Big Toe Joint Pain (Sesamoid Injury): One Example on How to Work Up the Patient using 14 Point Assessment Summary

 Patient #17: Big Toe Joint Pain 

                                                 . 

History and Chief Complaint

• Long distance runner presents with a 6 month history of progressively worsening pain at the ball of his right foot
• The pain had be smoldering for awhile, but got much worse when he attempted stair running at a local stadium
• Over the last 2 months, he could not walk well, so he got an appointment with the local podiatrist
• X Rays were negative by history, and he was placed in a removable boot for several months
• The pain was not any better in the boot, painful with each step, and a roommate gave him some old crutches stored at his mom’s house
• The big toe joint was swollen and painful to move
• Follow up appointment with the podiatrist an MRI was ordered. 
• The doctor said that he had a stress fracture in the medial sesamoid and that time or surgery would heal.
• He came to me for a second opinion only

Gait Evaluation

• Very limited due to the boot and need for crutches
• When asked, the patient stated he had been labelled a pronator
• Running shoes were not present, but minimalist in nature
• Gait evaluation for walking and running would have to be delayed (it can be months before I watch a runner actually run due to situations like this)

Physical Examination

• Swollen first metatarsal phalangeal joint
• Palpable pain plantar only on both sesamoids, perhaps the medial more
• Plantar pain on both maximum dorsiflexion and plantarflexion of the joint
• Plantar pain on contraction of the flexor hallucis longus against resistance
• Good range of motion of the joint however, although 10 degrees less overall motion than uninvolved side
• Probable negative lachman (swelling present can make the test unreliable)
• MRI showed no apparent fracture but bone edema in the medial sesamoid and surrounding tissue

Cursory Biomechanical Examination  and Asymmetry Noted

• Rigid Pes Cavus Foot Type
• Inverted Heel RCSP
• Mild Tight Achilles Tendons
• Plantar Flexed First Ray Right Worse than Left (perhaps only due to swelling)
• Everted Forefoot Deformity Left greater than right

Tentative Working Diagnosis 

• Medial Sesamoid Stress Fracture (stress fractures may not be seen even on MRI)

Common Differential Diagnosis (2ndary Working Diagnosis)

• Sesamoiditis with Bone Edema

Occam’s Razor and Rule of 3

• Simplest Solution after 6 months of pain and on crutches and a boot is surgical removal (no one would think that wrong)
• Rule of 3 looks for ways to rehabilitate, although can be also used post operatively to have a better outcome.
• The 3 forces that lead to stress in the sesamoids commonly are: tight achilles tendons that must be stretched out, pes cavus feet with high metatarsal declination angles that need to have the re-balanced, and plantar flexed first rays that must be off loaded

What Phase of Rehabilitation?

• Immobilization (but non-weight bearing with crutches can intensify the swelling accumulation and make the patient feel worse than they actually are)

Should We Image?

• X Rays and MRI already done
• I always look at the first MRI as just that “The First”
• I will get another MRI in 6 months to see how the healing is going

First Decision: How to Reduce Pain 0-2

• Minimal to No Crutches as non weight bearing increases swelling to a localized area like this
• Build an accommodation of at least ¼ inch adhesive felt inside of the removable boot (normally up to ½ inch)

Second Decision: Inflammation Concerns

• No NSAIDs due to bone problem
• Ice Packs or Soaks 3 times a day 
• Begin Contrast Bathing each evening to get rid of the bone edema

Third Decision: Any Nerve Component?

• Assume that nerve hyper-sensitivity begins 3 months after a problem like this.
• Start treating with ice for only 5 minutes, warm compresses, non painful massage, topical gels or patches (like Neuro Eze lotion or Lidoderm Patches)

Fourth Decision: Initial Mechanical Changes

• Get the boot comfortable so that we know we have a healing environment (make an internal float)
• Order a 9 month course of Exogen Bone Stimulator
• Begin designing or ordering off weighting pads like Dr. Jill's Dancer’s Pads of a ¼ inch thick

     This particular patient did well with conservative treatment over the next several years and was back running. The mechanical list from Chapter 6 (Book 2 of Practical Biomechanics for the Podiatrist) is so long due to the long period of experimentation needed for a patient like this. I have starred all the ones used for this particular patient as we moved him through his rehabilitation. 

