Chronic Big Toe Joint Pain: Turf Toe?

Dr. Blake,

I have been reading your blog for several weeks now and have watched many of your videos. I am emailing you on behalf of my daughter who is a 16-year-old soccer player (who will be a junior this fall) with the potential to play soccer in college. She has been suffering from an injury and is desperate to feel better and hopefully be able to continue playing the sport she loves. I am hoping that if you have some time you could give me your thoughts. I completely understand if you are unable to do so. 

She suffered an ankle injury in September 2018 while playing soccer. The orthopedic surgeon at the time said she most likely had torn the ATFL. She was put in a cast, then a boot and then went through PT for several months. She was cleared to play soccer in January 2019. However, after a few games, she continued to have pain and swelling in the ankle. She stopped playing, went back to PT and then was released to play again in April. Right at that time, she started to develop pain in the ball of her foot. She continued to have pain for several months until an MRI in June 2019 diagnosed turf toe. She was put back in a boot for several weeks and then went through PT for a few months. She returned to play in August but by October she started to develop pain in the same area after playing back to back games of 90 minutes each. All this time she continued to have pain and swelling in her ankle as well as the pain in her foot. She continued to play soccer until the date of her surgery on November 22, 2019.

After a year post injury, it was decided she would need ankle surgery. In November 2019, she underwent a modified Brostrom procedure and the doctor found that she had 3 torn ligaments in her ankle. I believe two were repaired with anchors and the third was reconstructed. (Note: this orthopedic surgeon was not the original doctor we saw when she suffered her injury in 2018) Once she was allowed to take her first weight-bearing steps weeks after surgery, she had immediate pain in the ball of the foot. The orthopedic surgeon had hoped that the rest after surgery would help and prescribed PT for both the ankle and the foot Jan-Feb 2020. We took her to a podiatrist in March of 2020 after continued pain in the foot. X-rays in the office were negative for any fractures or abnormalities of the sesamoids. He diagnosed her with sesamoiditis. He made her orthotics and shortly after she received them, the Corona virus hit and we were unable to see him for several weeks. During that time, we sought another opinion by an orthopedic surgeon specializing in the foot and ankle. He performed x-rays as well and found them to be negative also. An MRI was performed with the following results:

----There is very subtle bone marrow edema of the head of the second metatarsal. There is

no other bone marrow edema, marrow replacing process, or acute fracture. The
sesamoid bones of the first digit have a normal appearance with no signal or
morphological abnormality. The flexor digitorum tendons, flexor hallucis longus, and flexor hallucis brevis tendons are intact without edema or tenosynovitis. The extensor tendons are intact without edema or TR synovitis. The plantar fascia has a normal appearance without

inflammatory change. The muscle volume and signal is normal.
There is soft tissue edema in the interspace of the first and second metatarsal heads
tracking around the lateral sesamoid bone of the first digit.

IMPRESSION:

1. Mild bone marrow edema of the head of the second metatarsal with surrounding soft

tissue edema extending into the first interspace and around the lateral sesamoid bone.

Findings likely relate to chronic stresses/ superficial repetitive trauma.

2. No evidence of fracture or osteomyelitis. No soft tissue fluid collection.

Dr. Blake's comment: Many patients have irregular sesamoids on xray, never get an MRI like your daughter, and due to the chronic pain have the sesamoid out sadly. So, I am so glad you did get an MRI. Swelling around the lateral sesamoid from turf toe (grade 2 or 3 tearing of the lateral collateral ligament) can appear like a sesamoid fracture. I am confused that the MRI did not document turf toe, but maybe it was a severe stage 1 or mild stage 2. If we treat the MRI only, this should be all healed by now. 

He put her on a Medrol pack, showed her how to tape her toe (like the videos on your blog) and told her to wear a boot for a few weeks to relieve some of the pain. She did not feel any benefit from the Medrol pack. He did not recommend a cortisone shot or surgery. Shortly after, the podiatrist called us back to the office. He modified her orthotics. He took her out of the boot because he felt her muscles would atrophy and would require more PT to rehab her back.  He found her hamstring and calves to be very tight so he instructed her to stretch 3 times a day and ice afterwards for 20-25 minutes. She is to do this for several months. She just started PT this week. The therapist said she is strong in both the ankle and foot but is still weak from her surgery as she was never able to start conditioning due to the pain in her foot. She is wearing Merrell hiking shoes for more support. I put a J-pad under her foot and she did feel a little bit of relief. However, the podiatrist does not want us to use this...maybe because he wants the orthotics to start working to redistribute her weight naturally? She is continuing to tape her toe as well. Per your blog, we will file down the cleat right beneath the ball of the foot and will also purchase turf shoes for training and play when her outdoor cleats aren't needed. 

Dr. Blake's comment: This is wonderful. Dancer's padding (J Pad) are a must, and I will use on the orthotic and also on the foot. You typically need 1/4 inch sesamoid float to take pressure off, so you can see how much the orthotic does. It is time for her to get at least 5 things that are working for her: taping, orthotics, J Pads, cluffy wedges, icing, contrasts, stable shoes. Can you get a pair of Hoka One One to try to see if the rocker eliminates some stress? 

