Chronic Big Toe Joint Pain: Turf Toe?

Dr. Blake,

I have been reading your blog for several weeks now and have watched many of your videos. I am emailing you on behalf of my daughter who is a 16-year-old soccer player (who will be a junior this fall) with the potential to play soccer in college. She has been suffering from an injury and is desperate to feel better and hopefully be able to continue playing the sport she loves. I am hoping that if you have some time you could give me your thoughts. I completely understand if you are unable to do so. 

She suffered an ankle injury in September 2018 while playing soccer. The orthopedic surgeon at the time said she most likely had torn the ATFL. She was put in a cast, then a boot and then went through PT for several months. She was cleared to play soccer in January 2019. However, after a few games, she continued to have pain and swelling in the ankle. She stopped playing, went back to PT and then was released to play again in April. Right at that time, she started to develop pain in the ball of her foot. She continued to have pain for several months until an MRI in June 2019 diagnosed turf toe. She was put back in a boot for several weeks and then went through PT for a few months. She returned to play in August but by October she started to develop pain in the same area after playing back to back games of 90 minutes each. All this time she continued to have pain and swelling in her ankle as well as the pain in her foot. She continued to play soccer until the date of her surgery on November 22, 2019.

After a year post injury, it was decided she would need ankle surgery. In November 2019, she underwent a modified Brostrom procedure and the doctor found that she had 3 torn ligaments in her ankle. I believe two were repaired with anchors and the third was reconstructed. (Note: this orthopedic surgeon was not the original doctor we saw when she suffered her injury in 2018) Once she was allowed to take her first weight-bearing steps weeks after surgery, she had immediate pain in the ball of the foot. The orthopedic surgeon had hoped that the rest after surgery would help and prescribed PT for both the ankle and the foot Jan-Feb 2020. We took her to a podiatrist in March of 2020 after continued pain in the foot. X-rays in the office were negative for any fractures or abnormalities of the sesamoids. He diagnosed her with sesamoiditis. He made her orthotics and shortly after she received them, the Corona virus hit and we were unable to see him for several weeks. During that time, we sought another opinion by an orthopedic surgeon specializing in the foot and ankle. He performed x-rays as well and found them to be negative also. An MRI was performed with the following results:

----There is very subtle bone marrow edema of the head of the second metatarsal. There is

no other bone marrow edema, marrow replacing process, or acute fracture. The
sesamoid bones of the first digit have a normal appearance with no signal or
morphological abnormality. The flexor digitorum tendons, flexor hallucis longus, and flexor hallucis brevis tendons are intact without edema or tenosynovitis. The extensor tendons are intact without edema or TR synovitis. The plantar fascia has a normal appearance without

inflammatory change. The muscle volume and signal is normal.
There is soft tissue edema in the interspace of the first and second metatarsal heads
tracking around the lateral sesamoid bone of the first digit.

IMPRESSION:

1. Mild bone marrow edema of the head of the second metatarsal with surrounding soft

tissue edema extending into the first interspace and around the lateral sesamoid bone.

Findings likely relate to chronic stresses/ superficial repetitive trauma.

2. No evidence of fracture or osteomyelitis. No soft tissue fluid collection.

Dr. Blake's comment: Many patients have irregular sesamoids on xray, never get an MRI like your daughter, and due to the chronic pain have the sesamoid out sadly. So, I am so glad you did get an MRI. Swelling around the lateral sesamoid from turf toe (grade 2 or 3 tearing of the lateral collateral ligament) can appear like a sesamoid fracture. I am confused that the MRI did not document turf toe, but maybe it was a severe stage 1 or mild stage 2. If we treat the MRI only, this should be all healed by now. 

He put her on a Medrol pack, showed her how to tape her toe (like the videos on your blog) and told her to wear a boot for a few weeks to relieve some of the pain. She did not feel any benefit from the Medrol pack. He did not recommend a cortisone shot or surgery. Shortly after, the podiatrist called us back to the office. He modified her orthotics. He took her out of the boot because he felt her muscles would atrophy and would require more PT to rehab her back.  He found her hamstring and calves to be very tight so he instructed her to stretch 3 times a day and ice afterwards for 20-25 minutes. She is to do this for several months. She just started PT this week. The therapist said she is strong in both the ankle and foot but is still weak from her surgery as she was never able to start conditioning due to the pain in her foot. She is wearing Merrell hiking shoes for more support. I put a J-pad under her foot and she did feel a little bit of relief. However, the podiatrist does not want us to use this...maybe because he wants the orthotics to start working to redistribute her weight naturally? She is continuing to tape her toe as well. Per your blog, we will file down the cleat right beneath the ball of the foot and will also purchase turf shoes for training and play when her outdoor cleats aren't needed. 

