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 

                                                 . 

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. 

Treatment of Big Toe Joint Pain

Common Non-Surgical Treatments for a Painful First MPJ

                                        By Richard L Blake DPM MS

                                              

 

The first metatarsophalangeal joint is a fascinating area to treat because of all the variables involved. Since the end of normal stance in the gait cycle ends with pushing off the hallux with first metatarsal plantar flexion, we can have a difficult assignment. Patients with chronic big toe joint pain (including sesamoid problems, hallux rigidus, or chronic turf toe) may need multiple orthotic devices with modifications and accessories. Why do orthotic devices not work for these problems at times? Varus corrected orthotic devices work for some people to shift the body’s weight more lateral, but the higher the arch you make, the more plantar flexed the first metatarsal becomes, which can force the first MTPJ further into the ground and become further bent, worsening the pain. Therefore, where some custom orthotic devices (even an orthotic device made expertly for a pes cavus foot type) may work sometimes, other times you have to make a flatter arched orthotic device or no orthotic device at all. Below we will talk about various mechanical changes to help big toe joint pain in various stages and injury (from subacute to chronic to maintenance). I commonly think of pain in the big toe joint coming from excessive ground pressure, too much bend, malalignment with valgus forces, superficial pressure from shoe gear, compression forces across the joint, or a combination of some or all of these forces. To affect many of these causes, you have to direct treatment towards the propulsive phase of gait. Below are several strategies, (amongst many more!) that I hope will help you think outside your normal routine in creating a stable joint and improving pain.

Of course, it may be the left non bunion side that hurts

 

Immobilization Techniques

 

Spica taping helps restrict 1st MTPJ dorsiflexion. It is commonly learned with KT tape or Rock Tape since it goes around the bends of the toe easily. If the patient needs more restriction, and has the basic skill down, then 3M Nexcare Waterproof Tape is used. Typically one inch wide tape 7 to 8 inches long is centered dorsally over the top of the hallux. First the medial leg is brought down under the big toe joint and then runs under the first metatarsal. Then, the lateral leg is brought down under the big toe joint, and then runs parallel to the first strip along the same orientation of the first metatarsal. At least one half of the lateral leg should be touching the skin so that the tape can last 3-4 days. Rub the finished product to activate the glue of KT or Rock Tape for one minute. The big toe itself when you are finished should be just slightly below the 2nd toe. Spica taping is classic for hallux rigidus and turf toe, but can distribute the weight bearing forces away from the sesamoid for sesamoiditis or fractures as well. Spica taping can increase the compressive forces across the joint, which may hurt, so this may not work for all patients. https://youtu.be/l_4HESXCG40

       Spica Taping with paper tape to secure some loosened edges

 

Bunion taping is a technique done the same as the Spica taping except with different starting point and leg orientation. Done with the same tape as Spica taping, the center is placed on the lateral side of the hallux with one arm going superiorly and one leg inferiorly. When applied, the hallux is placed in neutral and first the plantar arm comes under the big toe joint and laid along the medial side of the first metatarsal. This is where you, and ultimately the patient, has to play with how tight to make it, balancing correction and too much pressure. The superior arm then comes across the joint and again is laid down on the medial side of the first metatarsal with about half touching new skin and half overlapping the other arm. This technique not only centers the joint, but also restricts some joint motion. Again, one minute of massage helps activate the glue. https://youtu.be/uD348O7pKwo

 

 

Accessories

 

Toe Separators/spreaders come in various shapes and sizes and materials. A medium gel toe separator that has the shape of an hour glass is conservative bunion care 101. Foam toe separators have more width and therefore work better for a lot of my patients. They can, however, be too long and cause ingrown toenails, but you can simply shorten them with a scissor. With overlapping toes, you either need the hour glass shape of the gel ones, or the toe separator that slips over the 2nd toe (or 1^st and 2^nd toes) and has a toe separator attached medially to the second toe, taking care it doesn’t migrate and sit under the 2nd toe, potentially worsening a hammertoe. My mantra in bunion care is to maintain stage 2. The toe separator immediately puts the bunion, which may have started the day in stage 3 or 4, back into stage 2. As you walk, the forces through the big toe joint are more normal and should slow down the retrograde forces. This centering of the joint will allow for normal muscle development and strengthening, as well as help alleviate pain from lateral joint impingement. Toe separators can and should be used after bunion surgery, if no second hammertoe surgery was done, to help maintain the correction while the muscles and scar tissue are transforming.

