Sesamoid Injury with Plantar Plate? Email Advice

Dear Dr. Blake,
First, thank you SO MUCH for all of the resources you have made available on your website. After I broke my sesamoid bone I struggled so much with conflicting medical advice (or a huge lack of familiarity with this issue) and was wobbling around for two months on a broken swollen foot until I found your site. I followed the suggestions on your site and within 3 weeks the swelling and the pain were totally gone! It was a miracle and I was in tears of gratitude for what you’re doing and how you’re helping people like me. After 2 months in a boot, I weaned onto a pain-free environment on a thick sneaker with a sesamoid cutout, but 3 months after the break, X-rays still showed a fracture line. Six months later, my MRIs seem to indicate there is no longer a fracture - however I am still unable to walk without the sesamoid cutout in my shoe without pain and swelling, while my big toe is still frozen and relatively immobile so many months later. 

Your opinion at this point would be heaven sent as my doc was very vague in explaining my MRI and just told me to come back in a few months. He said keep the foot in the cutout at all time to maintain healing, but then the physical therapist he referred said this was wrong and I need to get moving barefoot. Could I pay you for a little email consultation to interpret my MRIs and guide me on what is safe to do next? I’m confused RE if it safe for me to push myself in bearing weight on the sesamoid or pushing the extension of my toe (the MRI report also said something about a full tear of a plate on the first MTP joint?..I don’t even know what this is but apparently that is not healed) 


Thank you so much,

Dr. Blake's Response: It is not possible to record how strong the healing is going via xrays, so I typically go with every 6 month MRI if they are needed at all. I watch the patients monthly and gradually increase activity, and toe bend, while they work on strength and keep the area protected and keep the inflammation under control. Barefoot pressure on an injured sesamoid is sore for several years, even when the patient is back to marathon running so it is not a sign of poor healing. The initial treatment is to freeze up the joint unfortunately, and now you have to unfreeze it with painfree stretching, walking, PT if you can get it. Please no barefoot for several years as a rule, but you may be ahead of the curve. I just read the part about the tear. That adds some more complexity. Spica taping is great for now. How did the tear and sesamoid fracture happen? I am doing a project in September and will not be blogging, so please rush the CD of the MRI to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. All payment is voluntary and through blog donations and is never required. Rich

Dear Dr. Blake,

Thank you for your response. I'm enclosing all the MRI report and images in this email as I only have them on my computer. There are a ton and I'm sending them all in a compressed folder since I'm not sure which ones show what we are interested in. Another option would be to send them in a separate email so you can see all the images as smaller thumbnails and just open the ones that look interesting (please let me know if this would work better). I'm also enclosing the initial x-ray from March 2019 for reference (their finding was "a longitudinally oriented fracture through the lateral sesamoid bone underlying the first metatarsal head). 

Dr. Blake's comment: I have trouble always opening up files zip compressed. It may be the firewall at Dignity Health. Please send CD or you can try WeTransfer that has worked for some patients. Also reading an MRI with 144 thumbnail images is hours of work which I do not have. Rich

The initial fracture occurred (get ready for this one) after kicking myself repeatedly in my sleep during a nightmare, I kicked myself until I bled, must have hurt the sesamoid or joint somehow but never imagined anything serious, then proceeded to walk on it in heels for 2 weeks until one day I woke up and could not even stand on it. That is when I went in for x-rays. The first doctor had me walking on a flat surgical boot and soft cast for a few weeks with worsening pain and swelling day by day, until I found your blog and put myself in a cam boot with sesamoid cutout and went minimal weight-bearing on crutches, doing contrast baths daily and soft massaging the area with arnica cream. It was after those 3 weeks that the swelling went away completely and I was totally pain-free, enough to begin to wean onto the sneaker with the cutout, which I've been on for months ever since. Even for the shower, I wear a water shoe with a sesamoid cut-out. Recently, the two times I've tried taking slow steps barefoot since (1 month ago for progress check and a few days ago after my first PT consultation) I don't really feel pain while I'm doing it, but the pain and swelling comes the next day with a vengeance. 

My first question is, if you suggest no barefoot as rule for several years unless I'm ahead of the curve, how do you normally determine when it's safe for the patient to start barefoot?

Dr. Blake's comment: You can begin to try to walk flatfooted barefoot after 3 months out of the boot, daily painfree massage to desensitize and daily icing and contrasts to keep the inflammation under control. 

 How would I determine this on my own if the associated pain and swelling comes after and not during? 