The podiatrist would like to see her back in a few weeks to determine her pain level. If she isn't getting much relief, he said he would consider giving a Cortisone shot. He also indicated that if she continues with conservative treatment for a few months without much relief, and the fact that she's had this pain for over a year, he would consider surgery. While he said this is the last option, he did say she could recover well from it because it's the lateral sesamoid that would be removed. He felt that she would be able to return to playing soccer about 4 months after surgery. My concern is the health of the remaining sesamoid and keeping it healthy for the remainder of her life. I have read what can happen if both sesamoids are removed.

Dr. Blake's comment: Whoa!!!! There is no problem documented in the lateral sesamoid, and cortisone into a chronic turf toe may be okay, but may be not. Turf toe, which I think is our working diagnosis, is a tear or stretch of the ligaments. It can make the joint unstable, and I do not know if she is already naturally loose. She may consider an arthrogram of the joint where dye is injected into the joint to see if it leaks out, although have not seen that test for years. If a lachman test for turf toe has been done, find out what it was. She made need a couple of sutures placed into the big toe lateral collateral ligament if that is the case. Convince me that this is not ligament instability due to turf toe. Sorry, I know this is hard. I sure hope this helps your daughter some what. 

https://www.physio-pedia.com/Turf_toe

I am reaching out to you because my daughter is starting to feel hopeless that she will ever recover. She had to stop playing basketball a year ago because it was all too much for her ankle. She will be devastated to have to give up on her dream to play soccer in college. 

If you are able to provide any thoughts or advice, I would greatly appreciate it. I feel that the orthopedic surgeon and the podiatrist have conflicting ideas and a third opinion (hopefully yours) would possibly help us with our next steps.  I have been doing a lot of research and stumbled across your blog. By far, your site provides more information about this condition than anything else I have found. Thank you for all you do for the health of others.

Sincerely,

Crush Injury leading to Sesamoid Injury and CRPS

Dear Dr. Blake -

I am writing about a crush injury to my right foot 6 months ago (Aug 21 2018) when a large metal object fell from a top shelf onto my bare right foot  I’ve seen a variety of doctors and practitioners, but nothing I’ve learned has improved my condition, and I am in confusion and despair. I’ve read your blog during this time, and your recommendations always make more sense to me. I sent previous emails, but want to try one more time, because the end of my rope is near.

As a quick summary, the initial diagnosis was fractured 1st metatarsal. Second doctors found additional fracture to tibial sesamoid (also deformed), 2nd metatarsal (bottom), inflamed MTP joint, nerve sensitivity on top and bottom of foot.  

Pain has gotten worse rather than better.  Sesamoid/metatarsal area feels like shards of broken glass in my foot.  MTP joint is sensitive, and I keep my foot wrapped in sheepskin inside the boot for relief.
Dr. Blake's comment: That symptom would be intense nerve pain (neuropathic). 
During the day, pain increases the more active I am (light chores around house); better when I stay off it entirely.  During the night, pain can be worse, making it difficult to sleep. I’m still in boot, using wheelchair for total non-weightbearing, homebound from no driving.

Dec 2 MRI:

• Bones and joints:  No dislocation.  Moderate hallux valgus alignment with mild lateral subluxation of base of 1st proximal phalanx.
• Moderate 1st MTP osteoarthritis; severe sesamoid osteoarthritis. No joint effusions.
• Ligaments:  Lisfranc ligament intact.  No evidence of acute injury to collateral ligaments at MTP or IP joints.
• Tendons and muscles:  Mild edema/strain of the medial head of the abductor halluces muscle.  Mild muscle atrophy.
• Soft tissues:  Mild soft tissue swelling, greatest along 1st to 3rd MTP joints

Dr. Blake's comment: Your symptoms are of nerve pain secondary to the crush injury to an already arthritic big toe joint. 

Dec 18: 2 Cortisone injections, which caused extreme pain, fever, disorientation. No pain relief, but some reduction in inflammation.
Dr. Blake's comment: This is diagnostic as it only addresses inflammation. Since it did not work, the neuropathic pain must be addressed. 

Physical therapist has helped flexibility/strength in foot, ankle and leg. Electrical stim and light massage reduce pain temporarily, but sometimes nothing can be done because foot is too sensitive.

My two doctors recommended 2 different courses of action, both surgery. I resisted.

• Dr. 1:  Aggressive: remove both sesamoids, reconstruct MTP with pins, shave outside of bunion, all in one operation.
• Dr. 2:  Conservative: remove tibial sesasmoid.  If that doesn’t work, then remove 2nd sesamoid.  If that doesn’t work, reconstruct MTP joint.

Dr. Blake's comment: No surgery should be contemplated until neuropathic pain is recognized and addressed. The treatment is not easy, so as soon as you can have the neuropathic pain treated successfully the better. 

Jan 19:  Woken up by worst pain yet, like broken beer bottle jammed in my foot.  Decided surgery was necessary.

Dr. Blake's comment: Again, this is neuropathic pain, surgery has to wait for now, but could be avoided. 

Jan 24:  Went to yet another doctor for 2nd option on which approach to use; aggressive or conservative.  He temporarily put the breaks on, wanting more info.

• Increased nighttime pain may be related to L4, L5, SI nerve. I need to see ortho spine doc.
• X-rays show osteopenia in MTP area.  Bones may not have integrity to hold pins/screws, creating worse problem in future.  I need to see osteoporosis specialist.