Common Mechanical Changes at the First Metatarsal Phalangeal Joint

1. Spica Taping*
2. Bunion Taping
3. Toe Separators
4. Dancer’s Padding*
5. Cluffy wedges*
6. Morton’s extensions
7. Orthotic Devices for Weight Shift with no extrinsic post*
8. Orthotic Devices of Stability only with no extrinsic post 
9. No Heel Lift*
10. Zero Drop Shoes*
11. Rocker Shoes*
12. Bike Shoes with Embedded Cleats
13. Cam Walkers or Removable Boots*
14. Stiff Shoes (including post operative shoes)*
15. Flexible Shoes
16. Forefoot Padding
17. Skip Lacing*
18. Deep Toe Box*
19. Wide Toe Box
20. Shoe Stretching
21. Carbon Plate Full
22. Carbon Plate Morton’s Extension
23. Carbon Plate Dancer’s Modification
24. Proximal Padding Dorsal or Medial
25. Metatarsal Padding sub 2nd through 4th or 5th*
26. Self Mobilization for Hallux Limitus
27. Metatarsal Doming*
28. Abductor Hallucis Strengthening
29. Flexor and Extensor Hallucis Longus Tendon strengthening*
30. Night Splints and Yoga Toes
31. Correct Toes
32. No Achilles Tightness*
33. Avoid Excess Toe Bend*

 

     I saw this patient once a month for a year to progress the rehabilitation. He was in the boot for almost 3 months from the day I first saw him. While in the boot, he was working on bone health with  diet and bone stimulator, and he was working on the inflammation and nerve sensitivity 5 separate times each day. I should have at least got a Vit D blood level, as transient vitamin D deficiencies can lead to bone issues and prevent or slow down healing.The 2nd 3 months was still partial boot as we weaned him off the boot and into Hoka One One Shoes 1 size bigger and the widest one on the market. I needed room to build things for him. It was at 9 months along our rehab course when he had built up his pain free walking to 5 minutes, that he started the 10 level Walk Run Program. At one year from the start of seeing him, he ran a slow 10K in 73 minutes. In the shoes that he ran in were Hannafords (full length soft based plastazote custom inserts). I had made him a pair of Root Balanced plastic based orthoses due to the lateral column support I needed to get (high everted forefoot deformities) which worked best as scaled down dress orthotic devices. I had made him an Inverted Pair, but he was too laterally unstable as he began to walk and run. I also think the arch began too high in the Inverted pair, so the metatarsal declination pitch became too high. However, rehabilitation of these conditions, with all the modalities at our disposal is pretty awesome. 

Sesamoid Injury: Email Advice

Hi Dr Blake,

I have been reading your blog for a while and it has been very informative for me.

I have been dealing with sesamoid issues for a year now and I can't seem to move forward, so I'm looking for your advice.

I first started having issues in both big toes in January this year, right side was initially worse. I didn't do any sports at that time as I was recovering from another foot injury. Then, I started walking barefoot around the house (as recommended by my physio), but after about a week of this I started having pain in sesamoid area.

          Dr. Blake's comment: To let you know how my brain works, each word or sentence has a 

                          possible clue. January means we could be dealing with Vitamin D deficiency 

                          from lack of sun exposure. Another foot injury means alternated mechanics 

                          that could have stressed something out. Typically, if it is both sides, you did not

                          break again, and this is backed up by no impact sports at the time.  

In May of that year, an MRI was done on my right foot and it showed a small edema on the medial sesamoid. Then, the left foot started hurting a lot as well.

          Dr Blake's comment: Medial sesamoid bares more weight naturally than the lateral sesamoid

                          and many foot types have prominent first metatarsals (or at least more pressure)

                          including pes cavus (high arches), plantar flexed first metatarsals, hypomobile first

                          rays, and very pronated feet.

Throughout this I have been offloading the sesamoid using zero-drop, wide, stiff shoes with thick metatarsal pads from Dr Jill. During Summer I also did three months in a Darco shoe with a hole cut out where the sesamoid is. After all of this there was some improvement, but the pain is still there all the time especially on the left side. I have also tried orthotics, but I could not tolerate them as they gave me Baxter nerve entrapment. I have also developed pain in my pinky toe from compensation on both sides. I'm doing contrast baths every day as well. I have high arches, but had previously always been very active with little issues, I'm 33.

          Dr. Blake's comment: Well I am very proud of your attempt. Since orthotics can be a game

                          changer, and you could not tolerate the hardest in the heel, have the doctor/lab 

                          make their version of a Hannaford design (all over my blog). This will get you

                          a soft arch to transfer weight off, but a way of off weighting the sesamoid reliably.

                          Many patients need to add a Dr Jill's Gel Regular Dancer's Pad on top of the 

                          orthosis. Other mechanical treatments are spica taping, 4 hour per day of full 

                          immobilization with bike shoes with embedded cleats, cluffy wedges, or carbon plates

                          under your shoes.