Dr. Blake's comment: See above

This PT is really pushing me towards that (and dismissing my doc's more conservative recommendations i.e the cutout) saying I can't be afraid and breaking down of scar tissue will always involve pain, but after so many months of dealing with this, of course I'm afraid to undo any progress - especially after finding out about the plantar plate issue of the MTP joint. The PT has been pulling and stretching the toe joint as much as he can and now I'm a little paranoid if I should be moving it at all!

Dr. Blake's comment: I agree with you and you have to be cautious. I have never found that approach to be helpful when you are still with only partial diagnosis on the plantar plate. Is it grade 1,2 or 3, and is the plantar plate injury 50% healed, 90% healed, or 10% healed? Is there any chance you will need surgery for the plantar plate tear? I could not answer these questions. If the PT can with certainty, and you have total trust in him/her, they should be allowed to go for it. But, if there are unanswered questions, a bit of caution is advised. Nothing should hurt either while doing or after for more than an hour that ice does not help. Sorry. 

As far as the plantar plate tear, do you see it? I don't even know what a plantar plate does. How can/does this fully heal and is it normal to still have this 6 months post-initial injury? Does this complicate the sesamoid healing and/or impose any limitations in PT, like toe extension?

Dr. Blake's comment: Sorry about not seeing the images. Even with the nightmare, and it must have been a bad one, it is hard to image a plantar plate tear or a sesamoid fracture (bruising or sesamoiditis yes!) The plantar plate is the ligaments under the ball of your foot that keeps the joint together and the joint fluid contained. Tears in the plantar plate will cause the joint fluid to leak out of the joint, and can lead to chronic symptoms, and many times need to be repaired. 

Finally, what do you think of the sesamoids in the MRIs? Dr. Blake: sorry.

I am looking up spica taping on your channel and am definitely going make the donation to the blog. It has been such a TREMENDOUS help, thank you so much for lending us your expertise.

Dr. Blake's comment: Thank you. 

EXAM:  MRI RIGHT FOREFOOT WITHOUT CONTRAST
HISTORY:  Pain. Evaluate for sesamoiditis versus fracture of the first MTP joint.
TECHNIQUE: Multiplanar, multi-sequence noncontrast MRI of the forefoot was obtained on a 1.5T scanner according to standard protocol.
COMPARISON:  None.
FINDINGS:

Bone marrow edema signal within the tibial and fibular hallux sesamoid without disruption of the cortex or discrete fracture line compatible with sesamoiditis. The sesamoidal ligamentous complex is intact. Discontinuity of the plantar plate of the first MTP joint. Mild osteoarthritis of the first MTP joint and mild hallux valgus deformity.

The rest of the visualized MTP joints are intact without evidence of arthrosis or Freiberg's infraction. The medial and lateral collateral ligaments of the visualized lesser MTP joints are intact.

Small nodular isointense signal lesion in the plantar aspect of the second intermetatarsal web space, measures approximately 3 x 2 x 3 mm compatible with an intermetatarsal (Morton's) neuroma. Trace, physiologic intermetatarsal bursal fluid within the first, second and third web spaces.

The visualized extensor and flexor tendons are intact.

Intact intrinsic muscles of the forefoot. No selective muscle edema or atrophy.

The visualized plantar aponeurosis is unremarkable.
IMPRESSION:  MRI of the right forefoot demonstrates:

1.  Bone marrow edema throughout the tibial and fibular hallux sesamoids without fracture line or cortical disruption in keeping with sesamoiditis.
2.  Full-thickness tear of the catheter plate of the first MTP joint.
3.  Mild hallux valgus deformity and mild osteoarthritis of the first MTP joint.
4.  Small neuroma of the second web space measures 3 x 2 x 3 mm.

Dr. Blake's comment: So now reading this, and listening to your story of how it happened, I think the injury was probably a plantar plate tear with bruising of the sesamoids. The physician may consider fluroscopic evaluation with dye injection into the joint to see if it leaks out meaning the tear is still present. Carbon graphite plates for "Turf Toe" should be given as you progress to normal shoes. Surgical repair of the tear may very well be needed, another reason not to have the PT keep stretching things too far. Careful measurement of the big toe joint range of motion up and down today versus 3 months from now is important. Strengthening of the long and short flexors and extensors to his joint is important and a 6 month task. Please show this post to the PT and have them record the measurements, start the strengthening, and make comments. I am sorry I will be gone 8/30 to 10/15 to help. Rich

PS. I still need to see the images, as this may be totally incorrect, since plantar plate tears leak, that is what they do, and this report makes no mention of fluid collecting under the big toe joint. Perhaps, it is because the tear has healed. Here's to hope.

