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.

Bursitis vs Neuritis: Questions following Cortisone Injections

Hi Dr Blake,

I have intermetatarsal bursitis (2-3 and 3-4) following an incident with my foam roller 8 weeks ago. Last Tuesday I had ultrasound guided cortisone injections in both bursa and my ankle (for chronic synovitis following bad sprain last year). My ankle felt great within 24 hours but the bursitis is still worse than before the injection. Is this likely to be a prolonged flare? Is it usual for pain to be worse this far along or is there still potential for it to make a difference?

I'm not sure what preparation it was but have been icing regularly since reading your blog, using padding and now taking diclofenac. This helps but obviously don't want to have to take it long term. It's an intense sharp, electrical shock type pain in my forefoot, worse with walking. I rested my foot for the week after the injection but I'm once again on my feet all day now. Do you think I can resume elliptical and recumbent bike at the gym?

Your advice would be much appreciated.

Thanks and best regards,

Sara (name changed)

Dr Blake's comment:

Sara, please find out exactly what they injected. This is nerve pain, even if you have bursitis on ultrasound imaging. When you irritate the nerves with the deep massage/pressure of a foam roller, you have neuritis which can take awhile to mend. Cortisone is a weak help for neuritis at times, and the injection itself can irritate things. Typically, you should create a pain free environment with shoes, inserts, removable boots, crutches, whatever it takes. Have the doc help you decide on Extra Strength Tylenol (nerve pain) vs Diclofenac (inflammation pain). Also, ice can be irritating to nerves, long warm soaks can be soothing to nerves but irritating to inflammation. Acupuncture seems to help nerves alot. Elipticals are bad on this area, stationary bikes are okay if you can put the weight off the sore area. Ask some more questions. But, I got to run. Rich


Thanks very much for your message. Just to clarify, I was foam rolling my left ITB and the right (injured) foot was supporting on the floor. As I rolled there was a loud crack across the metatarsal heads (it would have been a pro/supination injury mechanism). The bursitis was found initially on MRI and I have a mulder's click as well. I wondered if there could have been a hidden neuroma alongside the possibly cured bursitis, which is now responsible for what would presumably cause similar neuritis type pain.

Best regards, Sara

Dr Blake's comment:

Thanks for clarifying. Can you send me some images with your phone of the MRI in T2 images (bone is black) which showed the bursitis. Definitely a neuroma can be hidden by the bursitis swelling. Does your foot look swollen, or discolored, from the other foot? If so, send a photo of the top of both feet. Rich

Hope these are okay - I assume the bursitis is visible as the bright white between the metatarsal heads but MRI interpretation is not my forte! On the ultrasound, the 2-3 bursitis was worse than the 3-4 although my pain was only attributable to the latter.

Thanks and regards,

Sara 

T2 MRI image noting white fluid between each interspace diagnosed as bursitis

Dr Blake's comment:

     I agree that you have some bursitis, but this may be normal for you. Bursae are noted in all 4 interspaces, with none being brighter than the others. I would guess that you irritated the nerves leading to neuritis with your foam roller and you should look at the various posts on Morton's neuroma treatment. Especially, for right now, creating that painfree environment and then advancing from there. Hope this helps. 

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