 

Carbon Plates with Morton’s Extension work well with an orthotic device on top. Here only the first metatarsal head and hallux have the carbon plate distally. You want a Varus biased orthotic device that gets you into the middle of the foot well. However, with some severely pronated feet, this can be a great challenge. If you can get the weight more central, this device works well allowing normal motion without big toe bend and it is appropriate to only use on the symptomatic side. A common problem with this design is when the hallux is too far lateral and falls off of the plate. Sometimes you have to use bunion taping (as previously described) and/or toe separators (also previously described) to get the hallux over the Morton’s extension. And again, if the patient pronates too severely into the Morton’s extension, the pressure can be too much, and may be more a candidate for the next design. https://jmsplastics.com/product/nrg-plates/

 

 

Correct Toes invented by Oregon podiatrist Dr. Ray McClanahan, slips over each toe, gently separating them, and were designed to use for walking and running. Since Correct Toes will place each toe in a much separated position from each other, there are only a select group of shoes that they will fit into. I tell my patients to look at the list on the following website, also start with walking around the house in loose slippers to get the feel of them. Altra, Keen, and Lems shoes are my go-to shoes right now known for their wide forefoot. Some patients have too narrow a foot for the current design, so I often remove the area lateral to the 3^rd or 4^th toes and they are still getting the benefit of the separation of the 1st, 2nd, and 3rd toes. Even if the patient wears them for a short time at home, they will get a benefit from them and many have described a greater sense of power at push off. https://www.correcttoes.com/

 

Orthotic Modifications

 

Dancer’s padding/reverse Morton’s extension is a ⅛ inch or ¼ inch pad that typically goes under the second through fifth metatarsal (1). If the fifth metatarsal has symptoms, then place it only under the second through fourth metatarsals. It can be applied to anything (orthotic device, shoe insert, sandal, ballet slipper, bare foot, etc.). If you increase the padding to ¼ inch, make sure the patient does not feel that they are “falling into a hole” which would make things worse. You can also offset the second pad a little laterally and proximally (or distally) which helps transition the edges (if you are layering 1/8 inch pads like adhesive felt). This pad typically reduces the plantar pressures across the joint by 50% or more, however, many times the pronation effect of the dancer’s pad must be balanced by an arch support to pull the patient laterally at the midfoot. I prefer OTC non plastic orthotic devices for this since the goal of plastic based orthotic devices is meant to increase 1st MTPJ motion. It may just not be the right time in the rehabilitation for a custom plastic device (Return to Activity Phase) when you are trying to off load a sore sesamoid or painful hallux rigidus (Immobilization Phase). I recommend Dr. Jill’s Gel Dancer’s Pads to every one of my patients with big toe joint pain. https://drjillsfootpads.com/retail/ They come in ⅛ inch and ¼ inch, and sometimes you need to make the hole bigger, depending on the patient’s problem. They stick on one side, which allows you to place it directly on skin or on an orthotic device or shoe insert, and are primarily for sesamoid injuries. You typically only need to place it on the affected side, unless you are using ¼ inch, which you should use a ⅛ inch on the contralateral side for balance.

 https://youtu.be/GG-mSjtSwj8

 

Cluffy wedges were designed by Dr. James Clough (play off his last name) in Oregon (2). It is a small pad that fits into the sulcus under the proximal phalanx to offload the sesamoids as your weight rolls forward. The ⅛ inch adhesive felt is usually 1 inch by 1 inch or slightly smaller. It cannot go under the distal phalanx or it will increase 1st MTPJ dorsiflexion. I never used it until 10 years ago when a patient of Dr. Clough moved to San Francisco and needed a new podiatrist. She was wearing her cluffy wedge as part of a fractured sesamoid treatment. When I asked her if it was helpful, she stated she would not leave home without it. So, it became part of my treatment from that point on, and like most of these mechanical treatments, 50% of patients feel that it is very helpful. So, when patients present with 1st MTPJ pain on their first visit to my office, they all leave with three mechanical changes to begin to manipulate the symptoms: spica taping, dancer’s padding, and cluffy wedges.

                                                                                      

No Heel Lifts is the general principle in treating any metatarsal problem (3). It can be a challenge when the heel lift is for a short leg which just happens to be on the side of the big toe joint problem. This can be remedied by making the lift into sulcus length with a cutout for the big toe joint (lift with dancer’s pad combined). A patient with an orthotic with a rearfoot post for increased stability can also act as a heel lift. This can be remedied by removing the rearfoot post and placing midfoot medial and lateral supports to hold correction. I using the rubber cork from JMS Plastics ¼ inch in the medial arch and ⅛ inch under the cuboid/5th metatarsal base. If the heel lifts are for Achilles tendonitis, then you have to decide what the worst pain is for now and make the appropriate adjustments. Lastly, patients should of course avoid shoes that have any heel for often longer than it takes for the 1st MTPJ pain to resolve (typically an extra month).

