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Saturday, August 17, 2019

Sesamoid Injury with Plantar Plate? Email Advice

Dear Dr. Blake,
First, thank you SO MUCH for all of the resources you have made available on your website. After I broke my sesamoid bone I struggled so much with conflicting medical advice (or a huge lack of familiarity with this issue) and was wobbling around for two months on a broken swollen foot until I found your site. I followed the suggestions on your site and within 3 weeks the swelling and the pain were totally gone! It was a miracle and I was in tears of gratitude for what you’re doing and how you’re helping people like me. After 2 months in a boot, I weaned onto a pain-free environment on a thick sneaker with a sesamoid cutout, but 3 months after the break, X-rays still showed a fracture line. Six months later, my MRIs seem to indicate there is no longer a fracture - however I am still unable to walk without the sesamoid cutout in my shoe without pain and swelling, while my big toe is still frozen and relatively immobile so many months later. 

Your opinion at this point would be heaven sent as my doc was very vague in explaining my MRI and just told me to come back in a few months. He said keep the foot in the cutout at all time to maintain healing, but then the physical therapist he referred said this was wrong and I need to get moving barefoot. Could I pay you for a little email consultation to interpret my MRIs and guide me on what is safe to do next? I’m confused RE if it safe for me to push myself in bearing weight on the sesamoid or pushing the extension of my toe (the MRI report also said something about a full tear of a plate on the first MTP joint?..I don’t even know what this is but apparently that is not healed) 

Thank you so much,

Dr. Blake's Response: It is not possible to record how strong the healing is going via xrays, so I typically go with every 6 month MRI if they are needed at all. I watch the patients monthly and gradually increase activity, and toe bend, while they work on strength and keep the area protected and keep the inflammation under control. Barefoot pressure on an injured sesamoid is sore for several years, even when the patient is back to marathon running so it is not a sign of poor healing. The initial treatment is to freeze up the joint unfortunately, and now you have to unfreeze it with painfree stretching, walking, PT if you can get it. Please no barefoot for several years as a rule, but you may be ahead of the curve. I just read the part about the tear. That adds some more complexity. Spica taping is great for now. How did the tear and sesamoid fracture happen? I am doing a project in September and will not be blogging, so please rush the CD of the MRI to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. All payment is voluntary and through blog donations and is never required. Rich

Dear Dr. Blake,

Thank you for your response. I'm enclosing all the MRI report and images in this email as I only have them on my computer. There are a ton and I'm sending them all in a compressed folder since I'm not sure which ones show what we are interested in. Another option would be to send them in a separate email so you can see all the images as smaller thumbnails and just open the ones that look interesting (please let me know if this would work better). I'm also enclosing the initial x-ray from March 2019 for reference (their finding was "a longitudinally oriented fracture through the lateral sesamoid bone underlying the first metatarsal head). 
Dr. Blake's comment: I have trouble always opening up files zip compressed. It may be the firewall at Dignity Health. Please send CD or you can try WeTransfer that has worked for some patients. Also reading an MRI with 144 thumbnail images is hours of work which I do not have. Rich

The initial fracture occurred (get ready for this one) after kicking myself repeatedly in my sleep during a nightmare, I kicked myself until I bled, must have hurt the sesamoid or joint somehow but never imagined anything serious, then proceeded to walk on it in heels for 2 weeks until one day I woke up and could not even stand on it. That is when I went in for x-rays. The first doctor had me walking on a flat surgical boot and soft cast for a few weeks with worsening pain and swelling day by day, until I found your blog and put myself in a cam boot with sesamoid cutout and went minimal weight-bearing on crutches, doing contrast baths daily and soft massaging the area with arnica cream. It was after those 3 weeks that the swelling went away completely and I was totally pain-free, enough to begin to wean onto the sneaker with the cutout, which I've been on for months ever since. Even for the shower, I wear a water shoe with a sesamoid cut-out. Recently, the two times I've tried taking slow steps barefoot since (1 month ago for progress check and a few days ago after my first PT consultation) I don't really feel pain while I'm doing it, but the pain and swelling comes the next day with a vengeance. 

My first question is, if you suggest no barefoot as rule for several years unless I'm ahead of the curve, how do you normally determine when it's safe for the patient to start barefoot?
Dr. Blake's comment: You can begin to try to walk flatfooted barefoot after 3 months out of the boot, daily painfree massage to desensitize and daily icing and contrasts to keep the inflammation under control. 