Dr. Blake's comment: This is wonderful. Dancer's padding (J Pad) are a must, and I will use on the orthotic and also on the foot. You typically need 1/4 inch sesamoid float to take pressure off, so you can see how much the orthotic does. It is time for her to get at least 5 things that are working for her: taping, orthotics, J Pads, cluffy wedges, icing, contrasts, stable shoes. Can you get a pair of Hoka One One to try to see if the rocker eliminates some stress? 

The podiatrist would like to see her back in a few weeks to determine her pain level. If she isn't getting much relief, he said he would consider giving a Cortisone shot. He also indicated that if she continues with conservative treatment for a few months without much relief, and the fact that she's had this pain for over a year, he would consider surgery. While he said this is the last option, he did say she could recover well from it because it's the lateral sesamoid that would be removed. He felt that she would be able to return to playing soccer about 4 months after surgery. My concern is the health of the remaining sesamoid and keeping it healthy for the remainder of her life. I have read what can happen if both sesamoids are removed.

Dr. Blake's comment: Whoa!!!! There is no problem documented in the lateral sesamoid, and cortisone into a chronic turf toe may be okay, but may be not. Turf toe, which I think is our working diagnosis, is a tear or stretch of the ligaments. It can make the joint unstable, and I do not know if she is already naturally loose. She may consider an arthrogram of the joint where dye is injected into the joint to see if it leaks out, although have not seen that test for years. If a lachman test for turf toe has been done, find out what it was. She made need a couple of sutures placed into the big toe lateral collateral ligament if that is the case. Convince me that this is not ligament instability due to turf toe. Sorry, I know this is hard. I sure hope this helps your daughter some what. 

https://www.physio-pedia.com/Turf_toe

I am reaching out to you because my daughter is starting to feel hopeless that she will ever recover. She had to stop playing basketball a year ago because it was all too much for her ankle. She will be devastated to have to give up on her dream to play soccer in college. 

If you are able to provide any thoughts or advice, I would greatly appreciate it. I feel that the orthopedic surgeon and the podiatrist have conflicting ideas and a third opinion (hopefully yours) would possibly help us with our next steps.  I have been doing a lot of research and stumbled across your blog. By far, your site provides more information about this condition than anything else I have found. Thank you for all you do for the health of others.

Sincerely,

Turf Toe with AVN Sesamoid: Email Correspondence

     I have had a 2 plus month relationship with this patient after she first contacted me around January 3rd, 2020. I have given her advice and had her send her images on a CD to me. Below in red is a note I sent her in February. The original injury was early September 2019 playing ultimate frisbee in cleats. No acute incident happened. Late October 2019 X-ray which was negative except bi-partite fibular sesamoid. Late November 2019 MRI documenting AVN fibular sesamoid, intersesamoid ligament tear and lateral collateral ligament suspected tear. Podiatrist at that time wanted to do surgery, but she wanted another option. Shockwave for the sesamoid flared her up with significant swelling. She went on crutches, and started reading my blog early December for advice. She was able to calm it down with the crutches, contrast bathing, etc. 

Thanks for the update. Just went down and had a wonderful discussion with one of our radiologists who went over the joint with a fine tooth comb for me. Most of this we know, but she added a twist. Her findings were:

• Fractured fibular sesamoid with AVN 
• Stretched or torn ligament from the sesamoids to the base of the toe (places the sesamoids in the wrong position)
• Torn and partially healed ligament between the sesamoids (moving the fibular sesamoid laterally too far)
• Partially torn lateral collateral ligament with adhesions to the base of the first metatarsal causing chronic irritation (this is the part I did not appreciate)

So basically the sesamoid lost its blood supply (which we are trying to bring back with contrasts and bone stim), but it is also stuck down in the wrong position so motion of the joint is painful. 

Time will heal the ligaments more, so that part of the course is fine.

The questions are will the AVN come back (only another MRI in 6-8 months will tell us if our direction is solid). But even if it comes back, will it be stuck down (like a frozen shoulder is stuck in the wrong position and people can not comb their hair) too much, that PT will not be able to rehab? Alot of unknowns. I will help you with them. Watch my video on self mobilization for hallux rigidus on you tube under drblakeshealingsole self mob and start doing that twice daily. Rich

https://youtu.be/FBTeWbdGrzs

The Patient's Response today March 23rd, 2020.
Hi Richard,

It's been a month, and I wanted to give you an update on my situation! I apologize for not getting back sooner, but things have been completely crazy with the coronavirus situation. I'm adjusting to this new life. I hope you are doing well and that your business is not too impacted by the current situation! I imagine that your hospital is bracing for impact...

Dr. Blake's comment: Thanks for the good thoughts. I am in an outpatient clinic within the hospital so we are completely shut down and it may be for a long time. Trying to learn Zoom video so I can use Telemedicine some. Hard to give my patients orthotics and adjust them via the internet however. LOL. Hope you are well and practicing good social distancing!

