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Sunday, March 15, 2020

Pre-Sesamoidectomy Advice Needed

Dear Dr Blake,

I have just come across your blog when researching the pros and cons of a lateral sesamoidectomy

I'm a former professional ballet dancer. I'd really appreciate it if you could give me some advice, as I'm trying to decide whether or not to go ahead with a sesamoidectomy over here in Europe where I now live. 

I never had much pain in the ball of my foot when I was dancing, but about a year after I stopped dancing professionally, I had consistent pain on the underside of my left big toe. I had a bunionectomy done in 2011. But afterwards I still had pain in the toe/ball of foot area. X-rays showed that the pins from the bunionectomy had come loose and were pressing into my lateral sesamoid bone, so I had surgery here in Europe in 2014 to have the pins removed. Once that healed, I was mostly pain free, apart from occasional periods when I'd get pain in the ball of my foot, but a local podiatrist would mobilise the joint and get the sesamoids sliding again, and that would help.
Dr. Blake's comment: Did they say anything about the joint position (like an elevated or plantar flexed first metatarsal) or your foot motion like over pronation? 

However, for about 9 months now I've had much more consistent pain in my lateral sesamoid area. I had an Xray done that showed a historic fracture in the medial sesamoid, but no fracture in the lateral sesamoid. I recently had an axial Xray taken, which showed that my lateral sesamoid is 'irregular', i.e. it's not smooth and round, the edge is a bit wavy. The surgeon (who is the same one who did my bunionectomy, and who has a very good reputation) said that I'm a candidate to have the lateral sesamoid removed. He didn't specifically say whether it is sesamoiditis or something else. The pain comes and goes, and I'm worried that the sesamoidectomy may cause other complications, and maybe the pain isn't bad enough to warrant having it done. I'm also wondering whether I should try a more concerted period of conservative treatment first.
Dr. Blake's comment: You absolutely must use all the means available to help save this sesamoid. The medial one is not perfect, and if you remove the lateral one it will get all the weight. Sounds like a potential problem.

Since December I've been wearing orthotics with a very stiff (fibreglass?) section under my big toe, to limit movement, and they help, but don't completely remove the pain. I can walk a decent amount when I'm wearing tennis shoes and orthotics, but the moment I try wearing a slightly nicer pair of shoes, the pain comes back, and I wouldn't want to walk more than 10 minutes. (I walk a lot here, as I don't have a car. I've been taking buses more recently because of my foot.) I don't dance regularly anymore, although I did take a contemporary class in December, but when I was pushing off the ball of my foot I felt a slight crack or something, and the sesamoid area was much more sore for a while after that. I don't think I could run or play sports with my sesamoid as it is. I'm frustrated with having limited my activities for at least 6 months, and I would love to have a 'quick fix', but I'm wondering if I should try a more concerted period of rest and immobilisation first, before resorting to sesamoid removal?
Dr. Blake's comment: First of all, an MRI would help us, but you can treat without. You are trying to create a consistent 0-2 pain level. Your orthotics limit big toe motion, but also increase pressure (which may be a problem). You should get a second pair that has more arch and frees up the big toe joint with traditional dancer's padding to off weight the sesamoids. Order Dr. Jill's dancer's pad both sides and both 1/8 and 1/4 inch. They can be used on the orthotic or on your foot. The hole for the sesamoid is alittle small so you will have to trim it. You want the dancers padding under the 2nd through 5th metatarsal heads. You want to be icing once daily and contrast bathes each evening. You want to make sure Vit D is fine, and getting enough calcium (usually 5 servings of food with calcium a day or you have to supplement. You want to get some Hokas to see if the Rocker helps you. You want to learn how to do spica taping. Take it 3 months at a time, meaning 3 months from now see how much better you feel. You should be at least 50% better, meaning you will probably need another 3 months. Personally, I would not do surgery unless I had an MRI and a CT scan, but that may be impossible in your situation. Keep me in the loop. Rich

Any advice you could provide would be greatly appreciated!

Thank you very much,

The patient later wrote:

Hi Dr Blake, 

I'm looking into getting some Hokas, as you suggested. I see there are two types of their 'meta rocker' sole: early stage and late stage. I think I want an early stage one, with the rocker behind the metatarsal heads. Is that right? I don't want to order the wrong type!

Thank you,
Dr. Blake's comment: I am sorry for my indecision, but so much depends on your gait pattern. You are right early stage sounds right to put the stress behind the sesamoid for sure. No way you can try these shoes, but I guess we are all stuck at home. Rich 
PS Stay safe!!

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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.