Dr. Blake's comment: Localized osteopenia could indicate that the neuropathic pain has developed complex regional pain syndrome. I have many blog posts on this subject. 

I sit here befuddled, exhausted, and defeated. I truly hope that you can provide some clarity on what is happening, and how to best proceed.  Thank you for your time and commitment to healing.

Respectfully,

This is a foot that looks like CRPS Stage 2 (vascular stage)

Dr. Blake's comment: I wrote to the patient at this time that I was on vacation and my response was going to have to be delayed. 

Hello Dr. Blake.  I hope your vacation was rejuvenating!

You asked that I resend the email below after your return.  Here are a few updates as well.  Thank you so much for your generosity.

Pain Relief:

I got a medical marijuana card last week. A daytime tincture hybrid of THC/CBD keeps me alert while reducing pain.  The nighttime tincture is 100% Indica for sleep.  To my surprise, the daytime product has reduced my pain considerably, particularly around the tibial sesamoid.  I’m mainly feeling nerves, but in a lower pain range. 

The amount of pain I have right now is bearable, which makes me more resistant to surgery. It feels good to have the boot off.  I’m still putting all weight on my heel and outside of foot. Only a few steps here and there.  Doing exercises recommended by physical therapist.  Still in wheelchair most of time.

Doctor Opinions:

Here is the full array of opinions that have my head spinning.

Dr. A (podiatrist):  Recommends removal of both sesamoids, rebuilding of MTP joint, shave bunion bump. Should all be done all at once in order to maintain my gait, but also recognizes it will be a difficult recovery.

Dr. B (Dr. B's partner):  Recommends removal of tibial sesamoid only.  If that doesn’t work, then follow with 2nd sesamoid removal, followed by reconstruction of MPT.  More conservative approach, but possibility of 3 separate surgeries.

Dr. C (my chiropractor):  Advises against surgery because of complexity of foot, but if surgery is necessary, then do it all at once.  He recommended Dr. D for a second opinion.

Dr. D (third podiatrist):  Not rushing into surgery after reviewing the MRI.

#1 - He thinks the tibial sesamoid is not that deformed, and the pain/inflammation is likely severe osteoarthritis aggravated by the accident. He also thinks some nerve pain may be originating in my lower spine...L4, L5, S1. He asked for a workup from an ortho spine doc. If foot surgery is necessary, he recommends it all be done at once.
Dr. Blake's comment: This is my choice of direction, but CRPS has not been discussed?

#2 - He is concerned with osteopenia in the big toe joint, and not confident that pins would hold.  He wants a workup from an osteoporosis specialist, before he would consider surgery.

CNP (my primary provider):  She did not understand Dr. Haas’ concerns. 

#1 - She doesn’t agree lower spine should be an obstacle.  She ordered x-rays, and results were as expected. 

Mild degenerative disc disease at L4-L5 and L5-S1 with disc space
narrowing. Facet arthropathy is present throughout the lower lumbar
spine. No acute fracture or malalignment is seen. No evidence of
spondylolysis.

#2 - I had a bone density last March, and there is osteopenia everywhere. It's being treated with Vit D3 caps, and calcium through diet.  Marcie doesn’t see a problem with pins holding.

She said I’m between a rock and a hard place, but agrees with Dr. B; one bone at a time.
Dr. Blake's comment: In California we have pain specialists that are neurologists, physiatrist, or anesthesiologists who need to be consulted. Dr. D was right about the nerve part, but CRPS type 2 is nerve hypersensitivity from nerve injury. This has very specific treatments. 

Finally, my physical therapist): He has seen my ups and downs more than anyone. Most recent trend is down, so he can’t even do exercises with me, and we've cancelled appointments until this gets sorted out. He said it will be a difficult recovery, but he recommends the full surgery.
Dr. Blake's comment: The full surgery is only recommended by caring people who want desperately to help you. You can not blame, but if the pain is neuropathic, the surgery is going in the wrong direction. See if there is a neuro-physical therapist in your area. They have a national organization and are attuned to CRPS.

Me:  When feeling my foot prior to medical marijuana, I am resigned to surgery.  Feeling my foot right now, under the effects of medical marijuana, I don’t want surgery.  

Bottom Line:  where do I go from here?

Warm regards,

Common presentation of CRPS post injury

Dr. Blake's first response after vacation (3 weeks ago), but before the two photos above were seen. 

Just read through all the emails to get my brain working. Do you have any images you should send of xrays or MRIs? If you have surgery on your foot, you only want the tibial sesamoid removed for sure. More and more surgery at one time is less predictable, and more trauma to your body. You had a very bad accident, which everyone wants to help you with, but more surgery does not make sense right now.

Secondly, I treat patients every day with tibial sesamoid fractures, and no one hurts like this. The crush injury may have caused a complex regional pain syndrome to develop which behaves like this. If so, you need a sympathetic block in your back soon. So, please have a neurologist or pain specialist work you up for this to rule it out, but also to treat the pain. If you are having nerve pain from this, surgery may make you worse unfortunately. So, get away from the surgeons for a few weeks and focus on nerve pain and its treatment. Send me any images. Keep up with the cbd oil which works well for nerve pain in some/most patients. Rich

The Patient's response:
Hello Dr. Blake -

I’m writing because I’m stuck, and need to make a decision on treatment for my foot. Last night, I had another high pain episode. My physical and emotional reserves are depleted after 5 months since the injury. 

