Sesamoid Injuries: Thoughts on Chronic Inflammation

Patients with sesamoid injuries deal with three types of pain: mechanical, inflammatory, and neuropathic (nerve-related). I thought this discussion with a patient would be helpful. They are trying to progress from non-weight bearing (NWB) to a weight bearing (WB) removable boot. 

Hi dr Blake, I seem to be finally making some progress as pain has significantly decreased. Starting the day of thanksgiving I have been on a knee scooter 95 percent of the time not stressing my foot at all. When I do need to walk it’s not more than a few hundred steps a day in my walking boot. I’m getting ESWT done weekly and have had a few sessions of dry needling with my PT. My custom orthotics have come in and they have been helping with the sclerotic sesamoid pain on my left foot.  I also have gone back to the gym to try and fight some of the atrophy I have faced all this time by doing NWB leg strengthening exercises. Though the pain has decreased, the inflammation is still present, and especially at the end of the day is it worse. I’m not sure when it is time to transition out of the scooter and into the boot or if I ditch the boot. Because even when I use the boot the inflammation is present. I don’t understand why inflammation is still there if it’s starting to heal, I would imagine if it’s healing the inflammation would subside. So it’s really hard to not get discouraged that maybe I’m not healing after all even though the pain has lessened. I tried to read the blog and find more out about inflammation but was hitting a dead end. Does it sound like I’m on the right track? Thank you

You are definitely on the right track, putting good pieces of this complex puzzle together. Dallas, there are two types of inflammation, acute (right after an injury), and chronic (related to the body's attempt at healing). Since inflammation causes symptoms, it is one of the hurdles you have to understand more. Swelling, which I assume you are doing contrast bathing in some regularity, will limit you, but you can still progress. Everything has to be done gradually. If you have been in a good place (0-2) for the last month, begin to transition from knee scooter to boot with your orthotics within the boot. The transition should be 2-3 days at one hour and then progress in 30-60 minute intervals every 3rd day as long as the pain remains low, and your expected increased pain is back to normal the next day. Hope this helps. Rich