     

Sesamoid Injury in a Rock Climber

First, thank you for the blog and book—both have been extremely helpful as I have been dealing with a frustrating sesamoid.  I am writing to get your opinion on returning to activity with this injury.

I’m a rock climber who sometimes loves to trail run.  I started having low-level foot pain in April. My pain gradually increased with time (had to quit running in June), but it never got to a point where I had to quit climbing.  One doctor told me I have AVN of my medial sesamoid.  The other two doctors I have seen said that the sesamoid is fractured but the bone hasn’t collapsed/isn’t sclerotic, so I should try to treat the fracture.   I found your blog around this time and started to follow some of your advice.  So for the past 4 months, I have been:

·      using the Exogen bone stimulator

·      taking Calcium and Vitamin D supplements

·      Wearing custom orthotics full time

·      Lots of icing and contrast baths

·      Activity modification (No climbing, lots of swimming and biking)

I have gotten to the point where I no longer have pain doing everyday activities, so I decided to start a walk/run program in December.  I can now jog for a total of 12 minutes with no pain.  (Yay!)  In January, I decided to see what climbing feels like.  After a little trial and error, I have found that with certain shoes, I will have no pain after 2 pitches.  But I definitely have pain if I do more climbing or if I wear shoes that are too soft.

Multi-pitch climbing. Multi-pitch climbing is the ascent of climbing routes with one or more stops at a belay station. Each section of a climb between stops at belay stations is called a pitch. The leader ascends the pitch, placing gear and stopping to anchor themselves to the belay station.

Multi-pitch climbing - Wikipedia

https://en.wikipedia.org/wiki/Multi-pitch_climbing

So based on my levels of pain, I was feeling like I was making progress.

Recently I got new X-rays and they showed no change/improvement.  My doctor doesn’t think I should be running or climbing at all for another 3 months if I want to give this thing a chance to heal.  And if it doesn’t heal after three months, then I need to think about whether I can manage/tolerate the pain or if I want to have surgery.

Dr. Blake's comment: I am so pleased what you are doing. You are doing everything right. Creating the 0-2 pain level is all you need for healing. And you need to stimulate the tissue for strength. A runner has to run and a rock climber has to climb. It is a basic part of sports rehab having the athlete do sports specific activities as long as they keep the pain level between 0-2 consistently. The xray will look bad for a while, even when internally it is healing. An MRI will show bone edema-indicating injury repair for long after the fracture has healed. How you feel is more important at this point because you are through the Immobilization Phase of Rehab, past the Restrengthening Phase, and into the Return to Activity Phase. Bone Stim for 9 months total. 

I have gotten so much value from your book and blog, so I am writing to get your opinion on a few things: 

Is it really necessary to give up the small amounts of climbing and running that I have recently added to my life?  No, unless there is more than just comparison x-rays, having another MRI 6 months after the first is great. Or, getting a CT scan to look for AVN signs now. If we have no other info, I say keep listening to your body and gradually build up what you are doing. 

Do you know anything about using shockwave therapy to treat sesamoid fractures (that was another suggestion recently made to me)? Sure, it is to cause microfractures in the bone to take a chronic healer and make it acute. You would then go back into a boot for 3 months and start the process all over. That does not make sense now. It also makes no sense to me that patients are getting this powerful treatment like a physical therapy session with no changes in activity, restrictions, etc. 

How and when do I go about making decisions about surgery vs. just dealing with it?  To me, surgery makes more sense than dealing with it. That can cause a breakdown in the joint, and compensatory pain. The surgery is typically very successful and then you have to protect the other sesamoid at high-risk activities with your orthotics. Not too big of a deal for most. But, in general, you want to save it if you can, common sense. If you were in my office tomorrow, and we had no cost restrictions, I would get a CT scan and repeat the MRI six months after the first. Then we would have a wonderful idea what the next year looks like. 

At this stage, climbing is really the only thing that gives me pain—but it is also my favorite thing to do.  I seem to keep meeting other climbers with sesamoid problems—do you have any experience working with climbers?  If so, any tips for returning to my favorite sport? 

Dr. Blake's comment: First of all, stay in rigid shoes that accommodate your orthotics and spend this year working on technique challenges that use mainly your upper body. Let your big toe have a break, so it is able to completely heal. Drills, like seen in this video with Daniel Woods, can be modified to avoid toe bending of the involved side. We are only talking about a short time in your long life. 

https://youtu.be/FEt35BKm2OI

https://youtu.be/s_GXGg31OqM

Thanks again for all the information--I really can't express how much it has at helped at a time when I have really struggled finding a medical team who understands my goals. Welcome

Sesamoid Injury: MRI evaluation

The following series of MRI images closes out my first full year as a blogger. I started in 2010 and still have not found my rhythm of sorts. I am amazed that the blog has hit 150,000 page views. Thank you readers.  I hope this blog has been helpful to many people and I will continue to work hard on the content in 2012. Happy New Year!! First some fireworks from the Hilton Hawaiian Village in Waikiki. 