     The side note to this is that flat shoes with no lift in the heel can make it harder and more stressful to push off. Typically, the no heel lift rule works for standing long hours since the weight gets back into your heels more. But, if flat shoes are painful to push off when walking and/or running, try to combine a small heel (even ¼ inch can help) with some good forefoot cushion and flexibility.

 

 

Shoe Variations

 

Rocker Shoes have been popularized by the Hoka One One shoe company and are a must try for my 1st MTPJ pain patients (4). These shoes are much better than the extrinsic rockers we used to ask shoe cobblers to add to shoes, as these tended to be a tripping hazard for my patients. The position of the rocker has to be just right to roll the patient gently across the injury, so your patients should speak to the salespeople about the 3 common positions for the rockers and what shoes have which one. Some of the shoes will naturally put a slight Varus bias in the roll which may help until they break down laterally, which is when patients will need to replace their shoes. New Balance 928 and the dress shoe line Allegria also have rocker bottom options. One negative of rocker shoes, however, is that sometimes the heel is too unstable and can create a negative heel effect, which can be further damaging for the 1st MTPJ. Rocker shoes do separate the ground from the foot more than traditional shoes, and elderly patients in particular do have to be extra careful about tripping.

 

Bike Shoes with embedded cleats have been a wonderful find for my practice. Chrome, a San Francisco company specializing in bike messenger apparel, has a line of non-athletic looking bike shoes that can pass as semi-dress shoes. Other companies like Shimano or Pearl Izumi have mountain bike shoes, called “hike and bike shoes”. The cleat is embedded so you are not walking on awkward cleats, and they serve as a very stiff soled shoe. These can be a much better solution than a CAM walker with an EvenUp on the opposite side, and are less irritating to people’s backs. The motion in these is abnormal, using more hip and knee motion since you cannot push off, but since they are used as a pair the symmetry tends to work well. Even if the patient is initially in a boot, these shoes or Hoka rocker shoes may be a great transition before normal shoes. You can also wear your orthotic devices, dancer’s padding, cluffy wedges, spica taping, etc. with this shoe (as well as with the boot). Just be careful when wearing outside during the rainy season, as these are more slippery than regular shoes!

 

Skip lacing can dramatically take pressure off the 1st MTPJ. The distal medial hole of the shoe lacing may or may not be over the big toe joint, but it can still produce pressure downward from the top. You can skip the medial and lateral last two holes distally, or you can just skip the medial hole to better maintain shoe stability. First, take out all of the laces except the most distal. Make sure that the laces are even. Take out only the lace that runs through the hole near the big toe and transfer it through the hole one above that is still on the medial side and then through the hole directly lateral. If you think about it, if you had placed it originally in the distal medial hole, it then would have ended up here in the second lateral hole. The original distal lateral lace will also go through the second medial hole, so two laces through the same hole. From this point on, the lacing is normal up towards the ankle. This will alleviate pressure from the top down onto the big toe joint. The link attached has a lot of other fun lacing variations to try.  https://runrepeat.com/top-10-running-shoe-lacing-techniques

Here the right big toe joint area is skipped

 

Exercising/Strengthening

 

Self Mobilization for Hallux Limitus (5) is a gentle tool that patients can learn when the range of motion of the big toe joint is limited. The technique of self mobilization was taught to me by Drs. Rue Tikker and Timothy Shea and has been a valuable part of my practice for 40 years. The principle of self mobilization is short, quick motions in directions that are not normal for the joint to move. So, to improve dorsiflexion or plantarflexion of the big toe joint, and to break up some scar adhesions, you perform four motions:

1. Dorsal and Plantar Gliding
2. Side to Side Rotation
3. Clockwise and Counter Clockwise Rotation
4. Long Axis Extension

These are grade 5 mobilization exercises, so are meant to be done with quick movements. I measure before and after mobilization and typically get a 5, sometimes 10 degrees gain. The principle of mobilization in this case is to stabilize the proximal segment (metatarsal) and move the distal segment (proximal phalanx). So, you stabilize the first metatarsal head so that does not move, and you grab the proximal phalanx of the hallux. Remember you are moving the proximal phalanx on the first metatarsal head in 4 ways it does not normally move. You glide it up and down, you abduct and adduct, you rotate like a clock in both directions, and you pull it out straight.  The patient must do it 3 to 4 times a day to slowly gain motion, and maintenance for some will be once a day indefinitely. https://youtu.be/FBTeWbdGrzs