So, here goes on the update - as a reminder, I'm the girl with the case of turf toe + AVN of the medial sesamoid. :-)

• Overall, I've been experiencing an incredible improvement that began towards the last week of February. The last 3-4 weeks have truly been a blessing and I'm starting to get my life back. It's strange that this would happen at a time where many are losing their lives, but that is the cruelty of life sometimes, I guess.
• I got off crutches and started to be able to walk for 10-15 minutes mid-February or so. Following that, I've been improving every day.
• I attribute a lot of my improvement to having gone to Physical Therapy over the last 3 weeks. He has truly helped me in actually pushing me to do a little more than what I thought I could. We do massages to decrease the swelling, but also strengthening barefoot on the ground and I even have graduated to doing small heel raises barefoot, which I am coping with very well!
• I have been able to take walks for longer and longer, (cluffy wedges have helped my toe mobility and gave me a further boost). I've finally managed to get back on my road bike using my clip-on shoes, which is just amazing. I used to swim a lot, but the pools have closed for the moment.
• I'm continuing the Exogen Bone Stimulator, along with PT, and revving up my walking and exercising. 

Dr. Blake's comment: I am so happy for you. By creating the 0-2 pain level, and gradually adding stress to the tissue, it sounds like it is responding well. So many of my patients need a PT which sees them at least once a week to gently but progressively move them along. Rich

My questions are quite straightforward at this point:

1. How slow or fast should my recovery go at this point? Am I doing too much? I'm trying to be really, really, careful, but I find that doing just a little more than what I'm used to helps bring me to the next threshold of recovery. Like, I need to feel a bit of pain, but not too much. Dr. Blake's comment: 0-2 pain which is very healthy is still pain. Yes, you will have pain as you do something that you think you are ready for but was not. You should take 2 steps forward, 1/2 step back at times. Each month should show improvement (sounds like you are much better than last month February). Just go with the rehabilitation gradually, do not think about time tables.
2. Is it possible that I am improving so much but that my bone is still dying? I will get a second MRI in May (at the 6-month mark) - what if my bone is still suffering from AVN? Will I need it removed even if my symptoms are almost none at that point?Dr. Blake's comment: The MRI is for some judgement of how the healing is going. Surgery must be matched up with disability. There is no reason to consider surgery if you have a non painful AVN. I am hoping the bone recovers. You made need another MRI summer of 2021. Your pain has always been from the injury, the inflammation, and probably nerve hypersensitivity. You are working on everything which needs gradual stress applied week by week. No more than 10% more each week, and you should be on the 48 hour recovery between the highest stresses. 

Thanks so much for all your help.

Kind regards and good luck with the current situation. My thoughts and prayers to you and your family. Stay safe and healthy! And you!

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.

     

Injury to Fibular Sesamoid in Rock Climber: Email Advice

Hi Dr. Blake!

I've been reading your blog and thought I'd try and see if you respond to my questions. I'm desperate for answers and I've seen 2 DPMs and 1 Ortho surgeon with foot/ankle specialization. Each of their prognoses is different and so is their proposed treatment. I'm going to get one more opinion from an ortho too but if you have any insights, I'd love to hear them.  I'm a 34 yo female construction manager, rock climber, dancer (ballet growing up, lots of Latin dancing in heels as an adult). I hate running so I'm not as concerned about losing my ability to compete in triathlons.

Summary of the condition:

1. initial injury occurred in rock climbing in late March 2018. There was no impact, but I was standing in a precarious position for over 45 mins standing over a chasm and didn't have much room to move. My weight was mostly evenly distributed between my feet but my toes were hyper-extended and all the weight was on the balls of my feet. I was in instant pain in my left foot that felt like a hit a pressure point. My foot became instantly numb and remained that way for the rest of my 6 hours climb and hike down the mountain. the feeling in my foot came back the next day but my toes stayed numb for 6 weeks. I did not go to the doctor because I had no idea I could have broken a bone by just standing on my foot. It's common for climbers to complain about toes going numb so I just rested for a few weeks and didn't think much of it.  (Dr. Blake's comment: The numbness is either from compressing a nerve for too long as you describe or from the intense swelling internally from a fracture or sprain, that pulls pressure on the local nerves. Or, a combination of course). 
2. Fast forward 3-4 months to July 2018 (I've been continuing to run, lunge, climb, and wear high heels to work all day).  I should also say that I drive a standard transmission vehicle with a stiff clutch and sit in traffic constantly for work. By the end of July, my left MTP joint would be swollen, most of the pain was on the side of my MTP joint, not on the ball of my foot. Eventually, I started having numbness in my toes again and finally went to a podiatrist. (Dr. Blake's comment: I am assuming the numbness went away and these months were not painful, and you did not have to limp.)
3. Aug 3, 2018, I was diagnosed with a lateral sesamoid fracture. I wore a boot and unna wrap for 4 weeks while my DPM was taking x-rays every 2 weeks telling me it was healing. 
4. By Aug 28, 2018, my pain was increasing not decreasing and the ball of my right foot is now hurting because of me trying to offload the left foot. The DPM Xrays both feet, says the left fracture is still healing and the right foot shows no signs of fracture. The DPM put me in the iWalk crutch and ordered an MRI of both feet since I was still having pain. 
5. I've had J pads in the boot on the left foot and orthotics also with a J pad on my right foot because I was starting to have pain in that foot now. (Dr. Blake's comment: I am sure this is Dr. Jill's Gel Dancer's Pads or something similar).
6. After the MRI I saw an orthopedic surgeon (who recently operated on my mom's foot with success) and a leading podiatrist in the state. Both of these doctors agreed that the Xrays showed NO signs of healing and that the original DPM was wrong. MRI indicates no sign of healing and is inconclusive as to whether or not it's a bipartite sesamoid or a nonunion fracture.  There are signs of AVN and edema. (Dr. Blake's comment: Yuck!!)
7. Here's where I'm confused:
   1. Ortho surgeon says he doesn't know if it's a fracture or bipartite but it doesn't matter because it's not healing and shows no sign after almost 6 months (the last 1.5 was immobilized). he says surgery is inevitable but he'll wait as long as I want. He gave me a cortisone shot and suggested within a week I transition to regular hiking shoes until I'm ready for surgery. he doesn't want me to stay in a boot that will cause muscle atrophy and all other sorts of problems while I decide on surgery. My question is, is 1.5 months enough time in a boot to be sure it won't heal. and if it's not a fracture, is there another cure than surgery? (Dr. Blake's comment: Sorry this is confusing. These time frames do not apply to sesamoids or a lot of other injuries. The wait with sesamoids can be a one year process, and sometimes more.)
   2. DPM #2 says it's fixable with 6 months in a boot and exogen bone growth stimulator. Do I really wait 6 months in a boot with an expensive contraption waiting for the bone to heal (what if it IS bipartite?). Will the exogen doing anything for bipartite sesamoid? (Dr. Blake's comment: I agree sort with the DPM #2. I will look at the images you sent below to comment on the bipartite aspect).
8. I have an active lifestyle but more importantly, I have to walk at work a lot. I can't afford to waste 6 months in a boot for a bone to heal that isn't even broken.  I also can't afford to have sesamoiditis in my right foot as a result of offloading for multiple months on the other foot. What do you recommend? (Dr. Blake's comment: Work can force people's hands at having the surgery, since the prolonged rehabilitation may not work for them. That is one of the huge reasons patients will have some foot surgery.)

Additional Questions:

1. No one has commented on the right foot having a bipartite sesamoid or not. It was not specifically mentioned in the radiologist's interpretation but when I look at the Xray it looks possibly bipartite to me. I've been researching this a lot and I've seen that 90% of bipartite sesamoids are bilateral and occur on both feet. Can you see from my Xrays if both my right and left foot of bipartite lateral sesamoids? 
2. Should I be considering selling my car? From what I read about surgery, it'll be a long time until I could press the clutch with my left foot again. Maybe I should buy an automatic transmission. (Dr. Blake's comment: Whether you end up in surgery or not, switching from manual to automatic makes sense right now. Can you rent one for a week to convince yourself?)
3. I'm worried that if I get a sesamoidectomy that my fibular sesamoid will fracture too. Should I worry about that? (Dr. Blake's comment: This is at the root of why we try to avoid the first surgery if possible. It is a rare occurrence because people are so protective of their remaining sesamoid. But, with rock climbing positions, who knows? Make sure your Vit D is at 55 with low normal at 32 or so, halfway on the normal scale. You would not want transient Vit D deficiency to cause a fracture.)
4.  I don't know who to believe the orthopedic surgeon or the podiatrist? How do you choose? (Dr. Blake's comment: First of all removing the sesamoid is technically simple, but the decision to do the surgery is not at all. Also, who is going to provide you will the best post-op course, orthotics, taping, etc? )
5. How long is too long to wear this boot? (Dr. Blake's comment: My golden rule of thumb is 3 months with the bone stimulator for 9 months total. The transition from boot to shoe can be tricky with the need for orthotics, perhaps rocker shoes like Hoka One One, taping, padding, bike shoes with stiff soles, etc.)

I've attached my L and R foot Xray from 8/28/18 and summary of the MRI interpretations, in case you have time to look at these. (Dr. Blake's comment: Please send me a disc of the MRIs to Dr. Rich Blake, 900 Hyde Street, San Francisco, Cal, 94109. Please email me at rlb756@gmail.com when you think I got it. I want to see how inflamed the sesamoids are). 

Thank  you in advance for your time!

