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. 

General Approach to See Patients

I thought I would share the general thought process I take with patients day in and day out. This 14 step approach has served me well (and of course complexed when a patient has multiple injuries and problems at the same time). Still the process of talking, evaluating, making decisions, and then seeing the patient in followup is time tried and true. Rich   

First, let’s review the general biomechanical approach for the first few visits (this can be accomplished in 1-3 visits based on the time you are allowed per patient). These are the common steps in a general biomechanical approach for the first several visits dealing with a new patient or new problem:

1. History and Chief Complaint of the injury and the patient’s understanding why they were injured.

2. Gait evaluation of walking (running is crucial if their activity requires running) to decide on gait patterns and if the patient’s complaint matches). And, if you are fortunate to use a computerized system it can help you here. 

3. Physical examination of the injured part (begin to separate the 3 sources of pain: mechanical, inflammatory, and neuropathic).

4. Physical examination of possible biomechanics involved.

5. Is there biomechanical asymmetry? 

6. Tentative working diagnosis made (your best guess).

7. Common Differential Diagnosis: common not rare (a good possibility, not all of the distant possibilities).

8. Occam’s Razor (simplest solution is most likely the solution)  and the Rule of 3 (3 most common causes and their treatment) for initial treatment help.

9. What Phase of Rehabilitation is the patient in at this visit? Immobilization, Re-Strengthening, Return to Activity. 

10. Should we do Imaging at this point?

11. First Decision: What do I have to do to get the pain consistently between 0-2? This is the real reason that the patient has to be put into Phase 1 of Rehabilitation where PRICE rules. The 0-2 pain level realm is where injuries can heal.

12. Second Decision: How Much Inflammation needs to be Addressed?

13. Third Decision: Is there any neurological component that should be treated?

14. Fourth Decision: What mechanical changes can I make in the first few visits that may help the pain relief, better biomechanics, and cause reversal? 

                               Patient #1

     History and Chief Complaint A 22 year old ballet dancer presents mid season with right big toe joint pain.

The rehearsals for Swan Lake had been very intense the last few weeks before her pain began. She feels that she just bruised it somehow and that it is really no big deal. She never had this problem before and can not remember doing anything. The pain is aching, not sharp. The pain is the dorsal joint, not medial or plantar. She would describe pain as 4-5 when performing, 3 when getting out of bed, 1-2 when walking around with a feel that she is walking on the outside of her foot a little, and 0 at rest. 

     Gait Evaluation In this case, a ballet technique examination may be necessary if the problem is recalcitrant or keeps reoccurring, as this sounds like a ballet overuse injury.  At the initial visit, the patient wore some flip flops as it was her day off, but barefoot she was a mild pronator, and she did not appear to limp. She did not bring in her ballet shoes for evaluation. Even if you do not know ballet well, the shoes can help in the wear patterns right to left both in the ballet pointe shoes and ballet slippers.  

     Physical Examination The examination reveals slight big toe swelling, no redness, no palpable pain, mild stage 2 bunion, and negative tendon and ligament stress tests. The patient had hypermobile metatarsal phalangeal joints, with over 90 degrees of big toe joint dorsiflexion, and a long first toe only on the injured side.                                                     

     Cursory Biomechanical Examination  and Asymmetry Noted Different from the normal physical examination of the injury, this looks further into the biomechanics of the patient that could have caused the injury or will slow down the rehabilitation, or just allow the problem to come back over and over again. The cursory biomechanical review included excessive ranges of motion allowing possible excessive big toe joint stress (as noted above), a pes cavus foot type with slight hallux hammertoe, forefoot valgus foot type, callus formation under the first and fifth metatarsals, first ray motion more than 10 mm but abnormally plantar flexed, a relaxed calcaneal stance position 5 everted right 3 everted left, no tight achilles tendons, pronation worse on the injured right side, great FHL strength. Therefore, marked biomechanical stresses (which will be discussed below), which could all be related in some way to our injury cause and upcoming treatment plan. 

     Tentative Working Diagnosis (your best guess) is based on your experience, historical review, and physical examination. Definitely ballet can overuse the big toe joint. My best guess would be a sprain of the big toe joint as a stress fracture would be more swollen. 

     Common Differential Diagnosis (2ndary Working Diagnosis) is not a list of the 10 possibilities in a standard differential, but the next best guess if proven that the tentative working diagnosis is wrong. For me, in the sports arena, overuse injuries are stress fractures or stress reactions until proven otherwise even though the examination does not match her pain level. 