It is very generous of you to provide your expertise, and i cannot imagine how busy you are. While understanding that, I also need to make a decision soon about surgery. I’ve been putting it off for months, and my foot is only worse. 

Is it possible to talk by phone/Skype, or do you have enough info to make a recommendation in writing?  I am so happy to make a contribution to your blog or pay you outright for your time. I just don’t know where else to turn. 

With respect,

Dr. Blake's next response:

I just reviewed the foot MRI. The Spine MRI is out of my expertise. The fibular sesamoid is out of its normal position, probably from the bunion or possibly a ligament tear. It will probably have to be removed. There is some arthritis in the joint, which could be part of the pain. I will have to read your original email to put it all together tomorrow. There is a lot of swelling around the tibial sesamoid which also probably hurts. The L4 nerve root is problematic and this goes to the big toe. Lucky you!!. I will think more on it tomorrow. Rich

Image under the big toe joint showing the fibular sesamoid out of its normal alignment

Another image of the same thing

Arrow points to intense fluid under a normal appearing tibial sesamoid, the fluid seems to be why she is hurting

This is another image of the intense inflammation under the tibial sesamoid in the subcutaneous fat, the tibial sesamoid looks arthritic, but it does not looked fractured or needing to be removed.

Here is the comparison more normal fibular sesamoid and fat pad

The arrow is on the flexor hallucis longus showing intense inflammation above near the fibular sesamoid. I wonder with the injury if the ligament connecting the 2 sesamoids was not torn. This would explain why the fibular sesamoid in the earlier images looked way out of place.
 

This image points to the gap between the tibial and fibular sesamoids possibly created by a tear of the ligament.

The architecture of the tibial sesamoid does not look injured, but you can see the swelling below in the soft tissue which will hurt on pressure

This image shows the mild wear and tear of the joint itself, osteoarthritis, that could be stirred up in the injury and resulting demineralization process going on

Another view of some mild wear and tear.

Thank you, Dr Blake. This is important information.

I’ve been regulating pain with medical marijuana (mm), and also using the Curable app. Both are helping a lot with calming down my nervous system, reducing discoloration and swelling. Mm is supposed to be good for nerve repair. Reading that I probably need surgery has released a flood of anxiety, and I’ll focus on that now. 

You are most kind.


Dr. Blake's comment: Yes, if you need surgery due to the fibular sesamoid out of alignment, that can wait and you may avoid it. Get the CRPS evaluated. Sounds like you are already calming your nervous system. On your recommendation, I introduced the Curable app for nerve pain in a recent blog post. It definitely looks promising. Keep me in the loop.

Big Toe Joint Injury Rock Climbing: Part 2

This is a follow-up post from a March 2018 rock climbing injury where the patient hung by her big toe for 45 straight minutes injuring the soft tissue and nerves. The original thought was sesamoid fracture, but there was not trauma, and the x-rays and MRI proved that they were bi-partite, with the left lateral sesamoid hot enough on MRI to call it stress fracture (probably the stress across the bipartite junction between the two fragments).  The general rule I use is that the nerves need 9 months of being good to them to heal or calm down. She started treating the nerves 3 months ago I believe.


https://www.drblakeshealingsole.com/2018/09/injury-to-fibular-sesamoid-in-rock.html

Dr. Blake, 

Happy Holidays! It's so nice to hear from you! I'm doing really well. I'm going to PT twice a week, still using exogen daily, taking 10 mg amitriptyline daily, and I've been able to start wearing Hoka One Bondi and Dansko clogs. These have saved my life. I've been able to return to most of my daily activities. Pain comes and goes but overall is much better. I've seen another orthopedic surgeon and he agrees with everything my sports medicine doctor has been doing to treat nerve pain. He suggested I continue to protect the sesamoid with rigid sole shoes and keep weight off the toe. It was good to get that reassurance in the treatment plan; however, I'm struggling a bit with how far I should be pushing things in PT.
Dr. Blake's comment: No need to push things until June 2019 as the thought of you bending too far or jumping on it prematurely scares me. Get stronger all the way up from feet to core. Get cardio with biking and gradually increasing walking up to 2-3 hours in your Hokas. Spica tape when you need to. Experiment with gentle massage 2 times a day up to 3-5 minutes to the area to desensitize as long as it is non-painful. Do neural flossing twice daily, and you can massage with neuro-eze or neuro-one both sold on Amazon. See if they will prescribe Lidoderm patches or a prescription nerve topical gel as long as it is covered by your insurance (they can be expensive if not). Try massage after a warm face cloth is applied under saran wrap to heat the area for 5 minutes.

PT has definitely helped and the therapists broke up a lot of scar tissue in the big toe joint that seems to have really helped mobilization of the toe joint. I still tend to get most of my pain in the areas the areas point to below.

The arrows are pointing to the front of the ligament (called joint capsule) before it attaches to the big toe itself. This is definitely more Turf Toe symptoms.

