Blogger Contact Question #2: Sesamoid Pain

Blogger Contact Question #2

I have been diagnosed with sesamoiditis (pending the outcome of a MRI taken
yesterday).  I am not in a boot but I have stopped running (the likely
cause of the injury--overuse and improper footwear).  It has been a week
since I stopped running and my big toe and sole of foot are still
swollen/tender and that concerns me, esp the swelling.  Is that "normal"
and is there anything I can do to expedite the reduction of
inflammation/hasten the healing process other than icing/spica
taping/dancer's pads? Thank you for your time.

Dr. Blake's response:
     The MRI will give us more details to help. The swelling is at this point should be helped with contast bathing 1 minute hot water (100 F) and 1 minute cold water (with a tray of ice cubes) for 20 minutes total. This gets a great pumping action going. Elevation at all times you can think of it. Even having your toes in the air with your heel on the ground causes the swelling to drain from the toe. I like a 30 minute super elevation each day where you put your feet on the couch as you lay on the ground. The swelling is normal, typically for sesamoid fractures then sesamoiditis. It is part of the healing response of your body, but it can be very excessive. Pain free massage with the palms of your hands for 2-3 minutes 3-4 times a day can desensitize the tissue. When you review the MRI, have the doctor show you 2-3 images that are the best that you can take a photo of and send my way. Hope this helps. Rich

Sesamoiditis: Email Advice

Hi Dr. Blake,

      It's been a while and I wanted to give you an update on my case. So last I messaged you in January I had just got the cast put on for my sesamoiditis. I had the cast removed in early April, 11 weeks with the cast on. After the removal, the doctor told me to wear the boot to walk in and gradually go into walking. I was confused as to what I was feeling, I had pain all over my foot, maybe from the cast immobilizing my foot for so long. I went back to see the doctor again, I reported to him that I'm walking with shoes, but I still have pain and that now I walk with a limp. He made custom orthotics for me.
Dr. Blake's comment: Here is the reading I did of this patient's first MRI in January when he sent it up to me. 

 I reviewed the MRI which shows you have bone edema in both the tibial and fibular sesamoids, and also the joint, and also the soft tissue. It is one unhappy joint. For mineralization of the bones, we needed protected weight bearing with orthotics, dancer's pads. You need to be doing icing twice a day and contrasts once a day. You need to see if you can get the Exogen 5000 bone stim, like Harry Potter's broom!! You need some PT to de-inflame the joint, and help with the off-weighting. No surgery since more than one thing wrong. A new MRI in 6 months to check progress. No NSAIDS or cortisone shots since they are bad for bone healing. No surgery should be needed, but it may take awhile for impact sports again. Has your overall bone health been checked? Questions? Rich

      I still had pain so I added dancers pad under the orthotics to relieve my sesamoids and help with the pain. The doctor was not very happy that I added dancers pad to the orthotics. The orthotic only relieved my sesamoids by 1/8 of an inch. After watching your videos I learned that I have plantar flexed 1st metatarsal, it's nearly 1/2 inch! I tried explaining that to my doctor and he asked where did I learn that and he immediately shut me down and told me not to look up anything on the internet. 

Dr. Blake's comment: This is the price we have to pay, but you have to create that 0-2 pain level. Did you try a cluffy wedge also? You are the one with the foot pain, but him. Doctors can be insulted by Dr. Google, but as patients, we got to try various things to get our individual situations under control. Thanks for watching my video by the way. I attached it here for the readers. 