About a month ago, another MRI was done on the left foot, and it shows again mild edema in the medial (bipartite) sesamoid. The toe hurts if I bend it up or when I press on the sesamoid.

          Dr. Blake's comment: If it hurts to bend up, definitely start using spica taping to see how that

                          helps. The nerves could be protecting or the soft tissue tightening up due to pain or 

                          prolonged immobilization. Make sure you are painlessly moving the top up and down 

                          10-20 times 3-4 times a day. Make sure you are doing some foot massage, but not 

                          pressing in, just to relax the soft tissues around and especially into the arch.  

I have now tried significant offloading and also more recently trying to work with the pain (so only doing things which do not make the pain worse for more than 24h), but still I'm very limited in my activities of daily living. I can't quite understand why a minor injury to the bone won't heal in over a year and also produce so much pain. Is this normal? Or do you think there is also nerve involvement? Do you have suggestions of things I can do?

         Dr. Blake's comment: Unfortunately, minor foot injuries, especially under your foot, that you 

                         have to continue to walk on, can spin out of control. After 3 months, all of these

                         injuries do have some nerve hypersensitivity issues. Between the massage, and topical

                         Neuro Eze or Neuro One gels, and add some warmth for 5 minutes before you 

                         massage. Check your Vitamin D, if you have an history of poor diet, then check your

                         Bone Density. Edema is a sign of both stress and healing. If you have been taking

                         off the stress corrcctly, and the bone is healing, a new MRI would show  great 

                        improvement. I like to wait 6 months between MRIs for their maximum change. So, 

                        you could definitely repeat the right side now. The bone may be healed completely, 

                        and your pain is all nerve now. It would be good to know. I am happy to look at any

                        MRI CDs that you mail to me. 

I have signed up for shock wave sessions now (ESWT), I hope this will clear up the edema. I'm also making sure I get all the nutrients for the bones and my bone density test came back normal. If this doesn't work, I don't know what more I could try, all this offloading has caused other issues for me. My doctor also doesn't know what to do, but told me I'm not a candidate for surgery despite only having very little success with conservative treatment.

          Dr. Blake's comment: One of my blog patients just had shockwave for chronic sesamoiditis 

                         with good results, so good luck. Glad bone density good. I am not sure why he

                         said surgery is not an option. Has be mentioned anything about your foot structure?

                        Please keep me in the loop, and always attach the URL for this post so I can refer

                        to it. Rich  

Thank you for reading this. If you want, I can also send you the MRI images, would be curious to hear what your conclusion would be.

          Dr. Blake's comment: Definitely. Dr Richard Blake 900 Hyde Street San Francisco CA 94109 

Best Regards,

Sesamoid Injury: Email Advice

Dr. Blake -

     On October 24th I was doing a tempo run as part of my half marathon training when I noticed my left foot hurting (on top) I took a week off and thought it to heal but it still hurt. I went to get an x-ray which revealed a clear break in my sesamoid bone.

Dr. Blake's comment: The sesamoid fracture should give you only pain when it first presents under the big toe joint.  I am assuming the examination showed pain under the sesamoids. 

     They gave me a CAM boot and said wear for 6 weeks and scheduled an mri to confirm it. 3 weeks after I got the boot I had the mri which confirmed the break. They said they want me in s boot for 12 weeks.

Dr. Blake's comment: So far, the advice is sound. The boot should be worn with an EvenUp on the other side. If there is pain in the boot over 0-2, you have to wear off weight bearing padding to shift the weight lateral. Also, this is the time to cross train with stationary bike, swimming, etc (just no impact). Also, winter stress fractures always have me concerned about Vitamin D deficiencies, so please have it checked.  

     I am on week 6 and it seems to hurt worse than it did at first. I am an avid runner and exerciser and I feel like I am losing my mind. They mentioned most likely me having to have my sesamoid removed. I want to try anything to avoid this. I am current in a post op hard soled shoe and want to know if I am doing everything I can to heal in the next 8 weeks. ANy advise would be greatly appreciated. I can pay you and can send over my x ray if needed.