 

Metatarsal Doming or Arcing is the best way to strengthen the short flexors (hallucis brevis) along with Single Leg Balancing. Metatarsal doming is an isometric exercise for a six second count, four second relaxation and then repeated ten times total, for at least three times a day. While standing or sitting, the first part of the exercise involves straightening all of the toes. Keeping your toes reasonably straight, lift the metatarsal heads upwards while keeping the tips of your toes against the ground as you count to 6. Try to feel the tension in the metatarsal arch as you squeeze the tissue as you do with every isometric. That squeeze feel is developing muscle bulk and tone, and patients begin to feel the difference in their feet within weeks. Once they are doing the exercise correctly and consistently, they can do it in the supermarket checkout line, etc, without having to look down. https://youtu.be/GY-mJjXmeIc

 

 

No Achilles Tightness is a very important aspect of 1st MTPJ treatment (6). A tight Achilles’ tendon drives a tremendous force downward into the metatarsals, which the ground reactive forces have to match. It is why when we talk about vital measurements, Achilles flexibility is crucial to learn. When the ankle can't bend past ninety degrees (more subtle forces as the bend gets closer to 10 degrees) at the middle of mid stance and as the body weight continues to move forward, the heel will lift up early, the midfoot collapses, or the foot abducts, all of which drive abnormal pressure into the forefoot. When you stretch the Achilles’ tendons, both with straight knee and bent knee positions, the actual stretching itself can put a lot of pressure on the big toe joint. Instead, you can hang the big toe joint off the end of a thick book, so as you stretch no weight goes into the big toe joint. You can also build a well with 4 books arranged to make a float for one spot. Purchasing a cheap but thick sandal, and then having a shoe cobbler cut out the big toe area, can help patients avoid irritating their joints while stretching, etc. https://youtu.be/0eAqJ4-oKTM

 

References

(1)Cohen, BE. Hallux Sesamoid Disorders. Foot and Ankle Clinics, 2009-03-01, Volume 14, Issue 1, Pages 91-104.

(2)Clough, JG. Functional Hallux Limitus and Lesser-Metatarsal Overload. J Am Podiatr  Med Assoc (2005);95(6): 593-601.

(3)Zhang X and Li B. Influence of in-shoe heel lifts on plantar pressure and center of pressure in the medial-lateral direction during walking. Gait Posture. 2014 Apr;39(4):1012-6.

(4)Lin, SY, Su PF, Chung CH, Hsia CC, Chang CH. Stiffness Effects of Rocker-Soled Shoes: Biomechanical Implications. PloS One. 2017 Jan 3;12(1).

(5)Brantingham JW and Wood TG. Hallux Rigidus. J Chiropr Med. Winter 2002;1(1):31-7

(6)Cazeau C and Stiglitz Y. Effects of Gastrocnemius Tightness on Forefoot in Gait. Foot and Ankle Clinics, 2014-12-01, Volume 19, Issue 4, Pages 649-657.

Big Toe Joint Pain: At Times You Limit Motion and At Times You Get the Joint Moving

     Patients present all the time to Podiatrists to help them with pain in their big toe joints. This pain can be traumatic (like sesamoid fractures), or arthritis (some version of hallux rigidus), or due to the simple malposition of the joint. I believe you should try various treatments first before leaping into a surgical fix. I do see surgeries occasionally fail since the wrong surgery was done. You can look at a foot and see a bunion deformity, as in the photo above. You can assume normally correctly that fixing the bunion will eliminate the painful process. But, not always is this the case. Typically, do 5 common treatments for the painful foot before you have the surgery. This can take you 3-4 months. If all your pain is gone by these treatments, I find patients can make a better informed consent on still having that surgery in the future. 

     So, to the title of this blog post I go. What do I mean? In general, we want the big toe to keep moving. Most sports medicine podiatrists agree with this concept. But, during painful episodes, you need to stop the painful motion for awhile. That is paramount to understand. You are only stopping the painful motion, even in the face of arthritis, for awhile and not permanently. Many of my patients therefore need two sets of orthotic devices: one that stops motion, and one that allows motion. Do not stop motion forever if it can be avoided. 

