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Monday, June 3, 2019

Big Toe Joint Pain: Diagnostic and Treatment Dilemma

Hi, Dr. Blake, 

I came across your blog and immediately felt the urge to ask you for your opinion on my foot condition. 

I am 38 years old woman and have been dealing with pain under the ball of the foot for a year. At first it was on the side of the ball which lead the orthopedist to think it was due to hallux valgus. 
But the joint was also swollen, so I did an MRI which showed a suspected "fracture" on the medial sesamoid bone, which could be a state after trauma.
Dr. Blake's comment: The one MRI view you sent me looked normal. What was the report? 
I got custom made orthotics (5 variations) and ate a box of Arcoxia, but after several weeks the pain was only worse. I do not have pain if I touch or press on the ball, but when I walk, the whole area is kind of sore. I walk on the outside of the foot, which I think makes it even worse - also the soft tissues around the ball are kind of stiff, I have to massage them. Some days it better, some its worse. 
Dr. Blake's comment: Start doing ice pack 10-15 minutes twice daily, and contrast bathing starting at one minute heat one minute ice for 20 minutes each evening. Non painful massage is wonderful 2-3 minutes and 2-3 times a day. Are the orthotics off weighting the area of the ball of the foot enough? 

I try not to walk a lot, since the condition gets worse after several minutes of walking. I can't do hiking or running anymore. I ride a bike, do Pilates (but no planks!), I also go swimming, but there is also pressure on the foot when swimming, so its not perfect. 
Dr. Blake's comment: this is great while you wait for healing to cross train. 

I made another MRI in January 2019: 
"In the distal part of the medial sesamoid bone transverse is a moderate hyperintense line. The bone structure of the distal pole of the sublingual bone is somewhat non-homogeneous, somewhere hyperintensive ________ (there is a word missing in a report). The proximal part of the sesamoid bone has normal signals also on the contact surface. It could be a bipartite sesamoide bone with degenerative 
changes in the distal core, less likely for a condition after an old injury."

Dr. Blake's comment: Try to send more images. You can send 8-9 that shows sesamoid bones for the 3 MRI directions.

The doctor said that MRI is not very clear, and it clinically looks like sesamoiditis, but that it's strange that it doesn't hurt when he presses on the area. He suggested PRP (platelet rich plasma).  Do you have any experience with it curing sesamoiditis?
Dr. Blake's comment: No, has promise for tendons and fascia. You do not know what is wrong yet. It would be very experimental and guess work at this point. 

I also tried taping the foot which helps a bit, physiotherapist did a laser, which kind of helped, but he said it's no use coming back, since it will be always be worse when I walk again. He suggested MBT shoes. 
Dr. Blake's comment: Start doing the normal stuff for sesamoids right now: Hoka Shoes with the rocker, cluffy wedges, dancer's padding, some arch support, spica taping. Do them all and limit walking this month June to day to day what you have to so. Work on the inflammation with ice, contrasts, arnica lotion. See if you can not turn this around. 

I visited 3 doctors and one of them said there's nothing you can do besides custom orthotics and 2 of them (which were private) said, they would try with PRP. A trauma doctor gave me a cortisone injection which didn't help at all. 
Dr. Blake's comment: stay away from cortisone if we do not know what is wrong yet. What lead up to this pain developing? Were you walking too much? Did you bang it? Are you a terrible pronator? 

I am very confused since I don't even know what is wrong and I am reading all about the different diagnosis over the web and different treatments, but my doctors don't seem to know anything about this possibilities. I was never offered a walking boot or suggested a period of immobilization. I asked about the option of doing some additional research, but he said he could do a scintiography, but it would only show if there is any inflammation, but would not show the cause. 
Dr. Blake's comment: I actually think the scinitiography would be great to see if the bone lights up. Definitely, walking in a removable boot (you can purchase the Anklizer type) at least to help you do more walking every day would be great. You have to place dancer's pads some times. Even if you wore only for the 4 hours per day that you are on your feet that would be helpful. If you feel off balance, get an Even Up for the other shoe. 

I'm also reading about contrast baths, HBO program, shock treatment therapy, Exogen bone stimulator (which I mentioned to my orthopedist, but he said, "you can't stimulate if there is nothing broken ...")
 ... but I am no doctor and I really don't know if any of these treatments would be good for me.  Non of the doctors I have visited haven't advised me anything of it. Custom orthotics, PRP and finally operation if all fails, that is all.
Dr. Blake's comment: Contrast bathes, usually one minute hot and one minute cold for 20 minutes in the evening is good to reduce swelling, while ice just controls it. 

Can you give me some advise? What is my problem, fracture, degeneration ...fragmentation ...?
Could I have AVN?
Dr. Blake's comment: need more images for sure. In general, when the sesamoid is injured, it is really sore on light palpation, so we have to make sure you even have a sesamoid injury in the first place. 

A big thank you in advance, I can't wait to read your opinion.
Regards, 

And when I did not answer (as I am taking a lot of vacations this year):



Hi, dr. Blake, 

I was just wondering if you got my email? I really could use an advice from someone experienced as you in this area. 
Since the condition hasn't got any better, I received a PRP injection last week. I asked the doctor about non-weight bearing and if I should use a walking boot and he said there is no need to. I am so confused, because I read on your blog that all other patient are supposed to not bare weight during a period of time. 
Dr. Blake's comment: The goal is to do what you can to control the pain to 0-2 levels. Typically, only really acute injuries need non weight bearing. Normally, I love the removable boots, anti-inflammatory measures, and activity modification to protect the area while the diagnosis is being made. 

After 6 days the area is swollen and sore, yesterday I even stepped a bit too hard on that area and experienced sharp pain (I am trying to not step on it at all, having custom made orthotics and dancers pads  and walking on the outside of the foot) and now it even more sore. 
Dr. Blake's comment: Non weight bearing typically makes the swelling worse, so protected weight bearing is better with the boot. Any step you take pushes fluid out of the foot. Occasional sharp pains are okay, as long as they only hurt temporarily. 
Do I ice it or do contrast baths or not? I am supposed to have another shot in a week, but I am not really sure if I should do it, since there is no improvement yet. 
Dr. Blake's comment: See above comments on ice and contrasts, get the boot ($60 on amazon), get the scintiography if you can, send me more images. Do non painful massage several times a day. Send me a photo of the top and bottom of both feet now. 

I would be very happy for your opinion.
Thank you

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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.