He told me to remove the dancers pad, I did not as without it I would have pain during walking. I then went back again for another follow up. I reported again that pain and swelling continues, even after having a cast and taking work off for nearly 3 months. He pushed and pushed towards a corticosteroid shot. He said to me it's the shot or we are out of options, unless we go to surgery. I went with the shot. I was incredibly sad that I went with the shot. But me and my wife just had a baby and she needs help, so I'm out of options. The shot was painful, doctor told me he will only give me one shot and make it half the recommended dose. After nearly 2 months later, I went back, I reported that pain and swelling remained. He told me there is nothing else he can do. I told him that now I have electric pain above my 1st and 2nd toes whenever I lift my toes up and also told him that I have pain on the fat pad of the sesamoid but right where the skin folds to curl the big toe down. He said it maybe nerve irritation from the cast. He said there is nothing else he could do about it, so he sent me to a Pain Management doctor, I just went to go see this doctor last week. He put me in Meloxicam 7.5mg for pain and inflammation 2 times a day for a month, and he also put me on Gabapentin 300mg for 3 times a day for a month for nerve pain... I don't know what else to do. It seems like things are getting worse, I now walk funny, my injured foot no longer flexes up or down straight, it curves out then in while I flex up and down, now I'm having nerve pain  more and more issues. I've always been a naturalist, no drugs or meds, but now I feel that with the corticosteroid shot, and now these meds, I'm straying from my beliefs, but there is nothing else that I know of what to do. I've done so much research and it's driving me crazy the thought of not being able to walk or run pain free ever again  If you know of a specialist in southern California that you know and recommend, I would really appreciate it.

Dr. Blake's comment: I am sorry. Demand another MRI so we can compare. I think the first MRI is our baseline, with the second invaluable to know how things are healing. In Los Angeles you can try my go-to guy, Dr. Dan Altshuler, also Dr. Arnie Ross is an orthotic guru, and Dr. Doug Ritchie I know well. All podiatrists. 

PS: I sent you a picture, I know it's so hard to figure it out, but in the sesamoid region, the skin is red... when I press it to hold it and release it, the area around it returns to normal colorfast but the location where it's red does not. I explained this to my doctor he said not to worry about it, and he got on me for looking online and always looking at the color of my foot. By the way, he shot down my request for another MRI or CT Scan said no sense getting a scan if there is still inflammation. I told him a bone scan then, he said nope, we already know the condition of the bone.

Dr. Blake's comment: I know there are 2 sides of everything so I will not judge. In a separate email, you are sending me a new MRI so we can see. The redness is sympathetic nerve vasodilatation. It is a sign of nerve hypersensitivity which we called vasomotor insufficiency. The pain doctor probably knows about it. The gabapentin may have to be increased up to 2400 mg per day or mixed with other drugs. Topical nerve creams should be massaged in 3 times a day. You have to treat the nerve component as well as the mechanics and inflammatory. 

Thanks for taking the time to read this, I truly do appreciate it.

Best regards,

Sesamoiditis: Email Advice

Hello,

I wanted to share some info on my foot injury and get some get feedback.

In the summer of 2017, I was walking at work, in my steel toe metatarsal boots, and I felt a nerve-type feeling in my right foot.  It was as I rolled my foot up and pressure from my boots was applied to the back side of the ball my big toe.  The nerve feeling seemed to go back toward my arch.  I repeated this a number of times once I first felt it.  The boots I was wearing were fairly tight and narrow on my feet and I had worn them for 6-7 months without any pain until that one step where I triggered something.  I immediately got new boots that were much roomier, the back side of the ball of my big toe began to hurt when I rolled up my foot while walking and pressure applied.  The pain wasn't severe, and I figured it would go away on its own.

In November 2017, it got worse.  I believe this was from wearing tight boots while walking outside in the woods.  The arch of my foot experienced a lot of pain, I had trouble placing weight on the bottom of the ball of my big toe, and the pain was starting to go into my big toe.

I went to a podiatrist at the end of November, was diagnosed with sesamoiditis.  The doctor checked for range of motion, pushed on the sesamoids, but could not replicate the pain and there was no stiffness in the big toe joint.  I then was given a prescribed anti-inflammatory, was told to offload the area and received custom orthotics. I also had an x-ray and MRI, which didn't reveal anything alarming.  After taking the anti-inflammatory, the pain under my big toe went away and I stretch the arch of my foot in the morning for a few days and the pain went away.  The pain in my big toe also went away.  After returning for my follow up visit on December 22, I was basically released.
Dr. Blake's comment: Good drug!!

Then, a few days later, I wore my tight boots in the front of my yard for 10 minutes, and the back side of the ball of my big toe became very painful.  For the next 3 weeks, I experienced a lot of pain.  I hurt to walk up and down stairs.  The first few steps I would take after sitting for an hour.  Very soft surfaces (like gymnastics mats for my daughter, of very soft running shoes) would hurt more than walking barefoot.  I had a lot of tenderness on the backside of the ball of the big toe, and it would not tolerate much pressure.