Here the injured tibial sesamoid (aka medial sesamoid) under the first metatarsal shows up white on this T2 image MRI. The arrow points to the injured sesamoid on the bottom of the foot at the ball of the foot. The first metatarsal overlying the sesamoid is also inflamed  on its weight bearing surface making it difficult to walk. The same injury on the top of the joint can walk more easily. The the top and side of the first metatarsal intense soft tissue swelling is seen making it difficult to bend the joint. Sorry Jen!!

On this image, the normal fibular sesamoid (aka lateral sesamoid) shows up dark black. On this T2 imaging, normal bone, tendon, and ligaments are dark black. When they are injured, the normal healing process brings fluid into them and they get white reflecting that fluid. 

On this image, the bottom of the ball of the foot is sliced. The tibial sesamoid is seen white, and the fibular sesamoid black. The arrow points to the grayish fracture line running through the sesamoid.

This same image is shown to demonstrate the intense swelling near the fracture, which occurred many months ago. This swelling will be addressed with contrast bathing (see blog post) and icing during the day. Anti-inflammatory medications like Advil or Aleve are contra-indicated since they can slow bone healing. Jen may need a bone stimulator to help heal this bone which is a notorious slow healer. She has been placed in a removable cast with her orthotics to off weight the injured bone. 

Again the healthy fibular is highlighted by the arrow. Jen is upping her daily Vit D and Calcium. We are going to get a Bone Density Screen and Vit D3 blood levels. She has run low in the past. The injury occurred 6 months after childbirth and perhaps her estrogen levels were off. We need normal Vit D and estrogen to move calcium into bones. Even transient drops in these levels, at a time of increase activity, can produce a stress fracture. 

On this section, the top of the foot, especially the top of the big toe joint is sectioned. The arrow points to the intense swelling at the top of the joint making it impossible to bend her toe. The initial X-rays taken were negative for fracture, but stress fractures can be a hair line and never show up. Many patients have X-rays for sesamoid injuries read as negative correctly, but still may have a stress fracture. With sesamoid injuries, you have to treat the worse case scenario, a possible fracture unless an MRI or bone scan proves it is not a fracture. X-rays are not great indicators since the injury can be too subtle to pick up. Many stress fracture locations are probably fine if the patient does not know exactly if the bone is fractured or not. The patient is still treated until the symptoms go away. With sesamoid fractures, when the stress fracture is not picked up, there is a greater chance of surgery down the road. As of right now, I told Jen she has about a 10% chance of surgery 6 to 12 months from now. We will get a new MRI in 3 months to check healing. If improvement is noted, the odds for surgery go now. If no improvement is noted, the odds for surgery go up. 

This is a T1 image highlighting normal bone as white. The arrow points to the fracture line in the tibial sesamoid. The fracture is non displaced and has excellent healing potential. I tend to use bone stimulators when there is some displacement of the fracture pieces which could make healing slower or not occur at all. I love Smith and Nephew's Exogen Unit. It is used 20 minutes twice daily. 

This T1 image shows the tibial (medial) sesamoid surrounded by inflammation. The inflammation is a grayish cloud that can be seen on top of the joint also. The fracture line is seen along with other areas of the bone which are darkened indicating healing is active. Emphasis on healing!! 

This image shows the normal fibular sesamoid. The difference in the 2 sesamoids is quite distinct visually. 

This T2 image really shows the healthy top bone, and the inflamed angry mad sore unhappy discontented "difficult to get along with" bottom bone. Sorry the image is on its side. When the bottom (plantar) part of the bone is involved, weight bearing can be difficult and harmful. If I can not get her weight bearing comfortably, but I should if I am worth my salt, she would have to be non weight bearing. The Golden Rule of Foot: You must always create a pain free environment for injuries to heal. Even though levels 0 to 2 pain is still considered good pain, pain is different for different people. Jen has a high pain threshold, so her level 2 may be a 4 or 5 for someone else. I have to be more cautious and protective in a high pain threshold patient, than a low pain threshold patient like myself.

The fibular sesamoid and underlying tendon to the big toe look normal. 

This image shows the non displaced fracture line in the tibial sesamoid.

