Total Pageviews



Thursday, December 22, 2022

Sesamoid Injury: Email Advice

Hi Dr Blake,

I have been reading your blog for a while and it has been very informative for me.

I have been dealing with sesamoid issues for a year now and I can't seem to move forward, so I'm looking for your advice.

I first started having issues in both big toes in January this year, right side was initially worse. I didn't do any sports at that time as I was recovering from another foot injury. Then, I started walking barefoot around the house (as recommended by my physio), but after about a week of this I started having pain in sesamoid area.

          Dr. Blake's comment: To let you know how my brain works, each word or sentence has a 

                          possible clue. January means we could be dealing with Vitamin D deficiency 

                          from lack of sun exposure. Another foot injury means alternated mechanics 

                          that could have stressed something out. Typically, if it is both sides, you did not

                          break again, and this is backed up by no impact sports at the time.  

In May of that year, an MRI was done on my right foot and it showed a small edema on the medial sesamoid. Then, the left foot started hurting a lot as well.

          Dr Blake's comment: Medial sesamoid bares more weight naturally than the lateral sesamoid

                          and many foot types have prominent first metatarsals (or at least more pressure)

                          including pes cavus (high arches), plantar flexed first metatarsals, hypomobile first

                          rays, and very pronated feet.

Throughout this I have been offloading the sesamoid using zero-drop, wide, stiff shoes with thick metatarsal pads from Dr Jill. During Summer I also did three months in a Darco shoe with a hole cut out where the sesamoid is. After all of this there was some improvement, but the pain is still there all the time especially on the left side. I have also tried orthotics, but I could not tolerate them as they gave me Baxter nerve entrapment. I have also developed pain in my pinky toe from compensation on both sides. I'm doing contrast baths every day as well. I have high arches, but had previously always been very active with little issues, I'm 33.

          Dr. Blake's comment: Well I am very proud of your attempt. Since orthotics can be a game

                          changer, and you could not tolerate the hardest in the heel, have the doctor/lab 

                          make their version of a Hannaford design (all over my blog). This will get you

                          a soft arch to transfer weight off, but a way of off weighting the sesamoid reliably.

                          Many patients need to add a Dr Jill's Gel Regular Dancer's Pad on top of the 

                          orthosis. Other mechanical treatments are spica taping, 4 hour per day of full 

                          immobilization with bike shoes with embedded cleats, cluffy wedges, or carbon plates

                          under your shoes.

About a month ago, another MRI was done on the left foot, and it shows again mild edema in the medial (bipartite) sesamoid. The toe hurts if I bend it up or when I press on the sesamoid.

          Dr. Blake's comment: If it hurts to bend up, definitely start using spica taping to see how that

                          helps. The nerves could be protecting or the soft tissue tightening up due to pain or 

                          prolonged immobilization. Make sure you are painlessly moving the top up and down 

                          10-20 times 3-4 times a day. Make sure you are doing some foot massage, but not 

                          pressing in, just to relax the soft tissues around and especially into the arch.  

I have now tried significant offloading and also more recently trying to work with the pain (so only doing things which do not make the pain worse for more than 24h), but still I'm very limited in my activities of daily living. I can't quite understand why a minor injury to the bone won't heal in over a year and also produce so much pain. Is this normal? Or do you think there is also nerve involvement? Do you have suggestions of things I can do?

         Dr. Blake's comment: Unfortunately, minor foot injuries, especially under your foot, that you 

                         have to continue to walk on, can spin out of control. After 3 months, all of these

                         injuries do have some nerve hypersensitivity issues. Between the massage, and topical

                         Neuro Eze or Neuro One gels, and add some warmth for 5 minutes before you 

                         massage. Check your Vitamin D, if you have an history of poor diet, then check your

                         Bone Density. Edema is a sign of both stress and healing. If you have been taking

                         off the stress corrcctly, and the bone is healing, a new MRI would show  great 

                        improvement. I like to wait 6 months between MRIs for their maximum change. So, 

                        you could definitely repeat the right side now. The bone may be healed completely, 

                        and your pain is all nerve now. It would be good to know. I am happy to look at any

                        MRI CDs that you mail to me. 

I have signed up for shock wave sessions now (ESWT), I hope this will clear up the edema. I'm also making sure I get all the nutrients for the bones and my bone density test came back normal. If this doesn't work, I don't know what more I could try, all this offloading has caused other issues for me. My doctor also doesn't know what to do, but told me I'm not a candidate for surgery despite only having very little success with conservative treatment.

          Dr. Blake's comment: One of my blog patients just had shockwave for chronic sesamoiditis 

                         with good results, so good luck. Glad bone density good. I am not sure why he

                         said surgery is not an option. Has be mentioned anything about your foot structure?

                        Please keep me in the loop, and always attach the URL for this post so I can refer

                        to it. Rich  

Thank you for reading this. If you want, I can also send you the MRI images, would be curious to hear what your conclusion would be.

          Dr. Blake's comment: Definitely. Dr Richard Blake 900 Hyde Street San Francisco CA 94109 

Best Regards,

No comments:

Post a Comment

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.