Jaime

This does look like a lateral or fibular sesamoid stress fracture with irregularities where the junction between pieces area. Bipartite usually look more symmetrical and rounded borders. To me, it is the incredibly long first toe and metatarsal that makes this prone to injury. Yes, removal of the one sesamoid could set up problems for the other.

Here the lateral sesamoid looks more like it is bipartite, which shows you have the bone overlap from the first x-ray distorted things. If it is bipartite and began to hurt with prolonged hyperextension, I wonder if you have a turf toe situation. Has anyone mentioned that?

I read this as mild injury to a bipartite sesamoid junction leading to a mild reaction of the tissues. Maybe once I see the views the mild level will look more like moderate. The biomechanics of Turf Toe, where you hold the toe on the ground, and you stress various things, like the bipartite junction to cause injury or one of the muscles or ligaments (not noted) makes sense here. If you switch to turf toe protocols, it may make more sense then sesamoid fracture protocol. The treatment can be some the same and some different. Create that 0-2 pain level consistently.

More obvious bipartite. A CT scan should be ordered for your left. Again, the long first metatarsal and toe (called Egyptian Foot in ballet)  which takes more stress than normal. 

 Again more bipartite looking with the two parts of the sesamoid with smooth borders and unequal in dimensions

Sesamoids look different on MRIs. They are wrapped up in ligaments and tendons, and unless they are abnormal (as in your left side) they look normal. Your workups have been good. Until I see your films, 3 months in the boot, with an EvenUp on the other shoe to keep the weight normal. If it is Turf Toe, spica taping is key, and probably advancing gradually to bike shoes with embedded cleats. 

https://youtu.be/l_4HESXCG40

1. Should I cut back on my glass of wine or a beer most evenings? No, unless it causes you to stumble.LOL

Turf Toe: Very Disabiling!!

Hi!  I found you through Youtube and have spent some time on your website.  The more I read, the more I realize I am in trouble.  I do not know if you still answer emails, but I thought I would send this.  I have nothing to lose, only to gain; right?
Dr Blake's comment: Hopefully, right?:)

So...  A year ago, I had a serious "Turf Toe" type injury, resulting in two fractures at the top-side of both joints of the big toe, one fracture, each.  I had ligament, tendon sprains, and nerve injury.  Eventually, it began developing into possible CRPS symptoms, which a physical therapist noted and got right on top of.  (I am very happy to report that those symptoms have been resolved.)
Dr Blake's comment: That therapist needs to be in your will, or at least a thank you!!

Because there was so much going on and pain and swelling everywhere, I didn't realize the pain under my foot was any different than the pain everywhere else, in the first couple months.  Through the entire year, except for wearing a boot for two weeks, around the clock, my instructions remained that I walk on it at home, with no boot (which, for me, meant barefoot, since I can't tolerate slippers or even a sock - nerve stuff) and only wearing the boot when I leave home.  

During this time, I have gradually turned into a shut-in.  Life as I knew it, stopped.  My job, gone.  As the months passed and pain, swelling, and inflammation persisted, I began asking about an MRI.  For months, my podiatrist kicked the can down the road, citing the expense for the insurance company.  Six months after the injury, he finally conceded.  The MRI showed that I also fractured both sesamoid bones.  And my resulting treatment?  IT REMAINS THE SAME!  Just keep on walking on it (booted only when I leave home, which is pretty much never)!  99% of my life is now lived banished to my recliner - but bootless, as instructed!!
Dr Blake's comment: One of the hardest things for docs in the short office visits we have is to fully understand the disability someone has! It is sad, and the patient gets into this predicament. Rehabilitation is a balance between pain and function. Sometimes we actually have to ignore some pain to increase function. It is also the role of cross training. Many patients can not walk but can build up to 2 hours a day on a stationary bike, and this can be emotionally and physically so healing. With a stationary bike, none of the weight has to go through those joints. 

A month and a half ago, I re-injured it while wearing the boot - toes being violently propelled over the top of the bootstrap, resulting in a fulcrum effect, at the base of the toes.  I fractured a new place in my low, big toe joint and the new MRI shows both sesamoid bones, still fractured.  

The doctor says he cannot tell if they are new fractures or old ones, that never healed.  My vote is the old ones never healed.  The pain and swelling never went away!  

And now...  I have de-mineralization (rated as moderate to severe) throughout my entire foot!!  I just saw a sports medicine podiatrist for a second opinion.  After seeing the two MRIs, he ordered a CAT scan, which I had done today.  He said, depending on the results, he may recommend removal of one or both sesamoids.  (He said recovery will only involve non-weight bearing on the front of my foot for 4 - 6 weeks, then I'll be good to go!  I suspected that wouldn't be enough, which I have learned from your site, is true.  Common sense!  But none of this last year falls under the category of common sense, for me.  Why not treat my fractures like fractures, instead of having me walking on them for a year??)
Dr Blake's comment: Please send the CT scan disc to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. It will be good to have a clear view of the injuries since my mental picture is getting foggy. I am from San Francisco known for our fog. 