This T1 image shows the inflamed tibial sesamoid, and the inflamed bottom of the first metatarsal. The fibular sesamoid and all of the other metatarsals look very healthy. We can not rule out actual injury to the first metatarsal also, so I will be talking to Jen about getting a CT Scan in the New Year (less than 6 hours at the time of this typing). The CT Scan will only show bone and show me if there is anything more happening than just (poor choice of words) a sesamoid injury.

Jen, we have a little adventure ahead of us. Rich

Sesamoid Injury: Email Advice After Complete Removal Both Sesamoids

This is an email I received 3 weeks ago. I apologize for being way behind right now with no end in sight to catch up. Any advice I give in situations like this must be generalizations only, and may not truly apply the individual I am corresponding with. I do hope some of the information however will be very helpful. I must always defer to the health care provider that has personal knowledge of the case.


Dear Dr. Blake,


I recently discovered your blog...a bright light in the midst of my deteriorating foot odyssey!

Can you help me with orthotic fitter guidelines? I had a complete sesamoidectomy 10 years ago, resulting from a barn/equine accident that completely fractured both sesamoids. The podiatrist recommended removing both as the only option. I consented, not being fully informed of the problems sure to arise. Over time my great toe has drifted, exerting increasing leverage on the second toe. I have used toe separators, as well as regular stretching of scar tissue (yoga) and the crooked toe joint. I wore 3/4 length, rigid custom orthotics.
Dr Blake's Comment: Any surgery, on any joint, weakens that joint. Over time the weakened joint can shows signs of problems with changes in position (as commented here), pain, or problems elsewhere due to compensation for the weakness.

Metatarsal pain has developed over the past 3 months. I manage discomfort with Birkenstocks, Birkenstock inserts, layman's padding, and limited exercise. It was a very happy day when I discovered Hapads on your blog.

A respected orthopedic surgeon in my city suggested osteotomy for 1st metatarsal and toe joints, screws, etc, but I absolutely lack enthusiasm for foot surgery. He also recommended new orthotics for proper pain relief and foot stabilization. My radar went up as the fitter took imprints with a styrofoam box...needless to say they are not doing the job. They are full length, bulky, soft laytex fused to a cork bottom, wrapping around my heel and arch while providing remarkably little support. I miss the fit of my old orthotics as they beautifully supported my high arches.
Dr Blake's Comment: The Styrafoam box technique will always flatten the arch over a suspension cast taken in a non weight bearing position. Patients, and especially those with high arches, need to have all of that arch supported to take weight off the ball of the foot. It is the orthotist's job to maximally support that high arch while making it comfortable. Even though I have been doing this for 30 plus years, it can still take me several attempts to get it right in this situation. But, it can be done.
I'm left with these questions...

Can I prevent further progression of the dropping metatarsals?
Dr Blake's comments: Yes, definitely, si, and yes again. The right orthotic device along with foot exercises to strengthen your foot painlessly can make great improvements in your stability and stabilize the collapsing problem. Exercise routines like yoga and Tai Chi can also greatly help.

In my quest for range of great toe motion could Down Dog yoga position and plank position have contributed to metatarsal instability?
Dr Blake's comment: Yes, forced dorsiflexion of the big toe joint for prolonged periods could increase joint instability. However, it is not definite, and may have enabled you to go 10 years without significant problems post surgery. Do not give yourself any guilt on that one! From this point on, use painfree activities as safe activities for your foot.

Can an orthotic be made providing firm support for my arches, as well as off loading and softer suppport for the forefoot?
Dr Blake's Comment: That is the simple RX for any orthotic device for this problem: Off weight the sore area by transferring support to the arch, and soften/cushion the sore area in the front of your foot. Every orthotic maker knows these 2 basic rules.

Can I be sure an orthotic fitter knows how to accurately get an imprint of my feet?
Dr Blake's comment: Whether you use the same fitter, or another, at least you have these goals and a pair of orthotics that do not provide enough support. I have my preferences like semi-rigid plastic 3/4 th length for the arch support part, and then soft topcovers full length with accommodative forefoot extensions to float sore spots. It is hard to know if the orthotic fitter was accurate, but having a conversation per manufacturing around these 2 things should help you.

How can I find an excellent orthotic maker in my area?
Dr Blake's Comment: In the Indianapolis area, there is a great lab called Allied/OSI. My contact there is Darlene. She should know who is good, really good, to help you. The good people usually demand the most out of the lab, ask the most questions, etc. Should she not be available, talk to the lab owner, or plant director. They are known world wide for their expertise. Show them this email.
http://www.aolabs.com/

I appreciate any ideas you have. I am increasingly limited and deeply worried about further structural deterioration of my forefoot.
Thank you,

Amy
Indianapolis, Indiana...will travel to the right foot doctor and orthotic creator, especially Chicago and DC areas.

