Big Toe Joint Pain (Sesamoid Injury): One Example on How to Work Up the Patient using 14 Point Assessment Summary

 Patient #17: Big Toe Joint Pain 

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History and Chief Complaint

• Long distance runner presents with a 6 month history of progressively worsening pain at the ball of his right foot
• The pain had be smoldering for awhile, but got much worse when he attempted stair running at a local stadium
• Over the last 2 months, he could not walk well, so he got an appointment with the local podiatrist
• X Rays were negative by history, and he was placed in a removable boot for several months
• The pain was not any better in the boot, painful with each step, and a roommate gave him some old crutches stored at his mom’s house
• The big toe joint was swollen and painful to move
• Follow up appointment with the podiatrist an MRI was ordered. 
• The doctor said that he had a stress fracture in the medial sesamoid and that time or surgery would heal.
• He came to me for a second opinion only

Gait Evaluation

• Very limited due to the boot and need for crutches
• When asked, the patient stated he had been labelled a pronator
• Running shoes were not present, but minimalist in nature
• Gait evaluation for walking and running would have to be delayed (it can be months before I watch a runner actually run due to situations like this)

Physical Examination

• Swollen first metatarsal phalangeal joint
• Palpable pain plantar only on both sesamoids, perhaps the medial more
• Plantar pain on both maximum dorsiflexion and plantarflexion of the joint
• Plantar pain on contraction of the flexor hallucis longus against resistance
• Good range of motion of the joint however, although 10 degrees less overall motion than uninvolved side
• Probable negative lachman (swelling present can make the test unreliable)
• MRI showed no apparent fracture but bone edema in the medial sesamoid and surrounding tissue

Cursory Biomechanical Examination  and Asymmetry Noted

• Rigid Pes Cavus Foot Type
• Inverted Heel RCSP
• Mild Tight Achilles Tendons
• Plantar Flexed First Ray Right Worse than Left (perhaps only due to swelling)
• Everted Forefoot Deformity Left greater than right

Tentative Working Diagnosis 

• Medial Sesamoid Stress Fracture (stress fractures may not be seen even on MRI)

Common Differential Diagnosis (2ndary Working Diagnosis)

• Sesamoiditis with Bone Edema

Occam’s Razor and Rule of 3

• Simplest Solution after 6 months of pain and on crutches and a boot is surgical removal (no one would think that wrong)
• Rule of 3 looks for ways to rehabilitate, although can be also used post operatively to have a better outcome.
• The 3 forces that lead to stress in the sesamoids commonly are: tight achilles tendons that must be stretched out, pes cavus feet with high metatarsal declination angles that need to have the re-balanced, and plantar flexed first rays that must be off loaded

What Phase of Rehabilitation?

• Immobilization (but non-weight bearing with crutches can intensify the swelling accumulation and make the patient feel worse than they actually are)

Should We Image?

• X Rays and MRI already done
• I always look at the first MRI as just that “The First”
• I will get another MRI in 6 months to see how the healing is going

First Decision: How to Reduce Pain 0-2

• Minimal to No Crutches as non weight bearing increases swelling to a localized area like this
• Build an accommodation of at least ¼ inch adhesive felt inside of the removable boot (normally up to ½ inch)

Second Decision: Inflammation Concerns

• No NSAIDs due to bone problem
• Ice Packs or Soaks 3 times a day 
• Begin Contrast Bathing each evening to get rid of the bone edema

Third Decision: Any Nerve Component?

• Assume that nerve hyper-sensitivity begins 3 months after a problem like this.
• Start treating with ice for only 5 minutes, warm compresses, non painful massage, topical gels or patches (like Neuro Eze lotion or Lidoderm Patches)

Fourth Decision: Initial Mechanical Changes

• Get the boot comfortable so that we know we have a healing environment (make an internal float)
• Order a 9 month course of Exogen Bone Stimulator
• Begin designing or ordering off weighting pads like Dr. Jill's Dancer’s Pads of a ¼ inch thick

     This particular patient did well with conservative treatment over the next several years and was back running. The mechanical list from Chapter 6 (Book 2 of Practical Biomechanics for the Podiatrist) is so long due to the long period of experimentation needed for a patient like this. I have starred all the ones used for this particular patient as we moved him through his rehabilitation. 

Common Mechanical Changes at the First Metatarsal Phalangeal Joint

1. Spica Taping*
2. Bunion Taping
3. Toe Separators
4. Dancer’s Padding*
5. Cluffy wedges*
6. Morton’s extensions
7. Orthotic Devices for Weight Shift with no extrinsic post*
8. Orthotic Devices of Stability only with no extrinsic post 
9. No Heel Lift*
10. Zero Drop Shoes*
11. Rocker Shoes*
12. Bike Shoes with Embedded Cleats
13. Cam Walkers or Removable Boots*
14. Stiff Shoes (including post operative shoes)*
15. Flexible Shoes
16. Forefoot Padding
17. Skip Lacing*
18. Deep Toe Box*
19. Wide Toe Box
20. Shoe Stretching
21. Carbon Plate Full
22. Carbon Plate Morton’s Extension
23. Carbon Plate Dancer’s Modification
24. Proximal Padding Dorsal or Medial
25. Metatarsal Padding sub 2nd through 4th or 5th*
26. Self Mobilization for Hallux Limitus
27. Metatarsal Doming*
28. Abductor Hallucis Strengthening
29. Flexor and Extensor Hallucis Longus Tendon strengthening*
30. Night Splints and Yoga Toes
31. Correct Toes
32. No Achilles Tightness*
33. Avoid Excess Toe Bend*

 

     I saw this patient once a month for a year to progress the rehabilitation. He was in the boot for almost 3 months from the day I first saw him. While in the boot, he was working on bone health with  diet and bone stimulator, and he was working on the inflammation and nerve sensitivity 5 separate times each day. I should have at least got a Vit D blood level, as transient vitamin D deficiencies can lead to bone issues and prevent or slow down healing.The 2nd 3 months was still partial boot as we weaned him off the boot and into Hoka One One Shoes 1 size bigger and the widest one on the market. I needed room to build things for him. It was at 9 months along our rehab course when he had built up his pain free walking to 5 minutes, that he started the 10 level Walk Run Program. At one year from the start of seeing him, he ran a slow 10K in 73 minutes. In the shoes that he ran in were Hannafords (full length soft based plastazote custom inserts). I had made him a pair of Root Balanced plastic based orthoses due to the lateral column support I needed to get (high everted forefoot deformities) which worked best as scaled down dress orthotic devices. I had made him an Inverted Pair, but he was too laterally unstable as he began to walk and run. I also think the arch began too high in the Inverted pair, so the metatarsal declination pitch became too high. However, rehabilitation of these conditions, with all the modalities at our disposal is pretty awesome.