At this point, I am at home, unbooted, with crutches - why not just use the boot, right?  I CANNOT walk bare-foot on the front of my foot, as instructed by the original doctor.  It seems like I will never be given the chance to let the bones heal through immobilization, because of the bone de-mineralization (that was NOT on the first x-rays/MRI, last March).  I would think that immobilizing, the way it should have been done, now, would make the state of my de-mineralized bones even worse.  If he recommends surgery, I will never know if my sesamoid bones COULD have healed, if given the chance.  This is so not right!
Dr Blake's comment: Docs are given mere thumbnail prints of your last year in one visit. This can make the correct decision clouded by the need for pain reduction and mobility so I can see why anyone with a heart would at least entertain the thought of surgery. 

Am I seeing this correctly?    

Then...  I followed a few sesamoidectomy video diaries on Youtube and the experiences of these poor people were awful!  Do I even want to do this to myself??  ONE AND TWO YEARS LATER, they were still giving updates about their continued pain and limitations!!  Is that my future if I have surgery?  Then, of course, comes the next question.  After a year of this, already, is THIS my future if I do not have surgery???  It all looks so hopeless.  I feel trapped, with no way out!
Dr Blake's comment: Surgery has complications, but sesamoidectomy is a very successful surgery overall. When I struggle with my patients, some do eventually need surgery, and I am sorry, but they do well. I tell my patients that all the skills you learn trying to avoid surgery, help you if you eventually need surgery. You have an unusual case that needs a lot of thought. You have not walked for far too long, and you had a second injury. Also, total healing comes from too many factors that I have time for, but you work through them. But, do not focus on the 1-2% of patients that have major problems post surgery. That will serve no purpose in your attempt to heal. 

(One woman had the surgery, her big toe crossed the others, corrective surgery did not work, they fused her big toe joints, there were complications with that, then the last post was that she had the advice of two doctors to amputate!!!  Scary stuff!!!)  

Does this surgery benefit anybody???  I haven't found that story, yet.  Is it possible to have a life without permanent pain and dysfunction after this??
Dr Blake's comment: Yes, but you have to find a good surgeon if it gets to that. 

Maybe the biggest question is, "How many doctors do I go through before I find one that listens and knows what they are doing?"  THAT is the greatest futility of it all.  (The two ER docs, from each injury, missed it, which is incredible to me.  The very first podiatrist recommended two surgeries based on x-rays that were not mine!  He is known for unnecessary surgery, apparently.  I ran from that place and into the care of an orthopaedic surgeon who said it was no big deal.  He literally said I was not to modify my life, in any way, and to walk on it until I saw him, six weeks later.  At that point, he re-x-rayed one of four fractures, missing the other three, then announced it hadn't healed and I needed six more weeks of un-modified walking.  "Call if you have any problems."  No follow-up appointment.  The next doctor is the one I spent the rest of the year with, until the second opinion, I just got.)
Dr Blake's comment: I am sorry. Let me know what cities you are around, and I will send you a recommendation or two. You will at least need another opinion at some point. 

Another question.  The in-office x-rays (second opinion doc) shows the toe fractures have healed, but I still have pain that shoots out of the joint at the base of the toe (where the fractures were) when I walk.  Is there any correlation to the sesamoid fractures?
Dr Blake's comment: Of course, they are in the same area basically. Occasional sharp pain which quickly disappears is not considered damaging.  The real job now is to create that 0-2 pain level as you begin to walk more. This typically needs some form of off weight-bearing padding and an arch support. Sometimes you need crutches to help. 

And, I am getting this weird internal/external swelling that both doctors don't have an answer for.  When I rest my foot on the floor, my big toe is elevated/suspended more than half an inch off the floor.  The toe next to it (which is also still having joint pain, swelling, redness) is lifted off the floor a little less than the big toe, then the third toe is almost on the ground, while the fourth and fifth toes are on the floor, as they should be.  It has been like this since the first injury, but improving, as time went on.  The second injury brought it right back and it is not improving, at all.
Dr Blake's comment: Anytime that there are positional changes you think of tendon or ligament tears (common in Turf Toe), and these may eventually necessitate surgery. Swelling in the big toe joint typically does not cause these toe positional changes. I would find out what ligaments are torn from the MRI, the bottom or plantar ones causing the toe to go up, and the top or dorsal ones causing the toe to go down. If you lose a ligament, you have to ask the tendon in the area to try to get stronger and compensate. You can initially tape the joint so it stays in the right position. 