In the middle of January 2018, I decided to call a foot and ankle orthopedic surgeon but had to wait over 3 weeks to get in.  During this time, I went to work and tried not to aggravate my foot.  And, in the evenings at home, I elevated my foot and iced.  By the time I got into the orthopedic surgeon, I felt a little better.  The tenderness went away and was able to walk around in my orthotics place in running shoes with minimal pain.  But, my steel toe boots at work still hurt my foot.

When I saw the surgeon, they also diagnosed me with sesamoiditis. The doctor showed me on the MRI where my sesamoid was inflamed.  They also pushed all over my foot, but could not generate pain.  They placed me in a walking boot for 5 weeks and gave me a prescription for the anti-inflammatory.  And, another MRI and cortisone shot are the next steps.

After 12 days in the boot, I not sure if I'm making any improvement.  I experience burning feeling and dull aches when I'm sitting around, or in the middle of the night when I'm sleeping.  And, I'll get a sudden pain if I lean/turn a certain way.  And, these pain are on the back side of the ball of my big toe.  Toward the outer side.  And, a couple times, I put on my shoe just for a few steps (to put gas in the car), and there is a lot of pain in the tendon as wraps from the back toward the bottom of the ball of the big toe.  But, that slowly went away as I was standing and took a few more steps.

My questions are:

Do you feel the doctors are on the right path with the diagnosis? Dr. Blake's comment: First of all, I am sorry for my delay in corresponding. I am having trouble shaking this cold/flu bug completely since Thanksgiving. I think the doctors are doing okay. They have ordered the right tests. You have some inflammation, some nerve irritability, some tension in the tendons in the area. You have to figure out how to not trigger this for the next 6 months: looser shoes, 100% wearing of orthotics with dancer's padding, icing for 10 minutes twice daily, every other day a full contrast bath. Perhaps the walking boot for the next several months when you are not working to relax the tissue. 

Are these treatment correct for the injury?
Dr. Blake's comment: The treatment of sesamoiditis is threefold: mechanical support to off weight, anti-inflammatory to cool the itis down, and neuropathic when the nerves are too irritable (wide shoes since nerve hate tightness, pain-free massage into the tissues to tell the brain that everything is fine, etc)

Is there anything I can be doing to help with recovering?
Dr. Blake's comment: Look back on all the times you irritated it, and try to not do that for 3 months. And, at the same time, constantly attack the inflammation and relax the nerves. Stay away from long-acting cortisone which can delay healing and mask pain. I am never sure 100% when the bone is inflamed and when it is has a stress fracture. I think they look the same on MRI. The first is a bruise, and off-weighting mechanically should solve. The second being a type of fracture may need more Vit D screening, bone density workup, even an Exogen bone stim. Try the Hoka One One shoes to see if they help you. You put your orthotics in the shoes and walk around the store. Good luck. Tell me if you still have questions or other comments. Rich

Thank you

The Patient's response: 

Thank you for the response.

I came out of the boot a few days ago.  Things are going a little better.  The nerves are calling down, but the tendons on the back and outer side of the tibial sesamoid seem inflamed but do not hurt to the touch.  The sesamoid bone doesn't hurt either, even if I take a couple steps on it.

I was recently given a topical anti-inflammatory, which seems to take the edge away.  I'm also using a graphite insert with cut out plastazote padding to unload the sesamoid.  It's almost like the boot.  My PCP suggested this, along with rolling my foot on a frozen water bottle at night to stretch the tendons and cool the tissue. 

I've tried the contrast bath, but it seemed to inflame the tendon on the outer side of the ball of my big toe.  Even just soaking in warm water does the same thing. Dr. Blake: So, just stick to ice. Definitely, pure anti-inflammatory measures help.

The orthopedic surgeon said the next step is injections, then a removal of the bone.  Which I obviously don't want to go that route, and don't even want to do injections.

This is the most frustrating injury I've ever experienced.  From what I've read on your blog, this can take a long time to heal.