     Occam’s Razor and Rule of 3 Occam’s Razor to me means the simplest solution is usually the solution. In this case, the simplest solution is to stop ballet until all the symptoms are fine, and then gradually wean back into ballet. Here is where the Rule of 3 helps out tremendously. Most ballet dancers would seek care elsewhere if told to stop dancing. The Rule of 3 means that we need to find 3 treatments based on our examination of possible causes that should help the patient progress. And, you can add 3 more next visit also if needed. The joint was sore and the dancer probably sprained her joint, so taping the joint to immobilize some is one good treatment. With a bunion deformity and a long hallux, the big toe joint typically gets stretched medially and pinched laterally, so the taping can try to correct that. Since the patient has a plantar flexed first metatarsal (typically causing more pressure on the first metatarsal), a dancer’s pad (aka Reverse Morton’s Extension) can help. And #3, using a Hapad adhesive felt arch support in all her ballet shoes, and her day to day shoes can both off weight the sore area and prevent the excessive pronation she presents with. Therefore the Rule of 3 helped us start treating based on her specific biomechanics. 

     What Phase of Rehabilitation? This patient is typically like so many patients really between phases. She needs some activity modification (in an attempt to get her pain more consistently 0-2). She also needs to ice, and will get some daily PT for anti-inflammation since she is in a ballet group. These are Phase 1 treatments, but she will continue to dance as we experiment with padding, taping, etc, so I would put her in the Return to Activity Phase 3. She is hurt, but she can dance completely, therefore she is definitely Phase 3. Phase 1 you are completely restricting her activity, and Phase 2 she can not dance professionally but you are working her through her sports routines. If she worsens as we attempt to get a handle on the injury, we may have to put her into Phase 1 or 2. Sometimes this is a big rehab failure, when the patient is not put into the right phase of restriction when they present with worsening symptoms. The patient should improve each visit, or changes are needed. 

     Should We Image? This is presenting as a minor soft tissue injury, so imaging will be delayed. 

     First Decision: How to Reduce Pain 0-2 This is for everything. The pain 4-5 when performing is too high. We have to reduce her rehearsals, and experiment with the above treatments to see if the pain can be reduced (our local dance medicine expert Joey Levinson had her get wider shoes just after her visit that helped). I prefer not to use NSAIDs at all as it masks pain and slows down bone healing (which we presently do not know if she has). Therefore my standard anti-inflammatory cocktail is icing twice daily, and contrast bathing each evening. 

     Second Decision: Inflammation Concerns This blends into the first decision as working on any inflammation (swelling, sudden stiffness, redness) found is crucial at helping these patients. If inflammation is found, and there was only a slight amount of swelling in this case, it needs to be addressed. My icing twice daily (especially just after she aggravates it) is important. 

     Third Decision: Any Nerve Component? This appears hard for patients and doctors to assess. Nerve pain can be numbness, radiating, electric, buzzing, vibrating, sharp, and just a hyper-sensitivity. Chronic pain (pain over 3 months) can lead to nerve hyper-sensitivity or tissue neural tension. The pain from nerves alone rarely swell, and it is characterized as pain out of proportion to the physical findings. In this case, no nerve pain was discovered or considered.  

     Fourth Decision: Initial Mechanical Changes This is now I end my initial visit with the patient--with 3 or 4 easy but effective mechanical treatments. Many times they are in a prescription to purchase. Sometimes, I am able to dispense something I have in my laboratory, or show them some tape technique (I pretty much love to tape all of my patients if I can find something to help them). Some of these treatments will be temporary until a more permanent fix can be found or made. Some of these day one treatments are forever (like toe separators for bunion improvement). In this case, the initial mechanical treatments were spica taping with an effort to straighten the bunion deformity, dancer’s padding instructions for her to attempt (luckily she had a PT who worked half days at the ballet), and medium Hapad longitudinal medial arch pads for pronation control and off weighting. 

     For this individual patient, the initial treatment was completely successful. It did take about 4 weeks with reduced dancing (50%) to really get her symptoms in control. For this injury, I did see her one other time for ballet slipper and pointe shoe application of arch supports (Hapad adhesive felt) and dancer’s pads. She was advised to wear medium gel toe separators long term for her bunions. Due to the pronation right greater than left, I had wanted her to get orthotic devices for her daily shoes (athletic and fashion casual) but I am not sure if that ever happened. That was for long term prevention.