathic pain treated successfully the better. 

Jan 19:  Woken up by worst pain yet, like broken beer bottle jammed in my foot.  Decided surgery was necessary.
Dr. Blake's comment: Again, this is neuropathic pain, surgery has to wait for now, but could be avoided. 
Jan 24:  Went to yet another doctor for 2nd option on which approach to use; aggressive or conservative.  He temporarily put the breaks on, wanting more info.
  • Increased nighttime pain may be related to L4, L5, SI nerve. I need to see ortho spine doc.
  • X-rays show osteopenia in MTP area.  Bones may not have integrity to hold pins/screws, creating worse problem in future.  I need to see osteoporosis specialist.
Dr. Blake's comment: Localized osteopenia could indicate that the neuropathic pain has developed complex regional pain syndrome. I have many blog posts on this subject. 

I sit here befuddled, exhausted, and defeated. I truly hope that you can provide some clarity on what is happening, and how to best proceed.  Thank you for your time and commitment to healing.


This is a foot that looks like CRPS Stage 2 (vascular stage)

Dr. Blake's comment: I wrote to the patient at this time that I was on vacation and my response was going to have to be delayed. 

Hello Dr. Blake.  I hope your vacation was rejuvenating!

You asked that I resend the email below after your return.  Here are a few updates as well.  Thank you so much for your generosity.

Pain Relief:
I got a medical marijuana card last week. A daytime tincture hybrid of THC/CBD keeps me alert while reducing pain.  The nighttime tincture is 100% Indica for sleep.  To my surprise, the daytime product has reduced my pain considerably, particularly around the tibial sesamoid.  I’m mainly feeling nerves, but in a lower pain range. 

The amount of pain I have right now is bearable, which makes me more resistant to surgery. It feels good to have the boot off.  I’m still putting all weight on my heel and outside of foot. Only a few steps here and there.  Doing exercises recommended by physical therapist.  Still in wheelchair most of time.

Doctor Opinions:
Here is the full array of opinions that have my head spinning.

Dr. A (podiatrist):  Recommends removal of both sesamoids, rebuilding of MTP joint, shave bunion bump. Should all be done all at once in order to maintain my gait, but also recognizes it will be a difficult recovery.

Dr. B (Dr. B's partner):  Recommends removal of tibial sesamoid only.  If that doesn’t work, then follow with 2nd sesamoid removal, followed by reconstruction of MPT.  More conservative approach, but possibility of 3 separate surgeries.

Dr. C (my chiropractor):  Advises against surgery because of complexity of foot, but if surgery is necessary, then do it all at once.  He recommended Dr. D for a second opinion.

Dr. D (third podiatrist):  Not rushing into surgery after reviewing the MRI.
#1 - He thinks the tibial sesamoid is not that deformed, and the pain/inflammation is likely severe osteoarthritis aggravated by the accident. He also thinks some nerve pain may be originating in my lower spine...L4, L5, S1. He asked for a workup from an ortho spine doc. If foot surgery is necessary, he recommends it all be done at once.
Dr. Blake's comment: This is my choice of direction, but CRPS has not been discussed?

#2 - He is concerned with osteopenia in the big toe joint, and not confident that pins would hold.  He wants a workup from an osteoporosis specialist, before he would consider surgery.

CNP (my primary provider):  She did not understand Dr. Haas’ concerns. 
#1 - She doesn’t agree lower spine should be an obstacle.  She ordered x-rays, and results were as expected. 
Mild degenerative disc disease at L4-L5 and L5-S1 with disc space
narrowing. Facet arthropathy is present throughout the lower lumbar
spine. No acute fracture or malalignment is seen. No evidence of

#2 - I had a bone density last March, and there is osteopenia everywhere. It's being treated with Vit D3 caps, and calcium through diet.  Marcie doesn’t see a problem with pins holding.

She said I’m between a rock and a hard place, but agrees with Dr. B; one bone at a time.
Dr. Blake's comment: In California we have pain specialists that are neurologists, physiatrist, or anesthesiologists who need to be consulted. Dr. D was right about the nerve part, but CRPS type 2 is nerve hypersensitivity from nerve injury. This has very specific treatments. 