The Physical therapist doesn't know why my pain is here. I'm assuming this is still part of the nerve damage. I still feel a lot of scar tissue too. Could there be another problem related to the scar tissue? Dr. Blake's comment: Yes, the scar tissue from the ligament injury from prolonged tension is the body's way of trying to heal and make itself stronger. Try doing the self mobilization from the video below. Typically scar tissue starts to naturally thin out 9-12 months post injury or surgery anyway.

 https://youtu.be/FBTeWbdGrzs  

The doctor and the physical therapist want me to get back into more flexible shoes soon and their goal is to get me back to walking barefoot and back to all activity. Ultimately that's my goal too but I don't want to rush it. However, I still don't feel much pain from the actual sesamoid bipartite area. That seems to maybe have stabilized.  Dr. Blake's comment: First try barefoot walking on a grass field or shag carpet with the toe spica taped for 15 minutes to see how it feels. Try the OOFOS sandals with the Dr. Jill's dancer's pad to longer and longer periods also.

How would you suggest I progress with returning to activity? I'm afraid to upset the sesamoid but if the nerve pain I'm still having could be reduced by starting to flex the joint and start walking. They have suggested I walk in the pool starting chest deep to see how that feels and eventually move to shallower and shallower water. I have not yet tried this but will soon.  I've been doing more and more balancing activities which cause pain in the areas pointed out above when my weight shifts there. 

Dr. Blake's comment: Try the balancing with the toe spica taped and some off weighting of the sesamoid. You can be doing high level activity by the end of next year, but still need some off weighting and spica taping at times. I find walking in a pool is great for hip and knee rehabilitation, but not good for feet. The foot takes all the stress of balancing and pushing off in any height of water, the deeper the harder for the foot. Increase walking with the protection mentioned above, increase biking, increase strengthening the core and lower extremity, increase poses with protection like Yoga and Tai Chi and single leg balancing. Go 9 months with the Exogen. I hope this helps. Rich

I tried Tens unit but it seems to aggravate the nerve more so I stopped. 

Any additional advice you can give would be helpful! 

Thanks again!!

Big Toe Injury from Fall: Email Advice

Hi Dr. Blake,

 

I realize you must get absolutely tons of emails from desperate foot patients humbly looking for advice--and, yes, I'm one of them as well.

First off, I am very grateful that you take so much time out of your day to work on your blog and also respond to perfect strangers. I'm glad I found it, since there is SO much helpful advice and perspective! (and I'm long overdue for making a donation, since I think I've read just about every single post at least twice). Since you are so generous in offering general opinions online, I'm hoping you may be able to advise on my situation (sesamoid-related, surprise surprise! I think you may be one of the best DPMs in the country for this issue). I'm on an HMO in DC, so it'd be challenging to see you for a proper visit, but I would be more than willing to pay a fee for you to give second-opinion correspondence from long-distance.

 

Long-Winded Nickel Tour:

I had a fall-injury in early March which impacted mostly the ball of my foot, and hurt my medial sesamoid (MRI report indicated "stress reaction"). I went in a boot right away, since the pain was awful. I also almost immediately developed CRPS symptoms (no swelling, but horrible pain and purplish discoloration). I have a history of the OTHER foot having a plantar injury with CRPS from 8 years ago, so I knew the signs and how to deal with it (get a pain management doctor, get on gabapentin immediately, keep the foot moving as much as possible, etc.) Fortunately, with a lot of daily work, the CRPS symptoms have slowly abated a lot in the past 4 months.

 

However, I think my bigger problem is the sesamoid (my podiatrist calls it a "deep bruise") that does NOT seem to be healing. I've had a total of 3 MRIs  in 4 months; here are the impression notes:

 MRI in March:

"Moderate edema within the medial hallux sesamoid with adjacent plantar subcutaneous soft tissue edema. Findings may be seen with a stress reaction or sesamoiditis. No acute fracture identified. Mild hallux metatarsophalangeal joint effusion with mild osseous marrow edema and subchondral cyst formation at the hallux metatarsal head. Findings most consistent with stress reaction or early osteoarthritis."

Dr Blake's comment: This is normal for a stress fracture (no fracture line seen) although the impact of the sesamoid may have irritated and damaged the metatarsal also (where they come together, seen in impact activities). Sources of pain at this point are nerve hypersensitivity from CRPS, inflammatory bone and soft tissue, sesamoid, and first metatarsal.     

MRI in May:

"Interval improving marrow edema along the medial hallux sesamoid and the head of first metatarsal. Subchondral cystic changes along the head of the first metatarsal along the plantar aspect of the dorsal aspect with resolving mild marrow edema"

Dr Blake's comment: Good improvement in 2 months. I tend to wait 6 months, so this is fun to read. 

MRI in June:

"Minimal interval improvement in marrow edema within the medial hallux sesamoid. Stable degenerative changes in the first metatarsal head at the crista" (not sure if "minimal" means "the radiologist can't really see a difference…")

Dr Blake's comment: The first change was probably just the decrease in overall swelling and inflammation. I would never expect any reliable change in a month. Do not get another MRI until October or December even. 

 

I went and looked at the images myself--to my (admittedly untrained) eye, the marrow edema doesn't look like it's changed at all in 4 months' time!