It also feels like I did something to the tendon at the center of my toe, travelling over the top of my foot and into the ankle.  It hurts just to touch it.  If it is the tendon, it has been very painful (with swelling).  No one responds to my concerns, at all.  I talk to the wind and the wind doesn't speak.  I wonder if that tendon could be pulling things upward, except the other two toes are involved, so probably not. 
Dr Blake's comment: No, the tendon could be in spasm, being partially damaged. Or there could be nerve issues causing the tendon to contract. Think of seeing a neurologist or physiatrist to evaluate the nerves. Send me the MRIs if you want another look, or I can give you the name of someone in your area, if I can find someone. 

From the moment of the second injury, I instantly became unable to move my big toe, at all (physical therapy had freed it up into an almost full range of motion, before the second incident).  I can get it to flutter a little, but nothing more than that, in either direction.  No one seems to think that means anything or that it needs any kind of intervention.  The MRI apparently says nothing about it, either, which is confusing to me.  (The previous doctor suspended physical therapy, to date.)

Doesn't it seem like doctors should diagnose/treat everything that is going on, rather than choosing the obvious spots to focus on, while ignoring the rest?  That's how I got here, to begin with. 
Dr Blake's comment: I agree. You probably need someone working on the exact injury, someone working on the pain, and perhaps someone overseeing it all to make sure each month you are moving ahead with progress. 

I guess I am sending a message in a bottle, so to speak.  If you have read this far, I deeply thank you for your time.  God bless you for bringing information to patients that wouldn't be able to find it, otherwise, because I am one of those.

Sincerely,

Addition:

If I walk in a boot, is that enough weight -bearing to help the increase of de-mineralization from occurring?
Dr Blake's comment: For sure. Take some photos of your feet and put some xs on where they hurt. Unfortunately, thru this conversation, I still only have a small idea of what is going on. Thanks Rich

 It's got to be better than not walking, at all, or so I would think.  Maybe if I get mobile, in a boot, at least I am walking.  I really do not know who to trust or how to proceed.  (This so sucks.)

Thanks, again...

Big Toe Joint Injury: Possibly Turf Toe

Hi Dr. Blake,

I came across your blog on the Internet and it is one of the most valuable resources I have ever come across in terms of foot health. I understand you are super busy but I would be extremely grateful for any advice you could give me.

Dr Blake's comment: Thank you so kindly. I am trying, I love teaching and I love podiatry. So thank you!!

Approximately six months ago, I suffered an avulsion fracture on the metatarsal joint of my big toe. I wore a boot for six weeks, and pretty much was pain-free once I took it off. I did have a bone spur/swelling to the side the joint, and my range of motion was much more limited with my big toe, but I was nearly pain-free and able to walk.

Dr Blake's comment: If you injure the joint enough to get an avulsion fracture, then you had to technically develop a version of Turf Toe. or plantar plate tear. You will have to tell us later in the comment to this post how the original injury occurred. The ligament attaches into the bones, and when the ligament is pulled too hard, either the ligament tears or the bone avulses. Either way you are left with some instability in the joint. 

Unfortunately, around New Year's day I made a very dumb decision. I performed a deep lunge and pushed off this same big toe when I was in deep flexion.

I immediately felt the pain come back, but I was still able to walk normally without any sort of limp. Unfortunately, I stand and walk on my feet all day for my job, and As the month went on The pain either intensified or stayed the same, but did not get better. 

Dr Blake's comment: So you need MRI or at least comparsion AP feet x-rays. The x-rays are taken standing and you compare the sesamoid position right to left foot. Then, with the toe bent upwards (still standing) 30 degrees another set of xrays see if the sesamoids are still equal in there position from the joint. You are trying to get an idea if the joint is asymmetrical to the other joint in how it functions. 

By February, I decided to take off time from work so I could focus on resting and getting off of my feet. I also saw a podiatrist who thought I might've had a sesamoid injury. I got an MRI and bone scan done, but there was no signs of a fracture at the sesamoid and my ligaments were intact. This was on or around February 1, 2017. I attached the MRI report, were you able to read it? I did say I had a mild nonspecific edema and other things as well.

Dr Blake's comment: The nonspecific edema in the third met is probably a stress reaction from limping. As long as it does not hurt there, no big deal. The ligament structure of the first metatarsal phalangeal joint, including the intra-sesamoid ligament, was ignored in the report. Ask them to look at this further. I am also happy to take a look. Send the disc to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

Now being that it is April 1, the last two months I have spent resting and healing the best I can. I am walking in normal shoes with inserts + dancer pads in them, but I still get occasional twinges of pain every so often.

Dr Blake's comment: I would definitely start taping the joint with Spica taping and see if it influences the pain. Also get flat Otto Bock carbon graphite plate to wear under the shoe insert and see if that helps. 

https://youtu.be/l_4HESXCG40

I just got back from the podiatrist today, and he noted that he thought it was a complicated injury. Between my avulsion fracture or of the metatarsal joint, re-injuring it when I performed a deep lunge, and standing on my feet nine hours a day at my job, I developed a chronic condition. He noted that there was probably a lot of information in there. And also that when I did my deep lunge, I probably aggravated it and resulted this with some turf toe. So: My ligaments and tendons were probably partially torn, completely torn, or definitely at least injured. He said this could take 6 to 12 months to heal, which I am accepting. At this point I just want the best situation possible and I will do whatever I need to.