Regards,

Dr. Blake's comment: Yes, you can send xrays and MRI to Dr.Richard Blake, 900 Hyde Street, San Francisco, California, 94109. Why are you not in a CAM walker now? Have they designed off weighting orthotic devices for you which can be worn in the boot? Boots can cut off the circulation, and sometimes patients wear too much (only need for walking). Is there alot of swelling, which can give you pain? Send a photo to the rlb756@gmail.com of the top and bottom of your foot. You can see if contrast bathing, usually very helpful, soothes the foot. Start with one minute hot and one minute cold water and rotate up to 20 minutes each evening. No surgery considerations until after you have had 9 months of Exogen bone stimulator for a non healing fracture. Typically repeat MRI at the 6 month interval, although 3-6 months are considered okay. I like to wait as long as I can, but sometimes we need to know sooner. Hope this helps. You have create that constant 0-2 pain level if you are going to predictably heal well. 

Patient answered:

Thank you so much!!! I can’t find anyone in my area that seems to be experienced with this break. They all say surgery most likely. The CAM boot hurt other areas of my foot and my opposite hip. It’s so heavy, I haven’t been fitted for orthotics as I’m not even sure where to start. I don’t really have much swelling and it looks a little bruised on the top of the ball of my big toe. I’ll send my records to you. I will also post this on your site.

Dr Blake's response: Try this local Podiatrist who is a member of our national sports academy, the AAPSM. 

David E. Linde, DPM

205-445-0661

One Independence Plz. #530

Birmingham

AL

35209

Also, try bike shoes with embedded cleats instead of the boot to immobilize. 

https://discerningcyclist.com/best-clipless-commuter-cycling-shoes/

https://www.drblakeshealingsole.com/2017/05/hike-and-bike-shoes-for-immobilization.html

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I have been managing my sesamoiditis since August, from an injury sustained 
in April due to 10k training. Initially diagnosed as arthritis until I saw 
a podiatrist in August who diagnosed sesamoiditis after x ray. By October I 
was in a boot without orthotic and improving, but unfortunately my 
podiatrist encouraged me to get out of the boot and go back to normal shoes 
with tape without a wean out period, and pain returned by Thanksgiving to a 
5-7 pain scale. I discovered your blog at the end of November, and have 
been doing boot (used felt to offload sesamoid) constantly, contrast baths 
BID, icing BID, and had some custom orthotics made to offload the sesamoid.

I decided to get a second opinion from an orthopedist, who took some x rays 
and found no fractures in my sesamoid itself, but that I had a stress 
fracture in the middle part of my navicular bone of my foot. He assures me 
this is unrelated to my sesamoiditis. The navicular area itself doesn't 
hurt. I wanted to see if you have ever heard of a navicular stress fracture 
causing sesamoid problems. I'm currently maintaining a 2-4 pain at my 
sesamoids and am hoping to start transitioning into shoes with orthotics 
next week when my pain is at a 0-2.

Any perspective you can offer would be valued.

John (name changed)

Dr Blake's comment: John, thanks for reaching out. There is no obvious connection, and the navicular diagnosis is suspect due the lack of pain in that area. Sounds like you are doing well. Make sure you experiment with cluffy wedges and spica taping as you attempt to leave the boot behind. I also recommend Hoka shoes for their rocker platform at least as a part time shoe. Rich 

Sesamoid Injury: Why do we MRI?

      There are so many reasons to get MRI images when you suspect a sesamoid fracture. I think it is important enough to have my patients self pay if there is any issues with their health insurance. I always think of an MRI for sesamoid injuries as the first MRI with another needed in 6 months if something is found positive. In this MRI, the medial or tibial sesamoid is white (signifying an inflammatory reaction) when it should be black on this T2 image. T2 imaging is hypersensitive for water (or inflammation) within structures when it should not be. All we know by this one image, and no other information, that something is going on which can be healing. This swelling within the tibial sesamoid is also called bone edema (bone swelling). Typically bone swelling when you have to walk on it is very sore. 

     After getting my first MRI, and finding a positive finding, I tell the patient that typically we will be repeating this MRI in 6 months to check for progress. I hope to initiate various treatments to get the pain level within 0-2 and allow for healing to occur. There are times that the patient is doing so much better that another MRI is not done. There are also times that the injury is too bad, complete healing does not occur, and the patient will either have surgery or is put on the 2 year wait and see plan. You always have to treat the patient and not the image, you always have to strive to make treatment changes when a subpar plateau occurs. And, since this is a bone, where bone health is crucial, consider Vitamin D levels and bone density testing. I hope this helps. 

Sesamoid Injury: Email Advice

Good afternoon Dr. Blake,

I hope this email finds you and yours well. Your foot and ankle injury blog and videos have been a great resource for me as I have been dealing with a sesamoid fracture/injury since late Feb/Early March. 