Dr. Blake's comment: Yes, please send me the CD or images via WeTransfer if you would like for another look. Keep figuring out how not to overload the next 6 months, while reducing the inflammation and reducing the nerve irritability. You are going in the right direction. Time tables are tough, but benchmarks are important. What you can do in April should be more than March, and on and on. Rich

Thanks

Sesamoiditis vs Sesamoid Fracture: Email Advice

Hi Dr. Blake,

I've had an extremely worrisome case of sesamoiditis that has been going on for over 2 years and seems to be getting a bit worse! Over the course of the past 2 years, I continued to run on it because I did not want to stop, but the injury would flare up. I would go through periods of time where I wouldn't run because of the pain and am currently taking another break from running. I went to a foot clinic and they gave me 3/4 length orthotics with dancer pads attached to take the pressure off the ball of my foot but it is not 100% effective. I have also been going to physical therapy but my injury is not going away. I have high arches and due to my biomechanics, my feet have a tendency to lean inward, putting more pressure onto the ball of my foot. I will also add that I have sesamoiditis in BOTH of my feet but it is worse than my left. 
Dr Blake's comment: I do find that high arched feet are the hardest technologically to help. Sometimes you have to consider a full length Hannaford type insert which works well. Please have several versions of orthotics made with someone whom is giving it some thought. 
No healthcare provider has recommended cortisone shots for me, but if I see another, I wonder if it will be. I have an eating disorder and I FEAR weight gain from cortisone shots but hear they are one treatment for sesamoiditis. Do I have other options at this point for healing it without getting cortisone shots? Having a limited ability to exercise has also made it difficult for me with my eating problems. I fear that there is no end to this injury and I will have horrible problems functioning in daily life. I am a college student who will have to walk to classes approx. 3+ miles per day to classes. 
Dr Blake's comment: Any bone injury needs the right nutrients to heal, so your eating disorder may be the issue. I assume you are working with a nutrition expert on this. Have you gotten the minimum of bone density and Vit D3 levels? And, are we sure it is sesmoiditis vs fracture by MRI?
I have some more questions....
Is there a good chance that this is a sesamoid fracture as opposed to sesamoiditis? Would a fracture be worse?
Dr Blake's comment: My thought actually. So, an MRI when you can. 

I saw in one of your comments that after surgery, one must wear orthotics and dancer pads all the time for the rest of their life....is this true for everyone? 
Dr Blake's comment: No, of course, there are so many individual factors: is there functional hallux limitus, is there a long first met, is there a plantarflexed first metatarsal, what is the demands of that activity, etc? To summarize, we want to protect your remaining sesamoid, but need to use common sense. 

My orthotics don't even provide relief in regular athletics shoes, they only work for me in a certain pair of fashion sneakers. If I am limited in what shoes I can wear, what do I do about my professional career someday? Do I bring in a doctor's note saying I have a medical condition that limits which shoes I can wear and take action if I were to receive discrimination based on not being able to wear high heels? What do most professionals who are supposed to dress up do? Also, if I were to get surgery, would I most likely be able to resume running again? 
Dr Blake's comment: Definitely this would be up to the treating doc. Hopefully, a simple dancer's pad will suffice in most shoes. Surgery is very successful, but we are trying to avoid it all together. The goal of that surgery is to allow full activity again. Sounds like you need the orthotics to be better though, and get an MRI. 
Thank you so much, I hope to hear from you. I know this writing is all over the place and jumping from topic to topic so let me know if you would like me to re-write this in a more concise way. 
Best,
Dr Blake's comment: I am so sorry I was late to respond. Keep me in the loop. Typically the more we learn now, even if you have to have surgery, the smarter we are after surgery. Rich

Sesamoiditis: Email Advice

Hi Dr. Blake, 

I have had sesamoiditis confirmed via MRI for 3 months now. I went to a podiatrist 2 weeks after I woke up with intense pain in my left big toe. She gave me a cortisone shot and sent me on my way. 4 weeks later the pain came back (not as intense as the initial pain) but was still limiting my ability to walk very far without pain. 

Dr Blake's comment: With sesamoiditis, one cortisone shot is fine, but I would stay away from long acting cortisone as a treatment option. It can slow down bone healing, and I think sesamoiditis can be a small stress fracture in disguise. What did you do the day before that made your sesamoid scream so much?? When treating this problem, you need an off weighting orthotic for the sesamoid and an understanding of how to make your own dancer's pads. 

