Oofos: A Soft Sandal for Heel or Ball of Foot Conditions

Oofos is a very cushioned sandal that many of my patients with heel or metatarsal area pain are raving about. They will not replace a removable boot and/or crutches when you need those, but they can help if you are in a more chronic stage. I am really not sure if there is a difference between them and the softness of crocs, but they have various styles to at least experiment with. If I have taught anything on this blog, I hope I have imparted the need for experimentation to help with foot problems. 

https://www.oofos.com/  

Forefoot Pain: Sesamoid or Nerve or Both

Hey Dr Blake, 

Through my despair yesterday I stumbled upon your blog and I must say I am so glad I did. I really wanted to e-mail you though, I hope you don't mind.

I'm a 23 year old female who hurt my foot 3 years ago! I literally stubbed the inside edge of my foot, just half an inch under my first metatarsal head. I never got an X-Ray but I was in agony for about 3 months, my local doctor told me it was just a "BAD bone bruise". If say the pain dissipated about half a year down the line and slowly but surely I got back into my fitness which I loved so dearly. 

For these 3 years pain in my big toe joint had been on and off, the pain itself is felt at the base of the head, sometimes on top but mostly behind but at the outer edge (there it is like a niggly/twingy pain that gets worse with activity) I get pain whenever my toe joint is in a bending push off position..and it ALWAYS clicks, that's recently got worse.
Dr Blake's comment: The niggly pain is nerve, as the biggest nerve in the front of your foot runs right there. It can develop into a condition called "Joplin's neuroma", but the nerve can be irritated and angry from simple internal swelling. The clicking means that there is swelling within the big toe joint, signifying some problem in that joint. 

I saw a private podiatrist about 2 years ago now who got me into Orthotics as she noticed I pronate and had "flexible flat feet". She disposed (diagnosed) me with Hallux Limitus. These helped somewhat, a lot.
Pain would go away for a couple months only to come back if I increased my activity or wore heels then I'd suffer with the pain and swelling for another month. 
Dr Blake's comment: Hallux Limitus is caused by many conditions, and you seem to have a very sensitive big toe joint. X-rays and MRIs are usually needed to help discover what you did to yourself 3 years ago. 

I went to see my doctor who thinks it's a sesamoid issue, so I get my X-Ray results on Fri. My podiatrist recently gave me acupuncture which kind of helped but I found the procedure painful. She also said I should go back in a month and we'll talk about seeing an Orthopaedic for a surgical outlook and also a steroid injection.
Dr Blake's comment: This is all right except I would avoid invasive (even shots) until I knew the diagnosis. Let me know what the x rays showed. 

My arches are also so tight and when I do strengthening exercises it hurts alot. The toe joint is really swollen, mostly on top but icing makes it so much worse, specifically that niggly feeling on the edge underneath, which makes me worry that it is a sesamoid issue. 
Dr Blake's comment: Nerves typically hate ice, so try some version of contrast bathing (see previous posts). Icing typically cools the joint, but does not move swelling out of an area like contrast bathing. Where the initial contact was sounds sesamoid. See if you can get the results of the x-rays to me, and possibly get an MRI. 

I'm just at my wits end because I'm so young and meant to be starting uni this year but exercise means, namely walking, but it hurts too much now and I seem to be compensating with my other foot and my other toes, I would swim but it flares up my acne and also makes my feet too cold which makes my toe sore.

Any advice would be grateful,

Sara (name changed to protect the innocence)

Monday's Image of the Week: Accommodation Par Excellence!!!

Pain in the Metatarsal area is a prime location to try various off weighting pads. These vary from metatarsal pads to dancer's pads to toe pads. Here is a great example of one of my patient's very successful attempts at off weighting the sore area of both feet. I gave her the 1/8 inch adhesive felt from www.mooremedical.com and she found a metatarsal pad. By pointing her in the right direction, and her spending time at home placing pads in various positions, she is feeling better than she has felt in several years. Bet you can tell where she is sore by the pattern of the padding!! 

Ball of the Foot Pain: Email Advice with MRI Images

This nice patient mailed me her CD from New Zealand. She is suffering from pain under and in the big toe joint from many years. This is my report to her.