Dr Blake's comment: Sound smart (because he agrees with me!!)

My main question is in regards to barefoot walking. The podiatrist says I should continue to hold off on barefoot walking as long as possible. I agree with him to an extent, however sometimes it just feels really good to barefoot walk. Honestly being barefoot is one of my favorite things in the world, probably one of the things I miss most since my injury.

Dr Blake's comment: Barefoot is fine, as long as you don't jerk the toe and have to start over. You have to create the 0-2 pain level consistency of a healing environment. Try spica taping during this time. 

I've noticed that when I do barefoot walk, my gait has definitely changed a little, I no longer push off of the big toe on my left foot anymore(because if I did, there would be pain and so my body automatically adjusted how I walk).

Dr Blake's comment: In my mind, that answers it. You have to not limp, or we will be talking of a more serious injury in the hip or knee or low back in several months. Test out barefoot walking monthly, and as the symptoms calm down, you may be able to walk barefoot more and more. 

He did say I could start doing strengthening exercises and also that I could start swimming again, which I am really excited to get back to some activity. However, I still really miss being able to run, jump and dance. And I am fearful that I will never be able to hike an inclined hill again. Hopefully six months or a year or two years or even five years from now I will have improved enough though, to where I can walk on at least gentle mountains again, anyway.

Dr Blake's comment: Really, if you developed Turf Toe, and you go on for awhile without improvement, then they need to find the ligament to fix and put some stitches in it. This is normally not a big surgery, and it has good results, but it can not be just an exploratory operation. The surgery starts a 1 year process towards complete healing and complete function. We expect complete function with some joint stiffness, but not pain. 

Anyway, what is your opinion on barefoot walking? How do I draw the line between "using my feet muscles/toes/connective tissues enough that they retain their function and gain strength and mobility", versus "using them too much that I slow down my healing or possibly re-injure them, because further inflammation/damage?"

Dr Blake's comment: No limping, and no pain over 2. 

He seemed really adamant that I should avoid barefoot walking as much as possible. Do you tend to agree with this?

Dr Blake's comment: See above. Plenty of my patients walk barefoot at least around the house with spica taping and 1/8th inch adhesive padding from www.mooremedical.com stuck to their foot and are fine with the above limitations. 

I noticed that you talk about having a 0 to 2 pain level, but I am able to walk pretty much pain-free barefoot as long as I use short strides and I'm careful not to push off from my injured big toe.

Dr Blake's comment: That sounds fine. The injury is one that you have to avoid bending the joint for a good period of time, but this has not even been documented, so I hope it is true. It is not the weight bearing, it is the bending. 

Any thoughts? Maybe I could still do a little bit of barefoot walking every day, and gradually build up overtime? Or do you tend to agree with him, that I should avoid it at all costs?

Just wanted to grab another opinion if possible, because I know there is the debate between wearing shoes/protection(which protects you more, but in theory could actually atrophy your feet/toe muscles more?) vs walking barefoot(which engages your feet/toe muscles and could potentially strengthen them and help them regain function, but also leaves them more vulnerable to further injury)

Dr Blake's comment: I am definitely in the middle, some of both because sometimes you need the protection (running a race hard downhills on irregular rocky roads). When you can get away safely barefoot, go for it. 

Additionally – – he said that I could see a chiropractor if I wanted to. I was planning on seeing one maybe three or four times total, for them to do a joint mobilization on my big toe and see if that might help me regain some motion. Since I cannot extend it downwards very far.

Dr Blake's comment: I love chiros, but you do not have an actual diagnosis, and if it is Turf Toe, you are trying to let it get stiff and scarred right now. It is all about timing, and I am not sure it is the stiffness that is giving you pain. 

To clarify – – I am not doing extreme amounts of barefoot walking. Just when I am walking around the house and relaxing. I will obviously wear shoes anytime that I go outside or go on a long walk. However, if you also have a strong opinion that barefoot walking should be sharply avoided, then perhaps I should be putting on my shoes even when I walk 15 steps over to go to the bathroom. I am willing to do whatever it takes to give myself the best chance of regaining activity.

Thank you again for any help that you can provide me with. This has been a really tough injury to deal with, but I am really thankful for the help I have an able to receive, and it's giving me a lot of time to focus on myself.

Thanks!!!

PS - I attached a picture of my feet, you can see that on my left foot there is a much bigger band/bone spur near my metatarsal joint where the injury has occurred. I also attached a picture of the MRI report.

Sorry these are on their sides!!