Here is a dancer's pad made of insole material cut up. You can purchase from www.mooremedical.com 1/8th inch adhesive felt, with emphasis on the adhesive part. In this way you can add dancer's padding to off weight the big toe joint area in any shoe, or on any insert. The goal is to try to get less pressure on the sesamoid as you roll through you foot. 

https://www.mooremedical.com/index.cfm?/MooreBrand%C2%AE-Adhesive-Felt-Orthopedic-Rolls/&PG=CTL&CS=HOM&FN=ProductDetail&PID=174&spx=1

For 2 months I've been in a surgical boot with offloading padding (new podiatrist). On most days my pain level is 0-2 but if I walk alot I end up really sore at the end of the day. My new podiatrist made custom orthotics and wants me to transition to orthotics in a neutral athletic shoe since my pain level has remained at a 0-2. I've also been icing 1x/day. 

It's now been 3 months and I haven't seen much improvement from 2 months ago when I put the boot on. 

Dr Blake's comment: Sounds like you are doing the best you can. Keeping the pain level between 0-2 and getting out of the hideous boot has been crucial. And typically 2-3 months of immobilization is just incase there was a small stress reactions. I have been following these sesamoids for years and at times the bone edema which makes everything very sore, is hard to resolve. So, you can email a photo from the original MRI that has the same view as the one below. If it looks like this one, I would definitely do a 6 month bone stimulator from Exogen (probably have to self pay). You have to wait 6 months at least between MRIs to see the percentage of healing. I have had them go out 3 years before the bone toughens up in the worse case scenario. We can do a new post alone on the image you send if you remind me. 

Questions:

1. How long is the recovery typically for sesamoiditis?

Dr Blake' s comment: Weeks to years. Sorry. Why would it take a long time? Perhaps foot alignment that puts too much pressure on the sesamoid. Poor or compromised bone health (like Vit D deficiency). The type of activity the patient does that may be high stress to the sesamoid. Inadequate treatment somewhere down the line. Too much immobilization that weakens the bone. The development of nerve hypersensitivity mimicking poor bone healing due to high pain levels. Etc Etc.

2. How would you recommend transitioning from boot to orthotics to ensure I continue to heal?

Dr Blake's comment: Typically keeping the pain level between 0-2, with an occasional sharp stab that lasts seconds and no residual. You want to transition when you can be in control of what you do, and can get off foot, or put boot right back on, so start after work going one hour for every days, then 2 hours, etc. Once you are fully weaned out for day to day activities, start weaning at work with one hour, then two, then three, etc etc.

3. Is there anything else I can be doing to speed up the healing process?

Dr Blake's comment: Vitamin D blood levels, possible bone density test, health diet (2 four ounces of red meat if you are a vegetarian per week), perfect the orthotics, get the dancer's pad material, ice for 10 minutes twice daily and do an evening flush of contrast bathing.

https://youtu.be/rRt5hC24Afg

4. I've had tingling in the ball of my left foot recently and my podiatrist says that means I'm healing, but I always thought tingling meant nerve damage. Thoughts?

Dr Blake's comment: Nerve Hypersensitivity is common, and presents in many ways like this. Get online some NeuroEze gel and begin to apply 3 times a day for 2 minutes into the injured area. 

5. Can I never wear heels again? I have high arches. 

Dr Blake's commment: Yes!!! Maybe with a small dancer's pad for good luck? When I watch people walk in heels (in San Francisco it is both sexes LOL), you can see that some heels work better than flats at getting the weight to the lateral side of the foot (4/5 toes). You have to try on many of the same heel height and see where the pressures go. Good luck. Rich

Thank you in advance for your time. Your blog has been very helpful. 

In good health, 

Sesamoiditis: Email Advice

Hi Dr. Blake,

I am so grateful to have found your blog about sesamoiditis. I have had it for three months and I've tried everything (complete rest, ice, anti-inflammatory, physio, acupuncture, custom orthotics, a boot, taping), and I've been five weeks non weight bearing completely. But I still have swelling and pain.

Dr Blake's comment: Any time someone mentions non weightbearing I know that the pain and swelling are going to last longer. When you go non weightbearing, the tissues swells much more, since weight bearing with every step pushes the fluid back towards the heart. Swelling is the body's way of healing, bringing in the right stuff, but it always brings in more swelling then it needs, and the non weight bearing does not allow you to get rid of it. 

