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Sunday, December 29, 2019

Flare Up Pain Post Examination: Nerve Related?

Dr. Blake,

I hope you're well. I have spent some time reading through you blog as well as various reviews. It seems you are a leading expert in sessamoid injuries. My story is I'm a 35 year old competitive runner. I never had sessamoid issues until recently. I went for a hike/run in the mountains and had the indicative stiff toe shortly thereafter. I was able to get around well and saw improvement through the week. I tested my foot 7 days later and had mild soreness after the run. Although I was able to walk without issue I was unable to run and wanted to rule out any sort of fracture. I went to see a sports medicine doctor three days after the light run. Before the doctor came in a resident physician on rotation examined me twisting my foot in various positions as well as pushing my big toe up to the highest point my body would allow. The pain was not immediately debilitating but on the way home from the hospital I began to feel pain on the top of my first metatarsal as well as pain in the ball of my foot for the first time. The pain got progressively worse over the next 24 hours.
Dr. Blake's comment: Sorry for that. I have inadvertently done that to a few patients over the years. Residents do not have experience yet, actually you are their experience. I was a resident once so I feel for you. It normally lasts a day or so. 

 I wasn't able to sleep that night and was unable to walk or weight bear the next day. It's been three weeks since that examination and I still cannot bear weight. I knew something was wrong and had an MRI done two days after my initial visit to the doctor. The MRI results did not show a sesamoid fracture just some metatarsal edema and "sesamoiditis". I have been taking prescription anti-inflammatory meds and limping around in a post op shoe putting my weight on the outside of the heal (i find the cam walker to be too uncomfortable). I use a scooter around the house. When I do limp in the post op shoe I try to put a ballet pad on my foot to offload some of the pressure from the sesamoid. I live in the Carolinas so literally across the country. Is it possible to schedule a remote consultation with you or do you only see patients in the office? I have been reading the horror stories and like most I have seen no improvement over the past month. I'd also like to have a second opinion since the doctor who initially diagnosed me as not having a fracture was the attending physician when I was injured by the resident.....which makes me question his familiarity with this injury. He recommended a graphite insert which I can't even imagine walking on anytime soon. 
Dr. Blake's comment: So sorry for your problem. I can review the xrays and MRI. You can have them mailed to Dr. Rich Blake, 900 Hyde Street, San Francisco, California, 94109. Look up my friend at the Barry University in Florida Dr. James Losito. He also may have a local recommendation. You need to get back in the removable boot with a cut out for the sesamoid. Some times I need 1/2 inch sesamoid accommodations to protect the sesamoid. Anti-inflammatories slow bone healing so try to change to ice and contrast bathing. With contrast bathing start with 1 minute hot and 1 minute cold for 10 minutes and see if it makes it feel better. I would rather you do that. This is very unusual to hurt like this after an examination, so if you forget about the diagnosis for awhile, the goal has to be weight bearing with 0-2 pain levels. Typically podiatrists are great at that, but if you have to also work with a pain specialist. The 3 sources of your pain are mechanical injury documented by the MRI, inflammation, and nerve hypersensitivity. So many patients with pain like this actually have nerve pain. If you float the sesamoid 1/2 inch off the ground and you still have major pain, then you have some nerve pain. And, nerve pain has to be treated differently than mechanical produced pain or inflammation produced pain. I hope this makes sense. Rich I also love Pat Nunan in one of those Carolinas!!


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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.