Image of Tibial Sesamoid under the first metatarsal showing irregularities within the bone. The bone does not look totally healthy, but is not fractured or fragmented.

A slightly different image of the tibial sesamoid. The fibular sesamoid looked healthier. This can simply be from favoring her foot with some demineralization of the bone.

Here a large bursae or ganglion cyst is seen under the tibial sesamoid.  Sesamoid Fractures are often diagnosed when, in fact, the source of pain is in the soft tissue swelling under the sesamoid

Another image of the soft tissue swelling with some swelling in the tibial sesamoid (very slight).

Here we are at the joint level with our slice. The irregular white areas can be also seen below in the next image. This abnormal tissue arises from the plantar (bottom) medial side of the joint (arch side). This tissue, referred to as chronic synovitis, can get trapped in the joint and constantly irritated. Again, since it is on the tibial sesamoid side, it is often misdiagnosed.

Here the irregular soft tissue appears to be coming from the side of the joint. 

Another image of the same soft tissue swelling. When it arises from a joint, it is called a ganglion cyst. This may need surgery to remove the sac of tissue and tie off the stalk where it comes off the joint. 

Great image of this soft tissue mass causing so much problems.

These sacs can be injected with cortisone, not into the joint, to see if they will reduce. If not, they are removed.

Another side image of this mass.

From this view, and others, we know the cyst is filled with fluid. The problem with cortisone is not to inject other than the cyst which is quite small. If your doc feels uneasy about injecting, he/she may recommend surgical removal as a safer approach. Cortisone placed in the wrong spot can be dangerous.

Ball of the Foot Pain: Email Advice

Hi Dr.Blake,

 I have been diagnosed with sesamoiditis and have had this foot pain for over a year now. It is beginning to develop in my other foot as well.

 I have tried almost everything imaginable: two different orthotics, cortisone injection, active release, had a chiropractor tape the joint with kinesio tape and even one of those electric wave machines.

 I really do not know what else to do the pain keeps getting worse. Do you have any other suggestions? I am extremely desperate. - Thanks, Ann (name changed)

Dr Blake's comment: 

     All we know from what you have said is that you have pain under the ball of your foot, that no one feels is broken or arthritic, and the pain is not getting better with people doing things to you. So, I would begin to be more active in your approach (very sports medicine) and begin to see what happens. Take this one month at a time and you can give me a followup 30-40 days from now. So, what can be done:

1. Attempt some form of better diagnosis (xrays, etc).
2. Ice pack the area for 15 minutes twice daily.
3. If swelling or stiffness noted, do contrast bathing once daily or once every other day.
4. Find a shoe that works best whether it is padding or stiff or flat, etc. Try to decide what is best.
5. Put your self in the Immobilization Phase I of Injury Rehabilitation by staying in an Anklizer removable boot or Ovation Medical Boot with EvenUp on the other side.
6. Spica tape your toe daily.
7. See if your doc will prescribe voltaren gel or flector patches for you (at least for when you sleep).
8. Figure out if either of the two pairs of orthotics actually do protect the ball of the foot (we need function not number of). 
9. To specifically deal with the pain, see a pain specialist. Avoid NSAIDs since you could have a bone injury.
10. See if any other activities you are doing daily is irritating things and make some change. 
11. Apply Neuro-Eze to the sore area 3 times daily (buy online).
12. Do Metatarsal Doming and Single Leg Balancing daily to keep some strength in the foot (painlessly). 

I hope this gets you started in a good direction. Rich

Severe Ball of the Foot Pain: Some Points to Consider

Ball of the Foot Pain: Eccentric Flexor Hallucis Strengthening may help

I have been corresponding with this patient for a long time after he injured his right sesamoid bone (forgot which one). The rehabilitation was long, but successful. This is one exercise I have never thought of or recommended that he felt was invaluable. Concentric strengthening of the long flexor to the big toe is to pull the toe downward (a standard exercise). This is eccentric strengthening of the same tendon where the toe is being pulled up while the patient tries to point the toe downward. Therefore, the long flexor (FHL) to the big toe is elongating while contracting which is the definition of an eccentric contraction. We use this technique all the time for hip, knee, and achilles/ankle problems, why not the big toe? You start with 2 sets of 10 reps, and gradually over time build up to 2 sets of 50 reps. Good luck and thank you to my blog patient!!!

