Sesamoid and Sciatica? Email Response

Hello Blake, I have read many of your blog posts about sesamoiditis and have tried my best to apply them to my injury. After a long period of issues I have decided to reach out for you personally for help.

I am (was) a high school runner and this injury occurred during December of my junior year (nearly a year ago as I am now a senior.) I had been running 50-65 miles per week during my cross country season with no big Issues. Only this lingering upper hamstring/piriformis issue that would appear when sitting for long periods. A deep, stabby type pain in my upper hamstring/piriformis. This is important later. In early December I had been having issues with numb/burning/tingly toes on my run. Along with plantar fasciitis type issues. I had attributed these issues to new shoes I was trying out, but I am now guessing these issues were pre-cursors to my sesamoid issue.

Dr Blake's comment: The upper thigh, heel pain, and toe numbness could be a sign of sciatic nerve irritation. 

One day I was running when I suddenly got a piercing pain in the ball of my foot. I hobbled home and rested. I have to this day not run because of the injury. In the following weeks, a lot of inflammation and dull aching was common. Still having no idea what it was. I stayed off of it as much as possible and did some icing.

At one point I went to my massage therapist and she mentioned my right leg was basically twisted out side ways. My hamstring/piriformis/hip were all screwed up. This led me to (and I still) believe that due to those issues changing my gait, I was putting excess pressure on different bones in my foot; causing the sesamoiditis. This theory may or may not be true. She worked on me and said it was better than before, but still not good. I didn't touch it after that.

I got x-rays in January that showed no issues with my foot. Inflammation and occasional ache remained, but the ache was less frequent than before. In April I got more X-rays. This time with different angles at a foot specialist. This revealed inflammation in one of my sesamoid bones. They gave me a foot pad to offload the bone and claimed it would heal itself soon. At this point the inflammation was still there and the bone didn't ache as much as before. I never wore the foot pad due finding it to be uncomfortable, now I know this was probably dumb. I went around in flip flops and barefoot all summer and the inflammation remained. I specifically remember it would ache when I woke up.

I found your website in September/October and have been applying some of your recommendation since. I wear the foot pad at all times around the house and have a similar set up in all my shoes. I ice multiple times a day and every couple days I do the contrast bath. There is rarely ever any pain, so I would put it in the 0-2 range. Maybe slight pain every couple weeks, most likely after I do something stupid to it. I also supplement with some calcium/vitamin d/magnesium to be safe. My question is: What else can I be doing for this injury? I feel the bone is healed, but some inflammation remains, but I feel the bone has been just about healed for a long time. The inflammation has been the real issue that refuses to go away. I can't wear certain shoes because my right foot is bigger than my left, I don't dare to run on it, etc. It has been almost a year and while I have made much progress from where I was 6-12 months ago, I am still sick of this inflammation. What can I add in to help? Am I doing anything wrong?

Dr Blake's comment: I would definitely see a neurologist or physiatrist to rule out sciatic nerve irritation versus piriformis syndrome. This could be causing some hypersensitivity along the L4 nerve root distribution. See my video on this. 

https://youtu.be/E0E60NpOSHg

Here is my issue with the upper hamstring/piriformis. It still gives me the deep stabbing pain when I sit in certain positions or for too long. I am wondering if you think there is any connection with this? Could my gait theory be correct? I have since begun hamstring strengthening exercises (specifically for my issue, which I believe may be a high hamstring tendinopathy injury) to try fix this issue as all the stretching/massaging in the world did not seem to fix it. I have been doing these for a couple weeks. Do you have any experience with this?

Dr Blake's comment: The pain syndrome seems to point to the sciatic nerve. Also, nerves hurt sitting or sitting or resting, and tendons with activity. So, that would be my next investigation. Good luck . Rich

Thank you for your time.

Sunday's Video of the Week: Piriformis Syndrome Stretches combined with Neural Flossing

Piriformis syndrome is quite common in the athletes our Sports Center treat. I have another few posts on this syndrome. Since the piriformis muscle/tendon is an external rotator of the hip, and since excessive foot pronation can cause excessive internal rotation of the hip, podiatrists are called on to design orthotic devices to correct that. If the hip internally rotates too much, the external hip rotators must overwork to stabilize the hip, and the piriformis may strain, swelling, tighten and irritate the sciatic nerve. Here is a wonderful video on combining piriformis stretching with neural flossing (see my other posts on neural flossing). Do these gently at first to see if they have any negative reaction. Or, review with your physical therapist on some modification that is tailored to you. But, sufferers of piriformis syndrome will be helped with some version of these wonderful exercises. Good luck! As you can tell from another post on neural flossing, I personally prefer spine neutral stretches with the patient laying on the back.