I've decided to get a cortisone injection. The doctor said if I haven't had healing from all the rest yet, I need to take  the next step. 

Dr Blake's comment: Cortisone, without knowing what the tissue looks like on MRI is risky. One hopefully is fine to shrink swelling, and diagnostically should tell you if all the pain is actually coming from within the joint. 

My question is how long I should keep my foot off the ground after the shot (to prevent tendon rupture)?

Dr Blake's comment: As long as the joint is within the joint, there is no weight bearing restrictions. You can not run for 2 weeks!!!

Should I go weeks non weight bearing? 

Dr Blake's comment: As soon as you can stop non weight bearing the better, but that has to be your doctor's decision (and you of course). 

And how long before I do some gentle foot exercises? 

Dr Blake's comment: Typically, even if you are non weight bearing you can do met doming, Single leg balancing with shoes and orthotics, posterior tibial and peroneus longus therabands, and achilles stretches. Remember, if there is weight bearing and if the exercise puts too much weight on the injury, you can stand on 3 or 4 books next to each other, with a hole for the injured area. Hope that makes sense. For the achilles stretch, just putting the front of the foot off a 2 inch thick book works. 

When can I deep water pool run?
Dr Blake's comment: Now!

 I'm willing to rest completely for as long as it takes, as this has been the worst experience of my life. I'll do anything to heal. I'm just afraid that this shot is only going to be short lived. 
And in your opinion, is it true that some people never ever heal from sesmoiditis? 
Dr Blake's comment: No, I have never seen a patient not heal from sesamoiditis. I have seen injuries that were called sesamoiditis, but were something else that required surgery. That is why I would even self pay if you have to for an MRI for peace of mind to know exactly what your diagnosis is. 

Thank you in advance. I'm hoping I'll be one of the lucky ones to whon you are able to reply.
Dr Blake's comment: This was sent during my vacation to Spain, so I am 3 weeks late. I hope it still helps. Rich

Ball of the Foot Pain: Email Advice with MRI Images

This nice patient mailed me her CD from New Zealand. She is suffering from pain under and in the big toe joint from many years. This is my report to her.

Image of Tibial Sesamoid under the first metatarsal showing irregularities within the bone. The bone does not look totally healthy, but is not fractured or fragmented.

A slightly different image of the tibial sesamoid. The fibular sesamoid looked healthier. This can simply be from favoring her foot with some demineralization of the bone.

Here a large bursae or ganglion cyst is seen under the tibial sesamoid.  Sesamoid Fractures are often diagnosed when, in fact, the source of pain is in the soft tissue swelling under the sesamoid

Another image of the soft tissue swelling with some swelling in the tibial sesamoid (very slight).

Here we are at the joint level with our slice. The irregular white areas can be also seen below in the next image. This abnormal tissue arises from the plantar (bottom) medial side of the joint (arch side). This tissue, referred to as chronic synovitis, can get trapped in the joint and constantly irritated. Again, since it is on the tibial sesamoid side, it is often misdiagnosed.

Here the irregular soft tissue appears to be coming from the side of the joint. 

Another image of the same soft tissue swelling. When it arises from a joint, it is called a ganglion cyst. This may need surgery to remove the sac of tissue and tie off the stalk where it comes off the joint. 

Great image of this soft tissue mass causing so much problems.

These sacs can be injected with cortisone, not into the joint, to see if they will reduce. If not, they are removed.

Another side image of this mass.

From this view, and others, we know the cyst is filled with fluid. The problem with cortisone is not to inject other than the cyst which is quite small. If your doc feels uneasy about injecting, he/she may recommend surgical removal as a safer approach. Cortisone placed in the wrong spot can be dangerous.

Ball of the Foot Pain: Email Advice

Hi Dr.Blake,

 I have been diagnosed with sesamoiditis and have had this foot pain for over a year now. It is beginning to develop in my other foot as well.

 I have tried almost everything imaginable: two different orthotics, cortisone injection, active release, had a chiropractor tape the joint with kinesio tape and even one of those electric wave machines.