Ball of the Foot Pain: Email Correspondance

Dr. Blake,

    I have been dealing with left foot pain for over five months. I was placed in a boot for five weeks for stress reactions in the 1st, and 2nd, and 3rd metatarsals, followed by six weeks of physical therapy. During the physical therapy, the pain on top of the second metatarsal and bottom of the 1st metatarsal got progressively worse and the physical therapist ended up cancelling half of my sessions because of the pain. I also ended up wearing the boot again for two weeks and then a surgical shoe for two weeks during the last four weeks of the physical therapy.

    In the last two months, I have worn athletic shoes full time, minimized the amount of time on my feet, and started experiencing constant swelling over a two inch area down the entire length of the top of my foot. If I spend more than a few minutes on my feet, the pain on the bottom of the 1st metatarsal gets worse and worse. I have also periodically had shooting pain over the 2nd metatarsal when walking.

    I recently had an MRI, which showed marrow edema in the plantar and lateral margins of the 1st metatarsal head and nonspecific marrow edema in the hallux sesamoids. When my doctor initially reviewed the MRI images, he said it looked like I had an extra outer sesamoid. After reviewing other images, however, he decided that this was not the case as he did not see it in those images. There is a black jagged horizontal line through the outer sesamoid in three of the MRI images. Other images of the same sesamoid show no line. Is it possible that this is a partial sesamoid stress fracture? The doctor determined that I have sesamoiditis and told me to wear a metatarsal pad in my shoe for the next six weeks to off-weight the sesamoids. I tried the metatarsal pad, but it has made the pain significantly worse.  

   What do you suggest? 

                                          Thank you!

Dr Blake's comment:

    Hey, thank you so very much for the email. Typically, you have one source of all this pain (say a fractured sesamoid or first metatarsal head) and when treated improperly, the pain and swelling magnifies to involve a larger area. Swelling alone is no big deal since it is a reflection of a healing response of your body. Pain and swelling means you have not stabilized things well enough and healing is being somewhat compromised. Remember stress fractures are tiny cracks in the bone, hurt as much and as long as true fractures, and normally may not be seen other than the bone edema (swelling) noted on the MRI. Thus, the confusion of whether a black line is seen or not probably means stress fracture vs true fracture. Stress fractures on the bottom of your foot take a long time to feel better since first the fracture and then just the resultant bone edema hurt. 

    The things you need to do in the next 2 months are: make sure the inserts have maximal off weight bearing padding (called dancer's pads), make sure you have high and tolerable arch support, ice minimum 3 times a day for 10 minutes to keep cooling down the area, do a full 20 minute contrast bath daily and twice on weekends, learn to spica tape to stabilize the big toe joint, keep your legs strong with biking (you can rest the arch area on the pedal), weight bear to tolerance (all immobilization and non weight bearing can increase the swelling in a foot/weight bearing great for moving swelling, make sure your Vit D and Calcium are normal, eat healthy, use crutches, get a new MRI 3 months after the first, and hang in there for some of these injuries to completely heal can take several years and your job is to create a pain free environment to allow healing. Another 3 tests that could give alot more information are CT scan, bone scan, and CT fusion (which is a combination of the above). If insurance allows, and the way you are struggling, I would try to get more information also with one of these tests. I sure hope this helps. The information on all of this (like contrasts) is all within the blog. 

                                                                    Rich

Ganglion Cyst Mimicking Sesamoid Injury: The Positive Role of an MRI

This young lady emailed me back in Dec 2012 to let me know that she fractured her sesamoid bone and was scheduled for surgery and should she seek another opinion. Her original email is at the bottom of this post. I encouraged her to get a second opinion. She cancelled the upcoming surgery and followed her gut. What was so different from other cases of sesamoid injuries was her feeling she was stepping on a golf ball. She was able to get another opinion and a MRI documenting the ganglion cyst with no fracture to the sesamoid. 