Sesamoid Injury: Email Advice

Hi Dr. Blake,


Thank you so much for your blog, I appreciate the information I have found there. I have a question for you about a sesamoid fracture that I believe is fibular one, on the pinky toe side.

Sitting under the first metatarsal at the ball of the foot are two sesamoid bones, which have the same function as the knee cap. These bones protect the big toe joint from impact and create more power at push off by increasing the lever arm of the tendons under the first metatarsal. So, if you talk about sesamoids, you normally talk about power and protection. The one closest to the 2nd toe is called the lateral or fibular sesamoid.

 I was sparring in karate and stepped on someone's foot, rolled mine, toes under, and stomped on the top of the foot. It is now seven months since the injury and I am still walking on the outside of my foot due to the pain when walking directly on the flat foot.

The pain is better, but still causes a limp and is red and slightly swollen. I had an MRI 4 months ago which is when they saw the fracture. I have used the bone growth stimulator now for 52 days and I have worn a boot for 4 months but am now mostly wearing tennis shoes for work with my foot wrapped to prevent the toe from moving upward.

 I am at the point where the ortho says the next step is to do a bone graft and wrap it with wires to hold the graph in place but he wants me to see a podiatrist first, which I will in two weeks. I have seen on your site about removing the bone all together, but not a bone graft. My question for you is this- do you have any information about the bone graft?
Dr Blake's comment: I have heard of a bone graft for a non-union of a large bone, but never for the sesamoid. The problem with this is that if the joint between the sesamoid and the first metatarsal is not smooth with normal cartilage, arthritis will set in causing just as much pain as with the broken sesamoid. I can not imagine how they could predict the amount of new bone that would form with a bone graft. Again, I am not a surgeon, and I have just never seen this in anyone. Therefore, you would want to talk to patients whom have had it and returned to normal activity before entertaining this novel approach.

You mentioned that the fibular sesamoid is the less vital of the two, what do you mean by that?
Dr Blake's comment: When I went through my surgical training, the fibular sesamoid was removed routinely during bunion surgery, and patients did well. The fibular sesamoid helps pull the big toe towards the second, and the tibial sesamoid pulls the big toe towards the other foot. They are in harmony working together to keep the toe straight in normal situations. As we age, and begin to develop even a early stage II bunion, the role of the fibular sesamoid can speed up the formation of the bunion. This is one of the reasons if you were to lose one sesamoid, most feel it would be better to lose the fibular sesamoid. And, as we use our first metatarsal to push off the ground, the tibial sesamoid normally takes more weight than the fibular sesamoid as the metatarsal plantarflexes and everts, thus more important in weight bearing during pushoff.



If the bone is removed what will be the consequences?
Dr Blake's comment: You remove the bone to eliminate the pain allowing a return to full activity, to hopefully prevent arthritis from developing under the first metatarsal due to the poor fit of the previously broken bone and the cartilage, and to re-establish proper biomechanics to the body without favoring/limping/etc. Your trade-off is that you weaken the joint by removing a vital component and performing the surgery. Any weakened joint must be protected by foot strengthening, types of shoe gear, padding, orthotics, etc, really whatever it takes to move painfree and biomechanically sound. The joint will never be perfect again, whcih is why we want to be 100% sure when we do surgery that the area would be better off by the surgery (normally the surgeon assumes that without surgery some permanent damage will occur, so surgery is the least of the 2 evils).  And when we remove the tibial sesamoid we also deal with the increased risk of bunion formation.  

I have pain in the ball of my foot on the inside and outside of it, the arch and the top of the foot, the big toe is numb most of the time and has very little range of motion. One of my students bumped the toe of my foot with her shoe and it was very painful and this last week I have had a cramp in the toe off and on. Is there a possibility that I have other injuries other than just the sesamoid bone?
Dr Blake's comment: When you fail to create a painfree environment, the pain gets heightened to protect you, the body feels constant attack so increases the swelling and you favor to protect by using all sorts of muscles and tendons in an improper way. I would much prefer someone walk normally with a removable cast and crutches if needed, then limp in tennis shoes for this reason. Therefore, all the various pains you have are pretty typical for a 7 month injury, in some stage of healing. The MRI should have caught other injuries if present, but I know that is not perfect.

 I completely understand that you can't give me specific answers, but any other information you can send would be greatly appreciated. I am very concerned about having surgery, but then again I can't keep dealing with the injury as it is. I have been practicing karate for about 10 years and kick boxing for about 1 year and since the injury I haven't been able to have my fun and exercise which is driving me crazy!
Dr Blake's comment: Not being an expert in martial arts, or marital arts, I can not imagine getting back into training for awhile. Surgery to remove the sesamoid is your best bet, but can you wear some type of dancer's pad (see blog) to protect it. When the sport does not allow protection, it takes much longer if at all to get back. But, one day at a time.