 I really do not know what else to do the pain keeps getting worse. Do you have any other suggestions? I am extremely desperate. - Thanks, Ann (name changed)

Dr Blake's comment: 

     All we know from what you have said is that you have pain under the ball of your foot, that no one feels is broken or arthritic, and the pain is not getting better with people doing things to you. So, I would begin to be more active in your approach (very sports medicine) and begin to see what happens. Take this one month at a time and you can give me a followup 30-40 days from now. So, what can be done:

1. Attempt some form of better diagnosis (xrays, etc).
2. Ice pack the area for 15 minutes twice daily.
3. If swelling or stiffness noted, do contrast bathing once daily or once every other day.
4. Find a shoe that works best whether it is padding or stiff or flat, etc. Try to decide what is best.
5. Put your self in the Immobilization Phase I of Injury Rehabilitation by staying in an Anklizer removable boot or Ovation Medical Boot with EvenUp on the other side.
6. Spica tape your toe daily.
7. See if your doc will prescribe voltaren gel or flector patches for you (at least for when you sleep).
8. Figure out if either of the two pairs of orthotics actually do protect the ball of the foot (we need function not number of). 
9. To specifically deal with the pain, see a pain specialist. Avoid NSAIDs since you could have a bone injury.
10. See if any other activities you are doing daily is irritating things and make some change. 
11. Apply Neuro-Eze to the sore area 3 times daily (buy online).
12. Do Metatarsal Doming and Single Leg Balancing daily to keep some strength in the foot (painlessly). 

I hope this gets you started in a good direction. Rich

Sesamoiditis: Email Advice

Dear Dr Blake,

I am contacting you from Australia as I have been suffering from a particularly persistent case of sesamoiditis for the past 4 months. I read your blog and was hoping you may be able to help as I'm desperate for answers. 

I have tried all methods of conservative treatment, including custom orthodics, 2 cortisone injections (FHL tendon sheath guided by ultrasound) and 1 MTP joint capsule. I had a negative reaction to the second injection, with increasing swelling pain in the 1 MTP. My orthopaedic sports surgeon, decided it was best to have a investigative synovectomy with biopsy carried out to eliminate any potential infection/underlying inflammatory condition that was not appearing on blood tests or MRI. The biopsy yielded no results.

I have also been in a cam walker for almost 3 months, with 2 weeks of crutches included in there post surgery. I have been training in professional football. I am desperate to heal this condition and am reaching out to you for help as I feel my options here in Australia are limited, with little success this far.

I am particularly interested in ESWT and the specific modalities applied so that I may be able to request from a clinic here. I would also be interested to hear your opinion on PRP injections or Augment for bone healing, even though no fractures are present in my case (just a bipartite sesamoid, confirmed via xray and 2 MRI's).

I would greatly appreciate your assistance Dr Blake as I am a very active person and this condition has severely affected my quality of life and aspirations of becoming a punter in the NFL.

Yours sincerely,

Dr Blake's comment: I am honored you have asked me. I have no experience in ESWT or PRP or Augment for this condition, but I think that there is a place for Exogen Bone Stimulation to strengthen the bone. You have been in the Immobilization Phase for typically the time you would for a broken sesamoid, so the question is how to progress you to the Restrengthening and Return To Activity Phases. I am happy to look at any MRIs that you want to send me. The Pacific Ocean is not that big. I would have to assume the length of time is either from inadequate orthotic protection, a misdiagnosed small sesamoid fracture, or pain more from soft tissue with inadequate physical therapy. If everyone is happy that the bone is not broken, find out who makes the best orthotics in town or in the biggest town near you. See if a physio can evaluate you for bone, joint, or soft tissue problems. Ice Pack the area 3 times a day for 15 minutes, and do contrast bath each evening. Buy a roll of 1/8 th inch adhesive felt from Moore Medical (www.mooremedical.com) and with a tennis shoe 1 size bigger, and a good deep toe box, try to design a dancer's pad and arch support that when you walk and run there is no weight on the sesamoid (a slight overcorrection of the foot as a temporary design). Send me photos of your foot, inserts, anything and I can give you advice. Do you have swelling? Does the joint have good range of motion? When does it hurt---with joint motion, or just with pressure? Let's start analyzing. Best to comment on this post, but it you want more confidentiality, email me again. I hope this helps some. Rich

Patient's Response:

Hi Rich,

Thank you so much for your reply.  