Essentially, I'm not sure how I fractured my sesamoid, but I didn't have a great podiatrist at the beginning of the injury, which, coupled with the quarantine (I'm in NYC), essentially means that I lost 3 months of proper treatment right away. I had x-rays and MRI with this doctor, but everything was taken very lightly. I was told it was maybe fractured, then just an itis, with no clear plan of how to get it to heal. I had to wait til June to get an MRI (now I know I should have had one right at the beginning.) It was all downplayed a lot and I even had to ask for a boot but with no instruction of how long to wear, when to wear, include dancer's padding etc. I stayed in the boot on and off for March/April but with no dancers padding and only outside. Inside I used slippers but was sometimes barefoot. Then in May/June (what is time anymore!?) I went to an orthopedic surgeon who saw me for 15 minutes and told me to get custom insoles, which I did get and now have for sneakers. I still knew something was wrong because I still had pain walking in the sneakers and did not feel comfortable putting all the weight through the ball of my foot and it just wasn't getting better. Fast forward to July, after getting more x-rays and a CT scan with a different podiatrist, he confirmed a fracture diagnosis, put me back in the boot and now I'm using a bone stimulator. I've been in the boot since July 29th and have been using the bone stimulator since August 17. Sometimes I use it twice a day. I've attached my MRI and CT scans below (if you'd prefer access to the portal to view all the images, I can certainly provide that).

Dr. Blake's comment: So sorry for the delay, but it did not sound like you made it worse, and it is sounds like good progress now!

As I've read from so many people who have this particular injury, it is incredibly frustrating, with little understanding of it, and very prone to setbacks. Right now, I'm wondering what else I can do besides the contrast baths, taping etc. I have gone to PT but haven't gone as much since I am back in the boot and am trying not to travel extra to the city. Plus I do a lot of leg strengthening at home. Should I be refraining from walking as little as possible and pretend as if this fracture happened yesterday and not in March? 

Dr. Blake's comment: Create the 0-2 level, walking within at framework actually is better for the muscle strength, bone demineralization, sanity!! There is no guarantee of complete healing for many reasons, but 3 straight months of immobilization in the walking boot, and then another 3 months of keeping the pain between 0-2 as you wean out seems vital to alot of these injuries. Unfortunately, the initial trial of boot does not count. 

I really want it to heal, yet I feel that this is going to be another 3 months, at least. It's so sensitive and a tiny little thing seems like it causes a flare up. My legs/feet and left foot just feel off/bad from being in the boot and even up on the left foot for so long, on and off this year, and I'm honestly afraid I'm not going to remember how to be in sneakers or how to eventually transition back into wearing them.

Dr. Blake's comment: It is not a waiting game since there are some many things to do now to prepare for the weaning out of the boot period. You need to make sure that your orthotic devices and dancer's padding off weight the area (so some visits with good shoes to the podiatrist office to make sure all is well is important). You want to have perfected spica taping, and have some stiff dress shoes for the holidays so you can place in Dr. Jill's Gel Padding as protection. PT is less important now since you are back in the Immobilization Phase, but without irritating the sesamoid, you need to keep strong, flexible, and with infrequent flare ups (but they will occur even in the best situations). 

I do ride my bike sometimes (walk down the stairs in the boot, switch to sneakers with insole etc-it's a process!) but sometimes even if my steps add up to 1 mile each day, that seems to aggravate my foot. It's all very frustrating :) I really want this to fully heal as it's been many months now. If you have any additional insight on my particular case, I would be so grateful! 

Dr Blake's comment: The 4 common areas you need to deal with are: protection (just discussed with boot, orthotics with dancer's padding, dancer's padding alone, cluffy wedges, spica taping, stiff shoes, or rocker shoes like Allegria dress, or Hoka One One type), inflammation (ice and contrast bathing very important, NSAIDs and cortisone shots can slow bone healing, and PT when needed), nerve sensitivity (pain free massage 3 times daily, big toe joint gentle range of motion with your muscle strength only, occasional topical or oral nerve stabilization meds), and bone health (eating habits, low vitamin D, smoking, etc). 

Thank you so very much.

My Best,

Dr. Blake's comment: So, now to the images you so kindly sent. A question I have was there a fall or accident before your symptoms developed since they have a diagnosis of medial sesamoid chronic ligament sprain? Also, any sesamoid injury which is definitely bipartite we need to know if you have a possible turf toe injury also. This is where the ligament is sprained, and the joint can become looser, and possibly require surgery. I assume since you did not mention anything, the doctors have ruled it out, but ask them about it and also if they have done bilateral Lachman tests for joint stability. The sprain can also just cause excessive scar tissue that gets in the way. 