Also check out this incredible video about the San Francisco Fog!!

http://biggeekdad.com/2014/02/san-francisco-fog/#.UvgAty4zOhQ.gmail

Sciatica and Piriformis Syndrome

Dear dr Blake,
    My name is Susan (name changed) I'm 33yrs old and suffer from piriformis syndrome. I was given your name by Dr Stephen Pribut, top sports podiatrist in Washington, DC. I have been injured for over 2 1/2 years now (in April it will be 3). I am in constant pain. I got injured as I was working as a nurses aid in a retirement home and I was helping a resident use the restroom. Well as he was standing there his knees gave out and he dropped and I jerked forward and twisted right. I immediately felt excruciating pain in my low back into my behind. Well about 8 months after I got hurt they finally did a second MRI and discovered my piriformis syndrome.
Dr Blake's comment: You will be able to see from the videos below what they saw in that MRI. What Dr Filler, neuro-surgeon, will say is that 25% of low back surgeries fail since they are actually piriformis syndrome in disguise. 

 I've tried everything from PT, pool, ice, heat, injections, chiropractic and finally surgery. Well my muscle is still tight and I still have immense pain and feel like I'm sitting on a rock. 
Dr Blake's comment: The importance of one of the below videos is that a percentage of piriformis syndrome patients have injured their SI joint (Sacro-Iliac) and the piriformis is in spasm to protect that joint. This could have easily happened in Susan's injury. 

Anyways I'm from Longview, Washington. Do you know anyone around here that specializes in this! My Dr is an Ortho surgeon and he has only done this maybe 4-5 times in his whole career! I'm desperate to have my life back! I'm even willing to travel I just need help!
Thank you for listening to me

Dr Blake's comment:

Hey Susan, I am so sorry. I would seek the advice of Dr Mark Reeves at the Virginia Mason Clinic in Seattle! This is a common problem and someone there should be familiar. Keep me in the loop and to speedy healing. Rich

Susan's Response: Thank you! I'm interested that you say it's common because I have been told it is an uncommon issue and most of the drs around here won't even take me as a patient because they don't know how to treat it and some have even said they've really never heard of it before! Lol so I hope dr reeves can take on my case and give me some relief! I need it! This pain is excruciating (hence the reason I've been awake since 3 and emailing you back so early!!) I'm just so ready for relief! And to be active again!! I appreciate your help and will definitely keep you updated!
Have a good morning
Susan
Dr Blake's comment: Perhaps a call to Dr Filler's Santa Monica office to see if they know someone in the Seattle area. All my Piriformis/SI joint issues see Dr Irene Minkowsky in San Francisco, so I am spoiled. She is a physiatrist specializing in that area. I would definitely have a non-surgeon tell you that you need more surgery. The videos below speak of some elements of rehabilitation, but as of now, there has to be a reason for your pain, and a common cure. 


After sending a note on her progress, Susan replied: 

Thank you. I talked to dr reeves and he referred me to a dr chun. I had another MRI done on Monday. And will get my results the 31st (10 days from now). You can share my story or whatever you would like to do. I was stuck in bed all week because of my pain. They taped my feet together so my hips would be in a certain way for the MRI and it was excruciating!! I couldn't walk by myself after that. I had one person on each side of me helping me. I just want to have my life back!! I can't do my normal life for the last 2 1/2 years! It would be nice to be active again! Anyways I'm trying to get into see dr chun I just need my referral and approval through labor and industries. :) I appreciate your help! 

Thank you 

Dr Blake's comment: So, I have a variety of very good videos below talking about so much of the syndrome. For Susan, Rehabilitation can not even start until we create a pain free environment. I am hopeful that Dr Chun can begin that process. The first stage of Injury Rehabilitation is Immobilization and Anti-Inflammatory. Susan is trying her best to Immobilize, but something is hindering her recovery. Since the piriformis is an external hip rotator in gait normally, which helps support the arch (preventing internal tibial and talar motion with pronation), as a podiatrist I will use a lot of highly corrected Inverted Orthotics to help this condition. If the problem lies in a jammed SI joint, the same orthotic can make the patient temporarily worse. Thus, the art of medicine. 

This is a good place to start a discussion on Sciatica and Piriformis Syndrome. Here are a few good videos discussing anatomy, diagnosis, and some elements of treatment.