Finally, my physical therapist): He has seen my ups and downs more than anyone. Most recent trend is down, so he can’t even do exercises with me, and we've cancelled appointments until this gets sorted out. He said it will be a difficult recovery, but he recommends the full surgery.
Dr. Blake's comment: The full surgery is only recommended by caring people who want desperately to help you. You can not blame, but if the pain is neuropathic, the surgery is going in the wrong direction. See if there is a neuro-physical therapist in your area. They have a national organization and are attuned to CRPS.

Me:  When feeling my foot prior to medical marijuana, I am resigned to surgery.  Feeling my foot right now, under the effects of medical marijuana, I don’t want surgery.  

Bottom Line:  where do I go from here?

Warm regards,

Common presentation of CRPS post injury

Dr. Blake's first response after vacation (3 weeks ago), but before the two photos above were seen. 

Just read through all the emails to get my brain working. Do you have any images you should send of xrays or MRIs? If you have surgery on your foot, you only want the tibial sesamoid removed for sure. More and more surgery at one time is less predictable, and more trauma to your body. You had a very bad accident, which everyone wants to help you with, but more surgery does not make sense right now.
Secondly, I treat patients every day with tibial sesamoid fractures, and no one hurts like this. The crush injury may have caused a complex regional pain syndrome to develop which behaves like this. If so, you need a sympathetic block in your back soon. So, please have a neurologist or pain specialist work you up for this to rule it out, but also to treat the pain. If you are having nerve pain from this, surgery may make you worse unfortunately. So, get away from the surgeons for a few weeks and focus on nerve pain and its treatment. Send me any images. Keep up with the cbd oil which works well for nerve pain in some/most patients. Rich

The Patient's response:

I’m writing because I’m stuck, and need to make a decision on treatment for my foot. Last night, I had another high pain episode. My physical and emotional reserves are depleted after 5 months since the injury. 

It is very generous of you to provide your expertise, and i cannot imagine how busy you are. While understanding that, I also need to make a decision soon about surgery. I’ve been putting it off for months, and my foot is only worse. 

Is it possible to talk by phone/Skype, or do you have enough info to make a recommendation in writing?  I am so happy to make a contribution to your blog or pay you outright for your time. I just don’t know where else to turn. 

With respect,

Dr. Blake's next response:
I just reviewed the foot MRI. The Spine MRI is out of my expertise. The fibular sesamoid is out of its normal position, probably from the bunion or possibly a ligament tear. It will probably have to be removed. There is some arthritis in the joint, which could be part of the pain. I will have to read your original email to put it all together tomorrow. There is a lot of swelling around the tibial sesamoid which also probably hurts. The L4 nerve root is problematic and this goes to the big toe. Lucky you!!. I will think more on it tomorrow. Rich

Image under the big toe joint showing the fibular sesamoid out of its normal alignment

Another image of the same thing

Arrow points to intense fluid under a normal appearing tibial sesamoid, the fluid seems to be why she is hurting

This is another image of the intense inflammation under the tibial sesamoid in the subcutaneous fat, the tibial sesamoid looks arthritic, but it does not looked fractured or needing to be removed.

Here is the comparison more normal fibular sesamoid and fat pad

The arrow is on the flexor hallucis longus showing intense inflammation above near the fibular sesamoid. I wonder with the injury if the ligament connecting the 2 sesamoids was not torn. This would explain why the fibular sesamoid in the earlier images looked way out of place.

This image points to the gap between the tibial and fibular sesamoids possibly created by a tear of the ligament.

The architecture of the tibial sesamoid does not look injured, but you can see the swelling below in the soft tissue which will hurt on pressure

This image shows the mild wear and tear of the joint itself, osteoarthritis, that could be stirred up in the injury and resulting demineralization process going on

Another view of some mild wear and tear.

Thank you, Dr Blake. This is important information.

I’ve been regulating pain with medical marijuana (mm), and also using the Curable app. Both are helping a lot with calming down my nervous system, reducing discoloration and swelling. Mm is supposed to be good for nerve repair. Reading that I probably need surgery has released a flood of anxiety, and I’ll focus on that now. 

You are most kind.

Dr. Blake's comment: Yes, if you need surgery due to the fibular sesamoid out of alignment, that can wait and you may avoid it. Get the CRPS evaluated. Sounds like you are already calming your nervous system. On your recommendation, I introduced the Curable app for nerve pain in a recent blog post. It definitely looks promising. Keep me in the loop.

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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.