Dr Blake's comment: Probably right, but a very indirect reflection on healing. The bone is getting stronger, but the remoldeling phase causes the bone to have more water than it should. It could be healing just fine. Also, have you been icing twice daily and doing contrast bathes each evening to help control the deep swelling. Also, as you bear more normal weight the swelling gets pushed out more normally. The bone mineralization process needs this period anyway. With no fracture line, you do not have to be overly concerned about the bone healing. You have to flush, insure you have good bone health, create your 0-2 pain level yet increase your activity (this is why we need to experiment with orthotics, dancer's padding, Cluffy wedges, rocker shoes, spica taping, etch.

 

I'm on my second DPM (first was a nightmare who didn't seem to even believe in CRPS), and I'm limited in choice by my HMO unfortunately--the second DPM has 30+ years experience, but doesn't see many sesamoid injuries, nor does any other doctor in the HMO--I think it's maybe because they serve general population and therefore not as many athletic types.  He said he doesn't read MRIs, so can't take a second look at the "progress" of the bone. He originally wanted to cast the foot for a period in the beginning, but I objected because of the CRPS symptoms (immobility=very bad). DPM has now advised to wean out of the boot with J-pad orthotics and Hokas/Altras, but I can't maintain 0-2 pain level (per your advice) in the sesamoid area for more than several steps--and I've experimented with dozens of shoes/orthotics/dancer pads/adhesive felt/jerry-rigged orthotics combinations, to try and offload the bone without upsetting the rest of the foot. No dice there.  I’m having a custom one made, but I'm not expecting miracles or even a better solution than what I've already constructed.

Dr Blake's comment: Sometimes you have to really work with the inflammation and nerve hypersensitivity alot, before the mechanical support gives you 0-2 pain level. Typically a good arch support, a metatarsal support and 1/4 inch dancer's padding, cluffy wedge, and spica taping will give you level 2. What level does it give you? If more than 2, try to work with anti-inflammatories, contrasts, ice, gentle massage and range of motion to bring the pain down. If you touch your skin, and the skin is sensitive, then there is a lot of nerve hypersensitivity. Work with bio feedback like mirroring to get the toe working. Any thing that increases normal touch or motion will tell the nerves all is fine, so stop hurting. People have to neural floss or use Neuro-Eze to relax the nerves. Some need an oral med, like Elavil or Lyrica, to at least calm the nerves while you sleep. 

 

I've read every single one of your (very helpful and informative!) posts about sesamoids (along with lots of other reading/research), and am doing everything I know of to help it: Vit D and other supplements, daily warm soaks, daily stretching/intrinsic strengthening of the foot (per a physical therapist), daily stationary bike and floor exercises (trying not to atrophy too much elsewhere),  trying all the different shoe/orthotic combinations, acupuncture, more antinflammatory foods.   Have recently added icing and 2x daily contrast baths--I tried in the first 2 months, but ice/cold often makes CRPS much worse, and my foot was definitely not happy with it then, when I had to ice the sesamoid in the first few weeks! Now that CRPS has calmed down a lot, though, I'm tolerating cold therapy, so I'm religious about the contrast baths (along with everything else. I am on the extreme-compliance end of the patient spectrum).

Dr Blake's comment: Since the fall cases impact to hurt the soft tissue, sesamoid and 1st metatarsal, it was a significant injury. You could have an element of turf toe (ligamentous involvement) in there. Be kind to yourself and do not rush, because it is probably not just a sesamoid injury. I would consider getting a CT scan to work at the 3 dimensions of the bone, a nerve evaluation for possible nerve entrapment, and of course an Exogen bone stimulator for the next 9 months. 

 

 It wasn't covered by my insurance since I don't seem to have a fracture, but I got an Exogen anyway, and doing that once a day--just in case it might help. I’m very worried that the marrow edema hasn't really improved in 4 months, and that it might start to get necrotic.

 

I've also read the horror stories about people not being able to walk normally for years because of sesamoid issues (or the bone eventually going AVN after fighting for months to save it, and then necessitating surgical excision). I'm desperately trying not to become a member of that camp! I will do ANYthing to help this get better. From my other-foot injury 8 years ago (which got complicated and had me on crutches for a whole year, with several awful years of leg-atrophy rehab following), I already have an INCREDIBLY deep appreciation of walking and mobility in general, so you can imagine how this latest injury is taking a huge toll on my psyche and soul. I'm extremely depressed/grieving and afraid that I'm looking at many more months of immobility and problems. Before March, I was very active walking-wise, ~7 miles/day, and need to walk a lot for my job (and sanity). I'm fully aware of the domino-effect of injuries--and I'm also having some mild symptoms of sesamoiditis in my other foot now, presumably due to compensation.

Dr Blake's comment: First of all, you are doing what you can as a super patient (if all my patients were this good!!) Somehow you have to stay positive to keep the blood flow going. Anxiety is a vaso-constrictor to the sesamoids, and a vaso-dilalator to the quads to make you run again from danger. This is why CRPS patients in general need meditation, gentle healing music, and psychiatric help. I am so happy the CRPS is better, but some nerve hypersensitivity, the type that lingers and lingers, may be still there. Typically a skilled neuro-physical therapist can help with this (what pain to honor, what pain to push through). I can not recommend over 2, but I have had patients okay pushing themselves with 5-6 pain max. That sensitivity is not the place for this blog. 