Hapad company (http://www.hapad.com/) makes some great pads to off weight the sesamoid or other areas of the foot. These are Small Longitudinal Medial Arch Pad with an adhesive backing used right behind the sesamoids to off weight.

Here is your classic dancer's pad, but if you feel better, martial art's pad.

 I really hope this is not the end of my martial arts career as I had planned to test for my third degree black belt this winter. Thank you for you help.
Dr Blake's comment: correction next fall at the earliest.
Tammy

Tammy, Good luck, and I hope this helps. Rich

Followup on Sundays 10.9.11 Post: Possible Sesamoid Injury

Here is a followup to my post on 10.9.11 (it was my last one).
http://www.drblakeshealingsole.com/2011/10/pain-in-ball-of-foot-email-advice.html


Thank you for your advice. I recently had an MRI, I was told that I had a bipartite and that there was no fracture. I'm sorry I should have been more specific. I am currently waiting for a Nerve Conduction Study (NCS)

Dr Blake's Note: When there is a possibility  between bipartite sesamoid and fractured sesamoid, the MRI is usually definitive, so I am very happy that you got the MRI to rule out the fracture. Now you have to figure out what another possible source of such terrible pain, and nerve pain is a great possibility produced by the orginal trauma to the foot or a jarring to the back. Back injuries like this may never present with back pain, only pain along the distribuation of the nerve involved. Lumbar 4 nerve root goes right down into the big toe.
This past Friday I had an appointment with my Dr and came home in a non weight bearing cast to help alleviate the sesamoid pain :( other than being very inconvenient, the pain in the ball of my foot has subsided some.

Dr Blake's note: This sounds like a great move because when there is pain not improving, you must seek to create a pain free environment.

 The nerve pain and the sesamoid pain are being looked at as two separate issues. I have not been offered any medication for the nerve pain. I currently take 800mg ibuprofen regularly (yes my tummy is not happy) Although I still continue to have the nerve pain, twitching, tingling, and burning sensations in my big toe :(

Dr Blake's note: Nerve pain has its own set of meds different from anti-inflammatory. I have never know the NSAIDs to help pure nerve pain. You need pain killers like Vicodin, Neurontin, Lyrica, Nortrypline, etc.
I did ask for clarification on the surgery, because I'm very concerned since my last surgery is when the nerve symptoms began. He said he would be removing a piece of the bipartite.

Dr Blake's note: I am not a surgeon, but I have never heard of this. It may be cutting edge, experimental in my mind. Does the surgeon feel the pain is being caused by the pieces of the sesamoid moving? Sometimes the two pieces of a bipartite sesamoid are held together by loose ligaments which tear with trauma. From that point forward, the sesamoid pieces move abnormally on each other causing pain and inflammation. However, if that was the case, I would assume that the MRI would show some form of bony or joint inflammation, not just a bipartite sesamoid. Since the pieces are not adding up totally, and the fact that I think this must be a relatively new procedure, I would make sure the nerve guy treats all of the nerve pain throughly before considering surgery.

I was also told that there was significant arthritic changes to my big toe? Could that be a reason for the stiffness and pain also?

Dr Blake's note: Significant Arthritic Changes mean Hallux Limitus or Rigidus, which is a totally different animal. Read some of my posts on this. Make sure if this is the cause of your pain, and you are going to have surgery, that you attempt to treat that condition appropriately before surgery. I am still confused about the MRI showing only bipartite sesamoid, and somewhere you being total you have significant arithitic changes?? Isn't this fun. Now you have 3 possibilities of your pain: 1) Sprained bipartite sesamoid with excessive motion between the pieces on weight bearing causing pain (this is where the surgeon may be going when he talks about removing a piece), 2) nerve trauma and chronic nerve pain, and 3) hallux limitus/rigidus with severe arthritic pain. Unfortunately, all 3 of these conditions may need surgery. Fortunately, all 3 of these conditions can respond to conservative treatments, if we know which one to treat. At least, the surgeon, who probably knows all this, will get a good laugh out of this. Surgeons do like to be black and white in their approach.

Thank you for your time, and yes your reply was very helpful!!

Dr Blake's note: You are welcome.

Pain in the Ball of the Foot: Email Advice

Dr Blake,


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

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

Sincerely

Dawn

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

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

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

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

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

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

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

Sesamoid accommodation placed under the bladder in a removable boot.