Possible AVN in definite bi-partite. You can fracture the junction between the 2 pieces and the treatment may be the same. 

Here less AVN looking with bone marrow. Bipartite pieces are different sizes

Here T2 MRI clearly shows no AVN!!

Turf Toe Possible Raised when Ligament Sprained

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I have been reading your book and blog.  Thank you so much for the information!!!  I have been to 3 doctors in the last month (2 orthopedic surgeons and 1 podiatrist).  I have xrays from September 2018 and an MRI from December 2018.  2 of the 3 doctors believe that I have a fractured fibular sesamoid and their recommendation is to have it removed.  The third doctor, an orthopedic surgeon, says that the xrays look like the sesamoid is multipartite and that the MRI just shows inflammation in the bone and surrounding tissue.  I am waiting for approval from insurance to get a CT Fusion.  I am a healthy, active 47 year old female and had some blood work to check Vitamin D, magnesium, calcium, etc.  Everything was normal. 
Dr. Blake's comment: The CT scan is a better test for fracture vs bipartite (2 or more pieces congenital) so I am glad you are having it. The bipartite sesamoids I think are weaker bones since they are not completely united, so they can more easily fracture along the junction. The junction of these multi-piece sesamoids are fibrosis (syndesmosis) like ligaments, cartilaginous or partial bone bridges. The cartilage (synchondrosis) or boney (synostosis) can fracture and should be treated like a fracture. So, at the end of the day, if the MRI is positive for bone inflammation, treating the sesamoid as a stress fracture is the safest way to go. 

I am not sure when I first noticed some pain in the ball of my foot.  I believe it was around November 2017.  I am a pilates instructor and I do recall coming home one evening and noticed the ball of my foot felt sore.  I went from teaching bare foot to wearing my normal minimal shoes (LEMS) and things settled down.   Over time, I would occasionally have a flare up (mild inflammation after doing loaded exercises/stretches in dorsiflexion of the big toe), but it would quickly go away.
Dr. Blake's comment: This is definitely the symptoms of sesamoiditis where you are bruising the bone and not enough passes to let it totally heal. It is not the history of something who has broken the bone.


In June 2018, my husband and I started swing dancing.  I don’t remember it bothering me too much until August when we started a style called “Charleston” swing dance.  It is a lot of bouncing on the ball of the foot and turning on the ball of the foot.  Our fourth week into it, last week of August 2018, I was having a flare up and remember thinking I shouldn’t go to the last class.  I went anyway and after that evening, it was uncomfortable to walk for a few days.  The week after that we were in Santa Barbara and I had a hard time walking there as well.  When I got home, I got xrays because I was concerned.


The radiology report indicated “1. Mild osteophytes first MTPJ. 2. Multipartite or fractured lateral hallux sesamoid.”  By the time I got the xray, it wasn’t really bothering me anymore, so I had a hard time believing that it was fractured.  I changed to Altra running shoes and started building up to wearing correct toes and using a metatarsal pad.  Things calmed down and in December, I did some jumpboard work on the reformer (jumping while lying down with springs attached to the carriage) and I had started pushing it a bit with stretching the big toe/metatarsal area.  I had another mild flare up (no more than a 2 or 3 pain) and my acupuncturist insisted that I go to a specialist to get it checked.

Dr. Blake's comment: The xrays indicate some wear and tear in the big toe joint. The MRI typically tells us how bad. But your symptoms are not bad, mainly very short lived, and not consistent with a stress fracture or full fracture. As of now, I would side with the bone bruise people. You will have to figure out if Dr. Jill's 1/8 th inch or 1/4 inch gel dancer's pads can help when you are barefoot (usually needs some tape to hold in place).  If you have a prominent ball of the foot, you may need 1/4 inch. Has anyone commented on your foot structure? Do you have a high arched foot which definitely will put more pressure on the big toe joint/sesamoid?

In late December, my foot felt ok when I went to the first doctor.  There was no pain upon palpation and ROM was normal.  He suggested surgery based on looking at my xrays.  When I said no, he suggested a carbon fiber insert and sesamoid pad be added to my shoe and wrote a diagnosis of sesamoiditis.  I asked for an MRI and he prescribed it.  I got it a couple of days later (December 21, 2018).  The radiology report is as follows:

“TECHNIQUE: Sagittal T1, sagittal and coronal fat-suppressed T2, axial T1 and T2 fat-suppressed, coronal PD, T2, T2 fat-suppressed.

COMPARISON: Radiographs dated 9/13/2018.