 

I'm so grateful for all the helpful information on your blog. Is there anything additional you might advise me to do here? I have these specific questions, if you are at all able to answer them:

 

• I now have good flexibility in my foot and joints (it doesn't hurt to flex, only to weightbear) and don't see the benefit of spica taping at this point in the injury. Should I be taping?

                            Dr Blake's comment: You can spica tape to hold your big toe down, and your sesamoid completely off the ground. We call it the ballerina walk. Give it a try to see if it helps. 

• I've read that biophosponates *might* be helpful for stress injuries (I believe the studies are limited, though--can you speak to this as a possibility?

                           Dr Blake's comment: First get a Vitamin D level and bone density and report back. 

• Does weightbearing on the sesamoid cause more internal bone inflammation and edema? i.e., Should I just get back in the boot full-time (sigh)? The edema doesn't seem to be going anywhere and I'm terrified that the weightbearing I'm doing may be hindering healing.

                           Dr Blake's comment: Without knowing you any better, and believing that maintaining 0-2 is safe for healing, spend the next 2-3 months in the boot and on crutches. We want some weight bearing for bone mineralization, swelling reduction, bio feedback, etc. Tell me what it takes to create the 0-2 consistently and we can go from there. That will be your July 1st benchmark, and you re-evaluate where you are August 1st. 

• Is it possible that the internal edema hasn't really healed in 4 months because the already-tenuous blood supply to the sesamoid has been compromised or injured by the internal bruise? And if so, is the bone likely to eventually die?

                           Dr Blake's comment: Sure, anything is possible, but not likely. The CT scan now, and in 3 months, will help assess the possibility of avascular necrosis. That is a much better test in the next 6 months than another MRI. You have done way to much to get necrosis (Exogen, contrasts, some weight bearing). I worry more about turf toe which could require surgery. Have them look at the ligaments really well to see if there is any sign of sprain. 

• Could the Exogen possibly prevent necrosis? Would you recommend upping the frequency? (I'm on once/day)

                            Dr Blake's comment: Sure, most recommend 2 times daily. It is one of the biggest factors to fight against dying bone because its purpose is to wake up those bone forming cells. And studies show that Exogen helps healing in pretty bad bone!!

• If you cannot do a long-distance consult, is there anyone you'd recommend in the DC/Baltimore area? I'm stuck with my HMO right now, but may change it at the end of the year, or even pay out of pocket for someone who has a lot of experience with sesamoids.

                           Dr Blake's comment: I love Dr Stephen Pribut. He is wonderful. Pay for a consult and after you get the CT scan, and let me know what he says. We should start there. Good luck. 

 

Please let me know if you'd be able to consult coast-to-coast.

 

Very warmly and appreciatively,

Big Toe Joint Injury: Possibly Turf Toe

Hi Dr. Blake,

I came across your blog on the Internet and it is one of the most valuable resources I have ever come across in terms of foot health. I understand you are super busy but I would be extremely grateful for any advice you could give me.

Dr Blake's comment: Thank you so kindly. I am trying, I love teaching and I love podiatry. So thank you!!

Approximately six months ago, I suffered an avulsion fracture on the metatarsal joint of my big toe. I wore a boot for six weeks, and pretty much was pain-free once I took it off. I did have a bone spur/swelling to the side the joint, and my range of motion was much more limited with my big toe, but I was nearly pain-free and able to walk.

Dr Blake's comment: If you injure the joint enough to get an avulsion fracture, then you had to technically develop a version of Turf Toe. or plantar plate tear. You will have to tell us later in the comment to this post how the original injury occurred. The ligament attaches into the bones, and when the ligament is pulled too hard, either the ligament tears or the bone avulses. Either way you are left with some instability in the joint. 

Unfortunately, around New Year's day I made a very dumb decision. I performed a deep lunge and pushed off this same big toe when I was in deep flexion.

I immediately felt the pain come back, but I was still able to walk normally without any sort of limp. Unfortunately, I stand and walk on my feet all day for my job, and As the month went on The pain either intensified or stayed the same, but did not get better. 

Dr Blake's comment: So you need MRI or at least comparsion AP feet x-rays. The x-rays are taken standing and you compare the sesamoid position right to left foot. Then, with the toe bent upwards (still standing) 30 degrees another set of xrays see if the sesamoids are still equal in there position from the joint. You are trying to get an idea if the joint is asymmetrical to the other joint in how it functions. 

By February, I decided to take off time from work so I could focus on resting and getting off of my feet. I also saw a podiatrist who thought I might've had a sesamoid injury. I got an MRI and bone scan done, but there was no signs of a fracture at the sesamoid and my ligaments were intact. This was on or around February 1, 2017. I attached the MRI report, were you able to read it? I did say I had a mild nonspecific edema and other things as well.

Dr Blake's comment: The nonspecific edema in the third met is probably a stress reaction from limping. As long as it does not hurt there, no big deal. The ligament structure of the first metatarsal phalangeal joint, including the intra-sesamoid ligament, was ignored in the report. Ask them to look at this further. I am also happy to take a look. Send the disc to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

Now being that it is April 1, the last two months I have spent resting and healing the best I can. I am walking in normal shoes with inserts + dancer pads in them, but I still get occasional twinges of pain every so often.