Dr. Blake,

 I am so sorry that is has taken so long to get back to you but I had an MRI yesterday and I am attaching 2 images. The Dr. suspected and the MRI confirmed that I don't have a sesamoid fracture but a very large ganglion cyst in my foot. I have been scheduled for surgery the end of May to remove the cyst and start the recovery process. Thank you so much for your encouragement to seek a third opinion, I consider you my second opinion,  I truly believe you have saved me a lifetime of suffering. 

Sincerly,

Large Ganglion Cyst is seen next to a totally normal sesamoid

Large  Ganglion Cyst noted on MRI under the first metatarsal near the sesamoids

Dr. Blake,

I was diagnosed with a fibula sesamoid fracture on my left foot. I feel like I am walking on a golf ball and that is what I call it now. I walk on the side of my foot to keep the pressure off of the ball of my foot but that is causing knee pain and hip pain.  The podiatrist that I saw took one set of x-rays sold me cushions for my shoes and arch supports to wear. I tried those for 2 weeks and no relief. When I returned to the podiatrist he suggested since the arch supports provided no relief that I try a cortisone shot. The shot took the inflammation out of my foot, for about a week,  so it felt like the golf ball went away but the pain was more severe since there was not any extra padding on the ball of my foot. I returned to the Dr. 2 weeks later and he said there is nothing else he can do surgery is my only option and sent me home. I feel after reading your blog that I really need a second opinion before I let anyone do surgery on my foot. My question is do I get that second opinion from another podiatrist or do I try to see an orthopedic doctor? I am scheduled for surgery on December 28, 2012. Any help or advice is very much appreciated. I have cried with my husband over this whole situation and how frustrated I am please help. 

Sincerely,

Ball of the Foot Pain: Email Advice

Hi Dr. Blake,

I found your blog on the internet, and was hoping you could shed some light on my rather longstanding foot problem.

Two years ago, after running a bit on the treadmill (no more than 2 miles at a stretch) the ball of my foot starting really hurting.  X rays and an MRI did not show any breaks or stress fracture, and 3 subsequesnt podiatrists diagnosed plantar fasciitis.
Dr Blake's comment: Pain in the ball of the foot is so rarely plantar fasciitis, but you may have a rare case. Normally plantar fasciitis presents with heel pain, and sometimes arch pain, but rarely ball of the foot pain. There is just no tension on the plantar fascia in this area. 

 I tried many treatments for  this including the strassburg sock, a night splint, icing, stretching, even custom orthotics.  The pain would get a bit better, but not go away. The pain seemed to be concentrated just at the base of my big toe, slightly toward the inside of the foot.
Dr Blake's comment: When you try a lot of treatments, try to stick with those that give some, if any, relief, and eliminate those that do not help at all. You may have to go back and add something you have already tried for the next week and see if you are some better. Try one new treatment every week over the next month. Treating plantar fasciitis, or another foot injury, somethings requires 5-6 treatments working in unison all at once. But, who wants to waste time on treatments that either do not help, or possibly aggravate the situation. 

Convinced there was somthing else going on (I never thought I had plantar fasciitis) I went to a physiatrist  (M.D.) specializing in sports injuries and rehabilitation.  He seems to feel the problem is an inflammation of my flexor hallicus brevis muscle and surrounding tissue casused by a weak or compromised hip.  (My gait puts too much pressure coming down on that big toe area.)  So I'm supposed to do hip exercises (which I am doing) and gradually some foot strengthening exercises as well.

He also suggested that instead of orthotics, which were only protecting my arch and doing nothing to protect my forefoot, I needed to wear something that prevented my toe from bending backward too far.  So I'm wearing this sort of half sole steel plate under the existing insole of my asics.  I think these plates are designed for turf toe injuries.  (Initially the injury was only on the left foot, but last year it came on my right foot as well.)
Dr Blake's comments: So, sounds more like Hallux Limitus/Rigidus, or sesamoidits, problems. The orthotic devices for ball of the foot pain must have a lot of work getting the right amount of off weighting, stiffness, and cushion. And the shoes you wear them in, or if you use a plate, must be analyzed and experimented with. It can take alot of work, as you can tell from some of my Hallux Rigidus patients. Definitely sounds like there is movement in the right direction. 