FINDINGS: Linear decreased signal intensity extends across the midportion of the fibular sesamoid on axial image 15. There is diffuse bone marrow edema within the sesamoid. There is also linear decreased signal intensity extending across the medial margin of the tibial sesamoid on axial image 15 and there is mild edema in the tibial sesamoid. 3 mm focus of chondromalacia with underlying subchondral edema at the plantar margin of the first metatarsal head. No effusion at the first MTP joint.

Flexor tendons and extensor tendons are normal in signal intensity and caliber. Musculature is normal in appearance.
Dr. Blake's comment: The linear decreased signal intensity is typically normal from the ligaments and tendons wrapping around the sesamoid and distorting the image. The chondromalacia part is wear and tear on the first metatarsal or mild arthritis. This may be the only reason you hurt and means that the joint has been beat up for a long time, even much before you started having symptoms. The symptoms you are having is of mechanical bruising and then inflammation that collects. Work real hard at protecting with dancer's padding and orthotics and changes in some routines that really pick on the big toe joints (like some Pilates routines with the weight on your arch and not the ball of the foot). These restrictions hopefully will be temporary, but I am talking about the next year.

IMPRESSION:

1. The fibular sesamoid does not appear fragmented as it did on the radiographs dated 9/13/2018. There appears to be a transversely oriented band of decreased signal intensity with surrounding bone marrow edema at the fibular

sesamoid worrisome for a nondisplaced fracture. There is also mild edema in the tibial sesamoid compatible with sesamoid stress reaction or sesamoiditis. 2. Chondromalacia with subchondral edema at the plantar articular surface of the first metatarsal head.”
Dr. Blake's comment: When there is chondromalacia, basically softening of the underlying cartilage, I think it is imperative to try to reverse with an Exogen bone stimulator for 9 months, and it will also help if you do have a stress fracture.

Approximately 3 weeks ago, I started wearing the carbon fiber insert and sesamoid pad.  I also started following the advice in your book/blog and have been doing contrast baths 2x/day (4 hot/1 cold for 20 minutes), icing 1-2x per day, and spica taping.  I am also getting acupuncture 1x/week.  Before all of this, my pain levels were typically 0-2.  I feel like where I messed up is that I didn’t keep that 0-2 pain level long enough.  The icing and contrast baths feel great.  The carbon fiber insert made things feel worse.
Dr. Blake's comment: Yes, the carbon fiber inserts are the opposite of off weighting that dancer's padding does.


I tried the Hoka shoes with the sesamoid pad and metatarsal pad, but could feel sensation in the sesamoid when I walk.
Dr. Blake's comment: Hoka shoes are wonderful, but each shoe has a slightly different place for the rocker. If the rocker is in the wrong place, it may put too much weight on the sesamoid. Try on 3 different types of Hoka and see if there is any difference to how you feel before giving up on this shoe.


Now, after 3 weeks of this, my foot feels worse.  Now things are stiff and I start to feel more discomfort later in the day.  At night when I wake up, I feel a warm sensation in my foot and mild discomfort (around a 2 level pain).  It does not hurt at all to press on the sesamoids. Dr. Blake's comment: You need to use a removable boot with the same off weighting inside to rest the foot. Hopefully it will only be for a few weeks, but we have to put you in the Immobilization Phase to calm things back to 0-2 pain levels. I know you can get there.

The second doctor does not believe that it is fractured based on his review of the imaging, his exam, and my story.  Again, palpation did not cause any pain and ROM was normal.  He said to “let pain be my guide”, to use the sesamoid pad/metatarsal pad, and stiff shoes, icing, contrast baths, and to remember that I need to be patient for a long time (he said 3-6 months and then slowly start to introduce activities that have previously irritated it).
Dr. Blake's comment: He sounds smart and wise.

Today I went to a third doctor and he said that it is broken and that it needs to be removed because lack of blood flow to bone, fracture, etc.  He did his exam and again no pain.  He didn’t have me immobilize my foot.  He said to wait until we get the CT done. 

I am feeling very frustrated and scared.  If you have the time, would you be willing to review the imaging.
Dr. Blake's comment: I would be happy to. Please mail to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109.


 For now, I have the following questions:

1. My pain has always felt more like inflammation (hot and a dull ache) and the pain (other than the one week after swing dancing) has generally never been above a 2.  The week after swing dancing was about a 3 or 4 and calmed down within a the week.  Is it possible to have a fracture and have minimal to no pain? Dr. Blake's comment: Very unlikely
2. Should I be immobilizing in a boot (until I get the CT and results) just in case even though my pain levels stay in the 0-2 range with my current setup? Dr. Blake's comment: You should have in your possession a removable boot to put on and minimize the days of your flare ups.
3. Any other advice/input based on my email? Dr. Blake's comment: Just to continue to learn about what is it about your foot that caused this. Is there any biomechanical explanation that inserts can help. My wife takes Pilates twice a week for 15 years and plenty of times the injured teachers have to change what they are doing for awhile to let something heal. Good luck. Rich

Thank you so much for reviewing!!! 