 How would I determine this on my own if the associated pain and swelling comes after and not during? 
Dr. Blake's comment: See above

This PT is really pushing me towards that (and dismissing my doc's more conservative recommendations i.e the cutout) saying I can't be afraid and breaking down of scar tissue will always involve pain, but after so many months of dealing with this, of course I'm afraid to undo any progress - especially after finding out about the plantar plate issue of the MTP joint. The PT has been pulling and stretching the toe joint as much as he can and now I'm a little paranoid if I should be moving it at all!
Dr. Blake's comment: I agree with you and you have to be cautious. I have never found that approach to be helpful when you are still with only partial diagnosis on the plantar plate. Is it grade 1,2 or 3, and is the plantar plate injury 50% healed, 90% healed, or 10% healed? Is there any chance you will need surgery for the plantar plate tear? I could not answer these questions. If the PT can with certainty, and you have total trust in him/her, they should be allowed to go for it. But, if there are unanswered questions, a bit of caution is advised. Nothing should hurt either while doing or after for more than an hour that ice does not help. Sorry. 

As far as the plantar plate tear, do you see it? I don't even know what a plantar plate does. How can/does this fully heal and is it normal to still have this 6 months post-initial injury? Does this complicate the sesamoid healing and/or impose any limitations in PT, like toe extension?
Dr. Blake's comment: Sorry about not seeing the images. Even with the nightmare, and it must have been a bad one, it is hard to image a plantar plate tear or a sesamoid fracture (bruising or sesamoiditis yes!) The plantar plate is the ligaments under the ball of your foot that keeps the joint together and the joint fluid contained. Tears in the plantar plate will cause the joint fluid to leak out of the joint, and can lead to chronic symptoms, and many times need to be repaired. 

Finally, what do you think of the sesamoids in the MRIs? Dr. Blake: sorry.

I am looking up spica taping on your channel and am definitely going make the donation to the blog. It has been such a TREMENDOUS help, thank you so much for lending us your expertise.
Dr. Blake's comment: Thank you. 

HISTORY:  Pain. Evaluate for sesamoiditis versus fracture of the first MTP joint.
TECHNIQUE: Multiplanar, multi-sequence noncontrast MRI of the forefoot was obtained on a 1.5T scanner according to standard protocol.

Bone marrow edema signal within the tibial and fibular hallux sesamoid without disruption of the cortex or discrete fracture line compatible with sesamoiditis. The sesamoidal ligamentous complex is intact. Discontinuity of the plantar plate of the first MTP joint. Mild osteoarthritis of the first MTP joint and mild hallux valgus deformity.

The rest of the visualized MTP joints are intact without evidence of arthrosis or Freiberg's infraction. The medial and lateral collateral ligaments of the visualized lesser MTP joints are intact.

Small nodular isointense signal lesion in the plantar aspect of the second intermetatarsal web space, measures approximately 3 x 2 x 3 mm compatible with an intermetatarsal (Morton's) neuroma. Trace, physiologic intermetatarsal bursal fluid within the first, second and third web spaces.

The visualized extensor and flexor tendons are intact.

Intact intrinsic muscles of the forefoot. No selective muscle edema or atrophy.

The visualized plantar aponeurosis is unremarkable.
IMPRESSION:  MRI of the right forefoot demonstrates:

1.  Bone marrow edema throughout the tibial and fibular hallux sesamoids without fracture line or cortical disruption in keeping with sesamoiditis.
2.  Full-thickness tear of the catheter plate of the first MTP joint.
3.  Mild hallux valgus deformity and mild osteoarthritis of the first MTP joint.
4.  Small neuroma of the second web space measures 3 x 2 x 3 mm.

Dr. Blake's comment: So now reading this, and listening to your story of how it happened, I think the injury was probably a plantar plate tear with bruising of the sesamoids. The physician may consider fluroscopic evaluation with dye injection into the joint to see if it leaks out meaning the tear is still present. Carbon graphite plates for "Turf Toe" should be given as you progress to normal shoes. Surgical repair of the tear may very well be needed, another reason not to have the PT keep stretching things too far. Careful measurement of the big toe joint range of motion up and down today versus 3 months from now is important. Strengthening of the long and short flexors and extensors to his joint is important and a 6 month task. Please show this post to the PT and have them record the measurements, start the strengthening, and make comments. I am sorry I will be gone 8/30 to 10/15 to help. Rich
PS. I still need to see the images, as this may be totally incorrect, since plantar plate tears leak, that is what they do, and this report makes no mention of fluid collecting under the big toe joint. Perhaps, it is because the tear has healed. Here's to hope.

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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.