Things seem to be getting better, but very gradually.  My foot doesn't hurt as much while walking.  I can pull my big toes backward without significant pain.  It is only when my big toe is pulled back and there is presssure on it that I get this sharp, stabbing pain down my toe and into my arch.  So, squatting is a problem, I can't stand on my toes, or when walking, I can't really push off too much.  While walking, I try to roll my foot forward instead of pushing off with my toes. Needless to say, I can't walk as fast as I used to.  This injury has been very frustrating to me because I am a very active 52 year old woman.  I can do the stationary bike, but I still can't walk very fast, or do many of the yoga poses I used to do.
Dr Blake's comment: I am assuming that the working diagnosis now is FHB tendinitis. Tendon injuries can be inflammation, a partial tear, or a complete tear. This is an MRI differential, so I recommend getting another one. After the MRI, you will know if it is safe to do PT, aggressive foot strengthening, etc. The MRI will tell us if we have a permanent injury, for you will see if any structures look worse than 2 years ago. 

I think I should start doing the contrast baths.  If it's just inflammation, won't it heal in time?  Is there anything else you might suggest I try?  I feel as if I am getting closer to figuring this thing out, but it seems the pattern is that it gets better for a while, then the slightest thing can aggravate it.  It was doing well last week until, while walking the dog, I mistakenly hurried down the hill with him so he could do his business in the right spot!  Then it took almost a week to be able to walk the way I did before that happened.
Dr Blake's comment: So, assuming that you have found that limiting the toe motion helps you, the three obvious additions without further info are: learn to spica tape (see my videos on the 2 versions), get one of the rocker bottom but stable shoes, like the New Balance 926, and have your orthotics modifed for more rigidity across the metatarsals (some form of extension under the metatarsal heads. You also need to be doing 3 to 5 minutes of foot exercises that do not hurt, like met doming, single leg balancing, etc. I have videos on all of these. It will take you a year from now to get your injured foot very strong, so that you can get back to all your activities. 

Your blog contains some great information, and it is so kind of you to try to help as many people as possible and encourage questions from readers.  I know it's difficult to diagnose problems and suggest treatments without seeing a patient, but I hope I've given you enough information to at least give you a sense of what is going on with me.  Basically, I can't put full weight on my big toe while it is flexed upward.  Can you see a time frame for me to be back to normal?
Dr Blake's comment: You may just have some neural tension in the deep peroneal nerve. This, of course, would be missed on an MRI, and give you some neurological symptoms of numbness, tingling, sharp, burning, etc. Ask the physiatrist if this is a possiblity. Good luck and I hope this helps some. Rich

Thank you for any insight, and may God Bless you.

Leslie (in Virginia)  (name changed)

Ball of Foot Pain: Email Advice

Dear Dr. Blake,
I have had a severe foot pain for many years that I cannot understand. The pain is located on the bottom of my foot, in between the first and second toe area, next to the joint of the big toe.  Can you look at my xray image and tell me if you see anything that might be causing it?  I'm concerned that a piece of bone has broken off of my large toe, underneath, and it isn't being detected because the x-ray is taken from the top, as best as I can tell.  Also, can you explain what the white circle on the right of the big toe in the xray is?
I'm sending the other view in the next email.

Thank you very much for your help.

Dear Margaret (name changed), 

     There are 2 very obvious possibilities, and probable a dozen of other ones. Pain between the first and second joints can be caused by the big toe sliding off of the joint laterally (towards the second) which is happening with you. I placed the pointer on the part of the base of the toe that is actually off the joint. You can see where the normal part of the first metatarsal head ends (the white strong part). You have a 2 mm subluxation of the toe on the metatarsal. If I placed your knee cap 2 mm out of its normal groove with the femur and had you move your knee, it would start to hurt very badly. You can check the blog on how to tape the big toe medially (bunion taping with kinesiotape or 3M Nexcare tape). Tape the toe over for a week and also use a medium gel toe separator (found in bunion posts) and see if you can see any relief. I do not see any bone spurs or chips. 