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

These poppies will always make me happy.

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

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

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

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

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

Sesamoid Fracture: Email Advice

Dr. Blake, I have been diagnosed with a fractured medial sesamoid bone. I wish I had a good excuse, such as training for a marathon or heavy duty salsa dancing, but I think I have to chalk it up to simply being a lover of high heels for most of my 35 years of life.

I went to 1 podiatrist, who after 1 month of electrotherapy and taping, recommended surgical removal. I sought a 2nd opinion from another podiatrist, and he thought it was simply sesamoiditis. He started by putting me on anti-inflamatories and gave me the short orthodic boot. 1 month later, and not much better, he recommended heavy duty steroids for a week. I went back in and still felt pain. He then recommended the weight-bearing air cast, which I wore for 1 week. I woke up one evening in the most pain I have felt since I started with this problem.

I called the next day and demanded an order for a bone scan to determine once and for all if it was inflammed or fractured. Results confirmed it was indeed, fractured.

Questions:
1) In your experience, could the use of the air cast have actually made it worse? I swear I feel more pressure on my sesamoid using the walking air cast, than simply wearing my Birkenstocks.

Dr Blake's Comment: Yes Victoria, the boot could place more pressure and aggravate the problem. I need to modify these boots all the time like in the photos below. Some boots are too rounded in the front forcing the big toe into too much bend. Other boots are constructed okay, but the patient wearing it tries to bend the toe naturally as they walk, driving the broken sesamoid into the stiff (somewhat hard) base. Unfortunately, it probably felt comfortable wearing it. And it was not until after that the symptoms occurred. If one does get a medical device for some purpose, and it causes pain, it must be discarded as good idea, or modified to create a painfree healing environment.

Accommodation of a Sesamoid (Big Toe Joint) placed on a removable insert that can be placed into a cast.

Adhesive Felt to accommodate (off weight) a sore sesamoid bone under the big toe joint.

Example of an accommodation with 1/4 inch adhesive felt for a fifth metatarsal fracture placed into a removable boot to create a painfree environment.

1/4 inch felt sheet prior to cutting into shape (customizing).

This type of accommodative pads for pain under the foot can be crucial in creating a healing environment for the injury.



2) All in all, nothing seems to have helped my foot more than wearing Birkenstocks. Besides being a great marketing story for Birkenstock, is there science behind this?

Dr Blake's Comment: I find that pain in the front of the foot (where the sesamoids are) is influenced by many factors. Each of these factors can produce a positive or negative body reaction. The rule is too see what seems to effect the injury at hand the most. These factors are: Heel Height, Cushioning, Flexibility, and the Combination of these 3. Some injuries need no heel height to transfer weight forward, others it is okay. Some injuries need alot of cushion, others it makes little difference. Some injuries need maximal flexibility, other max stiffness (rigidity) immobilizing the injury. Some injuries seem to have a delicate balance with these 3 variables: the right heel height, the right cushion, and the right flexibility. And now we should add the 4th variable of forward roll that some shoes like Sketchers seem to produce and all removable casts have that should roll you easily through your foot.

For you, birkenstocks probably provide just the right amount of minimal heel height and forefoot stiffness, that cushion is not an option.

3) No one has ever suggested taking extra calcium or simply going all out with a plaster, non-weight bearing cast with crutches. Would this be overkill? I am a very patient person, and would rather try every alternative possible before resulting to surgery.

Dr Blake's Comment: Thanks for your intelligence on this simple fact. You need to produce a painfree environment for the next 6 months, while you work on the bone strength (Vit D and calcium and possible bone stimulator), muscle strength (daily foot strengthening exercises), anti-inflammatory (daily icing and contrast baths whether you hurt or not--total of 3 sessions daily of something that reduces inflammation), perfecting spica taping for the next year plus, and getting orthotic devices that off weight the sesamoid (which should be worn for strenuous activity for 2 years to protect it, and will enable you to wean out of the cast sooner).

I would greatly appreciate any insight and recommendations you have. I have read about all the risks of removing the sesamoid bone, and besides being vain and wanting to avoid bunions, I am ready to get back into an active lifestyle to lose some baby weight and get back in to a healthy lifestyle. Thanks much in advance-

Victoria

Here is a chronically broken medial sesamoid that developed nonpainful non-union. We may have to surgically remove someday. Patient is completely active at a high level without pain.



Was it the heels that caused the injury? Probably not, but they are sure painful when you are dealing with a sesamoid issue under your big toe. At least I have been told!!



Dr Blake's comment: Hope all of this helps. For now, stay in the Birkenstocks which seem to give you good protection.