Key Words:

Big Toe Pain

Bunions

Hallux Rigidus

Big Toe Pain: Email Advice

Hi Dr. Blake,

     I found your blog after dealing with chronic toe pain for the past 4 years. It started in 2017 when I was trying to stay healthy and did a bunch of yoga. I ended up doing a lot of hand stands and every time I would end I would plant my right great toe to the ground. Didn't start bothering me until I did some minimalist incline hiking. 

     Limped for a few weeks and had some serious pain below my great toe, gradual felt better, never 100%. I wound up on a beach a month or so later and have never been the same. I walked a little and then all of a sudden couldn't plant with my great toe due to the pain. limped for weeks and finally saw a specialist. 

     I was initially diagnosed with hallux rigidus, seemed kinda crazy. Luckily I found hokas and was able to walk normal and have been in them ever since. Saw multiple other doctors and had an MRI a year later. 

     I had a sesamoidectomy after the surgeon thought there was an unhealed fx that may have been causing the issue. The certainly didn't help. Have seen multiple surgeons since and just had a 3rd MRI, this time it showed a possible partial tear through the plantar plate. 

     I initially thought this was the injury but was told it wasn't because there was no instability and the MRI read didn't mention one. But now since it did, I have a feeling that was the issue all along. 

     Anyways I am reaching out for advice. Would a partial plantar plate tear heal after 4 years? Dr. Blake's comment: Probably not, but when you had the sesamoidectomy didn't they see a tear, or make any comment? Odd. You probably have to at least send me the MRI reports: all 3 to look at. 

What options are out there for me? Dr Blake's comment: The treatments are many to control pain and allow activity including: Hokas, spica taping, off weight bearing orthotics, avoiding activities that cause pain over 2, etc. However, the diagnosis is what is crucial and 3 MRIs should be fairly conclusive. 

 I have been wearing hokas for the past 4 years and have not participated in any physical activities that I like or even ran since 2017. Really hoping to change that. Any recommendations or advice would be greatly appreciated. Thanks - 

Big Toe Area Pain: Years after Healing Sesamoid Injury

Hi Richard,

I wanted to write to you because of pain in my big toe that has been bothering me for the past few weeks (about 5 weeks). Unfortunately, this pain is fickle and elusive, and very hard to describe.

My history:

- turf toe and sesamoid AVN in 2019-2020, which I recovered from thanks to your wonderful blog

- I was walking perfectly fine for a ~6 months

- played tennis one day and had pain the next day in my big toe, but a different one than I'd had before - it hasn't gone away unfortunately

The pain:

The pain is sometimes very sharp when I put weight on my foot right after getting up, but then immediately subsides. At first it felt like "pins and needles", but now it hurts more "traditionally". I can't tell where exactly my toe is hurting, but it definitely hurts when I press in the webbing between the first and second toe. My joint clicks a bit (though when it does, it is painless), and to be honest I can't remember whether it did that before feeling the pain or not. Moving my big toe doesn't hurt, I have full range of motion, my sesamoids seem fine. It occasionally hurts when I compress my first phalanx with my hand, I think it's called the "proximal phalanx of the big toe". Overall the pain tends to be better in the morning, and worse after a whole day of walking.

Please let me know if you have any leads, because I admit I'm quite perplexed by my current condition!

May God preserve you and your family in this difficult time. 

With all my consideration

Dr Blake’s Comment: Thanks for your email and glad the sesamoid AVN finally healed and you were back to good activity. Some of the symptoms are definitely nerve, like the pins and needles and pain that comes on and disappears quickly. In your case, it could have just be the body trying to tell you that something is amiss that needs protection. Your original injury was to the big toe joint. Previous joint injuries tend to pop up from time to time. Like you are doing now, you have to take them seriously, but they represent that the joint is not perfect. Imperfect joints (for me they are the left ankle, right knee, low back, and right shoulder) from old injuries are generally alittle stiffer (so they can get jerked easier) and the body’s reaction is quicker (from nerve memory). 

     So, what does this all mean? Typically, we are not dealing with anything serious if the range of motion is normal and there is no swelling, black and blue, or redness. Also, it is a great sign that there are times of the day that it does not hurt at all. These aggravations of old injury areas need to be treated seriously since this joint is a weak spot for you. The 3 areas to address are mechanics, probably spica taping or bunion toe separators to start, inflammation (so icing and contrast bathing once or twice daily), and nerve hyper-sensitivity (neural flossing with non painful joint motions, and non painful massage for 2 minutes twice daily. This should be done for 2 weeks, and then based on the response, either lessen your treatments or increase them in some way. 

     I hope this makes sense. Rich