     The second reason is that the 2nd toe is subluxing toward the 1st toe. This happens alot with long 2nd metatarsals. See how the second toe sits on the 2nd metatarsal, and compare to how the 3rd toe sits on the third metatarsal. The 3rd joint is straighter, the 2nd toe looks like (and is) leaning over to the first toe. This again can give you pain in that area. Tape the 2nd toe to the 3rd and 4th for a week with 1 inch tape. See if that eases some of the intensity.

     I am very impressed on how white the 2nd toe is, but it could be just my copy. Whiteness on bone means stress. The second metatarsal should be whiter than the 2nd toe, since it handles more weight bearing. In your case, the toe is whiter than the metatarsal. Something is rotten in Denmark. 

     Another common structure in that area is the deep peroneal nerve. It can get irritated by the above mechanical problems, or other causes of stress like over pronation and some weight bearing repetitive stress like high heels or elliptical. The nerve can actually be irritated at your back around discs L4L5. Is the quality of your symptoms nervy--burning, tingling, electrical, buzzing, etc? 

     Since you have had severe pain, have you been able to get an MRI? That would probably help us immensely. Any other clues you can email me I will attach later to this post. Everyone is curious at helping you. I hope this helps some.  Rich At least tell me what helps the pain temporarily and what definitely bothers it. Thanks

Dear Dr. Blake, 

Thank you very much for your post. I will try to tape them the way that you suggested to see if that helps.

This all started when I was rear-ended on the interstate about 6 years ago by a 4 x 4 truck, about a 4000 lb truck, going about 75 mph.  I was going about 55 mph. The truck had a crash bar on the front, so it jettisoned my car forward, my car being only 1800 lb. In response to realizing the truck was about to hit us, I braced for the impact and floored the gas pedal to the floor. The last thing I remember was it felt like I stepped on a marshmallow, before I momentarily lost consciousness. I came to in time to get back up on the steering wheel, and get the car to the side of the road. I had no memory of what happened during the brief moment I lost consciousness.  No help arrived the scene for over an hour and half, and by then I was somewhat cognizant, and did not realize the extent of my injury, so I did not go to the ER.  Bad mistake. 

The next day my right foot really hurt, but I could not put the full weight on it because my pelvic area hurt so bad. A doctor told me later that I had smashed my knee in the dash. Right around the time we were starting to deal with the foot pain, I lost my insurance, so it went untreated for a long time. To avoid the pain at the ball of my foot, I have learned to curl my toes up when I walk to keep weight off that area. 

In these x-rays, I see a piece of bone, it looks like, near the little toe, in between the 4 and 5th toes area. I can feel it sometimes, its like something sharp is in my foot, cutting it. And when I look at the big toe, it looks like a fracture sideways. 

I am curious as to what is that white circle by the big toe on the xray on the right of the big toe, is that just where the xray overexposes?  I saw that on other foot xray's I saw on the internet.  One doctor told me a long time ago when I said "Thank God, I didn't break my foot"' and he commented "But you did" but he never went into any explanation of where it was broken. Can you tell?  Is it possible for a piece of broken bone to be behind the big toe on the xray, and it can't be seen?  I can tell from all the xrays I've looked at on the internet, that reading xrays is really an art that requires a lot of skill and experience.

Thank you.

Margaret,
     Wow!! You were very lucky! The white circle is called a sesamoid bone and it is normal. You could have injured it or the ligaments under the big toe joint in your accident. Look up a condition called Turf Toe to get an idea. There are a myriad on structures that could be injured and give you these symptoms. The X-ray below is called a Plantar Axial. You should get that, and an MRI, or at least the plantar axial. It will show if any structures under the big toe joint are injured. Here is an example.

Pain in the Ball of the Foot: Email Advice

Dr Blake,


I just came across your blog! Long story gets longer...In Dec 2008 I jumped over a large puddle on asphalt wearing tennis shoes, immediately I had a very sharp pain in the ball of my foot at the base of my big toe. I worked the rest of the day and when I got home I took some Advil and iced my foot and went to bed. The next day I could not put any weight at all on my left foot or even put on a shoe. I made an appointment and saw a podiatrist that stated with x-rays that I had a fracture at the base of my big toe joint, and a fractured 1st metatarsal. I was given an above the calf boot and crutches. The pain never subsided. It was then determined that the pain was from my bunion and bunion surgery was performed. Only to still have the same horrible pain on the bottom of my foot, numbness from the arch of my foot to the tip of my toe, and a big toe that no longer bends at the end and very minimal at the large joint at the base of my toe.

