Big Toe Injury: Email Advice for Possible Nerve Involvement

Dear Dr. Blake,

I had an injury in July 2019. I did some rock climbing and hiking (usual 
hobbies), and two days later I woke up with a pain in the ball of the 
foot.  The pain was coming and going. I went to an orthopedic doctor and he 
told me that probably I probably had an stress fracture ( clean x-rays) in 
the sesamoid and sent me home with a carbon insole  that did not work. 

After that I started using crutches and resting because I could not walk 
without pain. In August 23 2019 I had an MRI and in September 5 the doctor 
told me that according to the MRI the sesamoids were fine and the injury 
was a strain in the abductor hallucis very close to the sesamoid, and some 
arthritis in the first metatarsal joint   and that were the reasons why 
they thought that the pain was sesamoid related.  

He told me basically to do R.I.C.E and if the pain still on plateau to come back and get a 
cortisone injection in the joint to see if the pain was related to the 
muscle or the joint. After one month I did not feel any changes in my 
injury. I even got new shoes ( Hoka and Altra) with different insoles that 
felt better but still not any sign of healing.  Moreover, my toe was very 
stiff for not moving it for so long time. 

I went to the doctor to get an injection, but the injection in the joint but did nothing; the pain is 
coming from the tear and he is not very enthusiastic of injecting in the 
muscle and tendons. In October 15 the doctor told me that he did not know 
what to do with the injury, explained me some surgeries that he can do, but 
did not recommend it at that moment. The doctor sent me home and told me to 
get a bunion brace and  orthodics.

I decided to exercise to get my toe flexibility back.  By that time I had some vacation planned so I went 
vacation for two weeks and during my vacation I felt great.  I was able to 
walk 4 to 8 mile per day with very little or no discomfort. Moreover, my 
toe is flexible again.  However, after coming back from vacation the pain 
came back similar to September pain.

I am doing practically nothing ( less walking, more time sitting on my desk) compared to what I did on my 
vacations and the pain is worst. Sometimes I feel better walking that 
doing  nothing. I am coming back to do light legs workout to see if that 
work. A new doctor told me that I probably have sesamoiditis, even though 
the MRI did not show any problems with the sesamoid. I am stating physical 
therapist next week and getting new orthodics. after that if nothing work 
he recommended an injection.
Dr. Blake's comment: You are clearly describing neural tension, often reported at muscle or tendon tightness. 
     Nerve hypersensitivity can be the primary problem, or sets into the area secondarily as the problem gets more
     chronic. The initial issue was with rock climbing which can start a nerve irritation due to prolonged holding of 
     positions. Nerves love motion, hate prolonged stretching. The initial carbon insoles probably did not work 
     because they held the toe from bending thus increasing the neural tension. 
          I am glad sesamoid injury has been ruled out. You have to treat the mechanics with dancer's padding to off
     load the area (see Dr. Jill's dancer's pads). You have to treat the inflammation with 5 minutes of ice only or 
     contrast bathing. Typically nerves love heat not ice, but short times with ice 1-5 minutes is fine. Read about 
     neural gliding, neuro eze or neuro one topicals, and move the big toe actively every hour or so for one minute. 
     Move it up and down as long as there is no pain. Have the PT uses nerve treatments like TENs, and forget prolonged toe bending like with the downward dog for the next 6 months. I am not sure what shots will do. Hope this helps some. Rich

Regards,