From what I have been able to gather in my research, there are two different types of sesamoiditis.  One which is more related to a bony stress response, and the other which is more related to FHB and FHL tendon/ligament inflammation.  I think there's no doubt that initially it was a bony stress response, however I tend to think the sesamoids are now more reactive to the surrounding inflammatory soft tissue.  The MRI's reports detail tenosynovitis to FHB and FHL.

Dr Blake's comment: Tenosynovitis is an advanced, very sore, form of tendinitis and hard to get rid of. 

I was using a personal ultrasound device for a few days (ultrasound pro) which I bought over the internet, which has a low frequency setting.  I was using this around the FHL and FHB area, as well as 1st MTP.  It seemed to aggravate things for a couple of days and then settle down.

Dr Blake's comment: Ultrasound units that you can purchase are either for bone or soft tissue. The soft tissue ones are bad for bone healing, so you need to know which one you are getting. 

  So I have stopped this and am now only using the Melmak bone stimulator which my specialist recommended.  My specialist says its the same as an Exogen 4000.  Here in Australia you can't rent Exogen, you can only buy them for around $1,800.  So I am renting the Melmak for 1 month ($330) and doing 20 min per day treatment as prescribed. 

Dr Blake's comment: Definitely switch to twice a day for the same 20 minutes. 

 I was hesitant to use this as I have been told I don't have a fracture as such and was wondering how much good it will actually do for a "stress reaction" to the sesamoid.  I hope it helps rather then causes a negative reaction.  Do you think these devices help with soft tissue/ligament and tendons? What about 1st MTP swelling?  

Dr Blake's comment: I love this device for building bone strength. A bruised bone would be helped as would a broken bone. For the soft tissue, due regular PT, icing massage, spica taping to limit the motion of the FHL and FHB, and contrast bathing daily for the swelling. 

The 1st MTP is still swollen (6 weeks post synovectomy) and range of motion it limited, although it improving as I'm doing some light rehab like picking up pegs and just ROM exercises.  I'm also doing some heat treatment like hot bath soaks, sauna then swimming pool.  I still haven't had a proper answer from the doctors I have been consulting here as to why I had such a negative reaction to the cortisone injection into the 1st MTP.  I think it was administered incorrectly and have not doubt it set my recovery back significantly.  At the time, the doctor commented - "oh that's good, I got more in than usual there."  I was told he got about 1.5mls into the joint capsule, which from what I can gather was too much.  Also, if there was any bruising of the articular cartilage it can really respond badly.  Would articular bruising show on an MRI?

Dr Blake's comment: Yes, articular bruising shows on MRI. Typically, when my cortisone shots irritate things, for whatever reason, it is 2-4 weeks before we are back to square one. And, in those cases, you never get any benefit from the cortisone, which I do not understand why.

Regarding the orthodics, these have been fitted by one of the best here in Brisbane.  He is the podiatrist for our professional sporting teams, although he didn't employ casts for my high arches.  Techniques include heal cups, posts from 2 to 5, dancers pad and arch support.  I have attached pictures of my inserts for reference.

Dr Blake's comment: Do they or do they not take pressure as you walk off the sesamoid? If not, modify!!!!

I have also contacted the radiologists who took the MRI's.  They are able to set up a web site for you so you can view the images online.  For this option I need to provide them with the following - name, location, provider number, specialty etc). We would then create an account for this doctor so he can log on.  If this doesn't work I can arrange to have the pictures sent via email, although these would be still images.  Would you mind providing the details so I can have QSCAN set up an account on our end?  I will also get copies of the MRI reports to emailed across to you.

Dr Blake's comment: Great, will do in the original email.

I continue to ice each night for 20 minutes which helps.  I have also just started (this last week) getting out of the boot more and back into my trainers with orthodics around the house.  I have also been taking silica as it's supposed to help with connective tissue strengthening (i.e. ligaments and tendons).  I am also taking glucosamine, fish oil, Vit D and calcium supps, in addition to a multi.  I eat a very good diet so I don't think there is anything more I could be doing nutritionally to aid in recovery.

I am seeing my surgeon on Monday (tomorrow) for another post op review and I will request another MRI to see how things are progressing and will keep you posted.

I am happy for you to repost this email on your blog.  Feel free to modify/amend parts as you see necessary.

Thanks again,