Now 3 years later... I had just come to the conclusion this was going to be how my foot would be and I was going to just have to live with it. I began to lightly walk jog. Within one week, the pain that had never really gone away was so unbearable I thought I re-broke my foot. This time I went to an orthopedic foot Dr. after reviewing all of my x-rays from previous injury and new x-rays from now, it was determined I had never broken my foot and that I had a bipartite sesamoid bone. His diagnosis has been sesamoiditits. It has been 5 months and I have tried to cut out a pad so that area of my foot is over the hole. I have also tried gel pads that sit behind the sesamoid area. The pain is now 24/7. It wakes me up in the middle of the night; I have a really hard time even being up on my feet. The orthopedic Dr. has decided that it would be beneficial to shave down the sesamoid bone and "hope" that it will reduce the pain. I’m so scared to have surgery! I already have what appears to permanent numbness and I’m very scared to have another surgery. I’m 39 years old and am terrified that my foot has been permanently injured. Do you have any suggestions?

Sincerely

Dawn

Dawn, First of all I must put in the disclaimer that I can only speak in generalizations and can never take the place of a doctor that can look at your foot and see all the tests, etc. That being said, these are my initial thoughts.

     You probably landed hard and broke one or both of the sesamoids under the big toe joint. This is much easier to do (since they are lower to the ground) then to break the first metatarsal and big toe bone. See the image below on the anatomy.

The bottom of this image is the floor. The sesamoids are great protection for the first metatarsal and will break before it will.

Bipartite sesamoids look like fractures, fractures can look like bipartite sesamoids, bipartite sesamoids can fracture, so I am never sure on xray what is going on. A bone scan or MRI is needed to tell the difference between the 2. Let us assume you have a broken bipartite sesamoid which never healed.

Now, sesamoids are notorious for slowly healing, and some fail in that process despite appropriate treatment. So do not take anything personally. Your sesamoid was not mad at you or something like that. You need to get an MRI to verify the bone is damaged. A bipartite sesamoid has normal bone density on MRI, and a fractured sesamoid is all full of fluid.

Anatomical Skeleton of the foot showing the 2 sesamoid bones under the first metatarsal (ball of the foot).

CT image of a broken or bipartite sesamoid (looks like either to me). Turns out both sesamoids were hurt in this patient, yet both became asymptomatic with removable casting.

Sesamoid accommodation placed under the bladder in a removable boot.

Remember to wear socks like this when you stop loving your foot. It will help get the love back.

These poppies will always make me happy.

When you injure the sesamoids, there is alot of nerve pain symptoms. There are alot of nerves in this area which become hyper-sensitive to protect the area. Chronic pain in an area can also lead to more pain (pain begets pain). Chronic swelling in an injured area can produce pain as the tissue gets starved for blood flow (the same ischemic pain as in angina). Also, and one of the reasons you need to know if you have truly hurt the sesamoid, another cause of your pain could be nerve trauma pain. If you read through my blog, you will see mucho treatments for sesamoid injuries which you have not been doing. You will also see reference to treatment of nerve pain, which is rarely immobilization and allowing the pain to continue.

So Dawn, please get the MRI to decide if it was a sesamoid injury (which will probably have to be removed, but you should do great with that). If you do have a sesamoid injury, see if you can get the pain calmed down for several months (the old break the pain cycle routine!!) before considering surgery. See a nerve specialist now to make sure your nerve pain, probably initially secondary to the sesamoid injury, is now advanced to some version of complex regional pain syndrome (meaning that it is taking on a mind of its own). CRPS has its own set of treatments, and even when surgery is anticipated, surgery is normally delayed under the pain syndrome can get under control.

Thank you for your email Dawn, and I wish you luck. You can write a comment to this post any time you would like over the next few months, or years, as you learn more info, or if you have more questions. Did I answer your basic question? Rich Blake

Rich and Patty Blake gearing up early for another Halloween Party.

PS. I have never seen anyone have their sesamoid shaved.