Dr Blake's comment: I would definitely start taping the joint with Spica taping and see if it influences the pain. Also get flat Otto Bock carbon graphite plate to wear under the shoe insert and see if that helps. 

https://youtu.be/l_4HESXCG40

I just got back from the podiatrist today, and he noted that he thought it was a complicated injury. Between my avulsion fracture or of the metatarsal joint, re-injuring it when I performed a deep lunge, and standing on my feet nine hours a day at my job, I developed a chronic condition. He noted that there was probably a lot of information in there. And also that when I did my deep lunge, I probably aggravated it and resulted this with some turf toe. So: My ligaments and tendons were probably partially torn, completely torn, or definitely at least injured. He said this could take 6 to 12 months to heal, which I am accepting. At this point I just want the best situation possible and I will do whatever I need to.

Dr Blake's comment: Sound smart (because he agrees with me!!)

My main question is in regards to barefoot walking. The podiatrist says I should continue to hold off on barefoot walking as long as possible. I agree with him to an extent, however sometimes it just feels really good to barefoot walk. Honestly being barefoot is one of my favorite things in the world, probably one of the things I miss most since my injury.

Dr Blake's comment: Barefoot is fine, as long as you don't jerk the toe and have to start over. You have to create the 0-2 pain level consistency of a healing environment. Try spica taping during this time. 

I've noticed that when I do barefoot walk, my gait has definitely changed a little, I no longer push off of the big toe on my left foot anymore(because if I did, there would be pain and so my body automatically adjusted how I walk).

Dr Blake's comment: In my mind, that answers it. You have to not limp, or we will be talking of a more serious injury in the hip or knee or low back in several months. Test out barefoot walking monthly, and as the symptoms calm down, you may be able to walk barefoot more and more. 

He did say I could start doing strengthening exercises and also that I could start swimming again, which I am really excited to get back to some activity. However, I still really miss being able to run, jump and dance. And I am fearful that I will never be able to hike an inclined hill again. Hopefully six months or a year or two years or even five years from now I will have improved enough though, to where I can walk on at least gentle mountains again, anyway.

Dr Blake's comment: Really, if you developed Turf Toe, and you go on for awhile without improvement, then they need to find the ligament to fix and put some stitches in it. This is normally not a big surgery, and it has good results, but it can not be just an exploratory operation. The surgery starts a 1 year process towards complete healing and complete function. We expect complete function with some joint stiffness, but not pain. 

Anyway, what is your opinion on barefoot walking? How do I draw the line between "using my feet muscles/toes/connective tissues enough that they retain their function and gain strength and mobility", versus "using them too much that I slow down my healing or possibly re-injure them, because further inflammation/damage?"

Dr Blake's comment: No limping, and no pain over 2. 

He seemed really adamant that I should avoid barefoot walking as much as possible. Do you tend to agree with this?

Dr Blake's comment: See above. Plenty of my patients walk barefoot at least around the house with spica taping and 1/8th inch adhesive padding from www.mooremedical.com stuck to their foot and are fine with the above limitations. 

I noticed that you talk about having a 0 to 2 pain level, but I am able to walk pretty much pain-free barefoot as long as I use short strides and I'm careful not to push off from my injured big toe.

Dr Blake's comment: That sounds fine. The injury is one that you have to avoid bending the joint for a good period of time, but this has not even been documented, so I hope it is true. It is not the weight bearing, it is the bending. 

Any thoughts? Maybe I could still do a little bit of barefoot walking every day, and gradually build up overtime? Or do you tend to agree with him, that I should avoid it at all costs?

Just wanted to grab another opinion if possible, because I know there is the debate between wearing shoes/protection(which protects you more, but in theory could actually atrophy your feet/toe muscles more?) vs walking barefoot(which engages your feet/toe muscles and could potentially strengthen them and help them regain function, but also leaves them more vulnerable to further injury)

Dr Blake's comment: I am definitely in the middle, some of both because sometimes you need the protection (running a race hard downhills on irregular rocky roads). When you can get away safely barefoot, go for it. 

Additionally – – he said that I could see a chiropractor if I wanted to. I was planning on seeing one maybe three or four times total, for them to do a joint mobilization on my big toe and see if that might help me regain some motion. Since I cannot extend it downwards very far.

Dr Blake's comment: I love chiros, but you do not have an actual diagnosis, and if it is Turf Toe, you are trying to let it get stiff and scarred right now. It is all about timing, and I am not sure it is the stiffness that is giving you pain. 

To clarify – – I am not doing extreme amounts of barefoot walking. Just when I am walking around the house and relaxing. I will obviously wear shoes anytime that I go outside or go on a long walk. However, if you also have a strong opinion that barefoot walking should be sharply avoided, then perhaps I should be putting on my shoes even when I walk 15 steps over to go to the bathroom. I am willing to do whatever it takes to give myself the best chance of regaining activity.

Thank you again for any help that you can provide me with. This has been a really tough injury to deal with, but I am really thankful for the help I have an able to receive, and it's giving me a lot of time to focus on myself.

Thanks!!!

PS - I attached a picture of my feet, you can see that on my left foot there is a much bigger band/bone spur near my metatarsal joint where the injury has occurred. I also attached a picture of the MRI report.

Sorry these are on their sides!!