Fractured Sesamoid with long first metatarsal: 2 Year Need Minimum of Dancer's Padding

Dr. Blake,

Thank you for your very informative blog. It has more information about sesamoid fractures than most other sources combined. 

I'm 56 years old and have always been very active outdoors hiking and biking, although I've never been a runner. 12 months ago I felt a pop while squatting during some home repairs. The immediate discomfort was not great and I quickly forgot about it and learned to favor that foot slightly and not squat, thinking it would work itself out. As the weeks and months progressed, so did the discomfort. I never had any discoloration, obvious swelling or point tenderness. The range of motion is good.
Dr. Blake's comment: That is the history of the big toe joint sprain, not fracture. The sprain is the ligaments in that area and can be the ligaments around the sesamoids or between a bipartite sesamoid. 

6 months after the injury I finally got an x-ray with a diagnosis of the fractured lateral sesamoid. The podiatrist said the pieces had moved too far apart to knit back together and gave me a steroid injection to help calm down the tendon. We also put a cut-out dancer's pad under my insoles to relieve pressure around the sesamoids. I started an ice massage 3-5 times/day. The plan has been to let things calm down, then make custom orthotics to replace the dancer's pad. Surgical removal was mentioned as a possibility if things didn't improve.
Dr. Blake's comment: Remember, steroid injections give some relief up to 9 months, but they also mask pain which may not be good. 

By 9 months it was feeling much better and I was able to routinely hike 4-8 miles again, with pain levels in the 0-2 range. I stopped icing. Then I got a new pair of cycling shoes and did ONE RIDE without the relief pad. The next day I noticed slight discomfort had come back and it continued to get worse over the next two weeks. I resumed icing. A new x-ray at 10 months showed the sesamoid remains non-union and I got another steroid injection. As the first injection, it took about 2 weeks before I sensed improvement. 

It's now been 12 months since the injury and I'm again feeling like there's hope of a good long-term outcome. But information here has me wondering. My questions are:

1) Is the steroid injection simply masking symptoms? Dr. Blake' comment: Yes, stop doing those, you can hurt other things by masking the pain. These long-acting cortisone shots, I am assuming this is what you got, work for 9 months. With 2 in your system, you have 7 more months of the shots doing something so it will be May 2019 before they are out of your system. If your symptoms are still good in May, then you will probably be fine. 

2) At this point, is there any hope that the sesamoid pieces will heal back together? If not, can I have an active lifestyle (backpacking, mountain biking) with a fractured sesamoid? Dr. Blake's comment: The last 2 xray views show very round edges to the junction which means it was probably a bipartite sesamoid that broke. This means it will never go back, you just want the injury to stabilize and stop hurting. Your injury made sense for a bipartite sesamoid sprain where the two pieces separated more than a fracture. 

3) How concerned should I be about the degradation of cartilage on the metatarsal head caused by the rough, fractured edges of the sesamoid? Dr. Blake's comment: I am not sure. We don't remove the sesamoid for fear of this being a problem. When sesamoids are removed, it is due to the disability the whole problem produces. It can be hard to know exactly what is the trigger of pain in some patients. Sesamoid removals are in so few patients who break their sesamoids, and some heal with a lot of irregularity. Yearly checks on the condition by the treating doc is advised if only to refurbish orthotics and occasionally take x-rays. 

4) What symptoms should I be alert for that would indicate avascular necrosis? Is AVN still a risk 1 year after injury? Dr. Blake's comment: Not much of a risk here. Full examination with MRI and CT scan would be required. Bone stimulation for 9 months if any signs.  I sure hope this information helps you. 

I'm emailing x-rays, in case they help if you have a chance to answer. 

Irregularities noted on the bottom of both sesamoids, especially lateral

Smooth borders of separated sesamoid fragments appearing to show bi-partite condition

The lateral or fibular sesamoid has definitely been remodeling. The irregularities within the bone show this process. I love the Exogen 5000 bone stim if insurance covers. I also love contrast bathes each evening as a deep flush to the bone to remove swelling that can slow bone healing. I also want you in sesamoid protection nonstop until you are back doing everything for several months.