Patient #17: Big Toe Joint
Pain
.
History and Chief
Complaint
- Long distance runner presents
with a 6 month history of progressively worsening pain at the ball of his
right foot
- The pain had be smoldering for
awhile, but got much worse when he attempted stair running at a local
stadium
- Over the last 2 months, he
could not walk well, so he got an appointment with the local podiatrist
- X Rays were negative by
history, and he was placed in a removable boot for several months
- The pain was not any better in
the boot, painful with each step, and a roommate gave him some old
crutches stored at his mom’s house
- The big toe joint was swollen
and painful to move
- Follow up appointment with the podiatrist
an MRI was ordered.
- The doctor said that he had a
stress fracture in the medial sesamoid and that time or surgery would
heal.
- He came to me for a second
opinion only
Gait Evaluation
- Very limited due to the boot
and need for crutches
- When asked, the patient stated
he had been labelled a pronator
- Running shoes were not present,
but minimalist in nature
- Gait evaluation for walking and
running would have to be delayed (it can be months before I watch a runner
actually run due to situations like this)
Physical Examination
- Swollen first metatarsal
phalangeal joint
- Palpable pain plantar only on
both sesamoids, perhaps the medial more
- Plantar pain on both maximum
dorsiflexion and plantarflexion of the joint
- Plantar pain on contraction of
the flexor hallucis longus against resistance
- Good range of motion of the
joint however, although 10 degrees less overall motion than uninvolved
side
- Probable negative lachman
(swelling present can make the test unreliable)
- MRI showed no apparent fracture
but bone edema in the medial sesamoid and surrounding tissue
Cursory Biomechanical
Examination and Asymmetry Noted
- Rigid Pes Cavus Foot Type
- Inverted Heel RCSP
- Mild Tight Achilles Tendons
- Plantar Flexed First Ray Right
Worse than Left (perhaps only due to swelling)
- Everted Forefoot Deformity Left
greater than right
Tentative Working
Diagnosis
- Medial Sesamoid Stress Fracture (stress fractures may not be seen even on MRI)
Common Differential
Diagnosis (2ndary Working Diagnosis)
- Sesamoiditis with Bone Edema
Occam’s Razor and Rule
of 3
- Simplest Solution after 6
months of pain and on crutches and a boot is surgical removal (no one
would think that wrong)
- Rule of 3 looks for ways to
rehabilitate, although can be also used post operatively to have a better
outcome.
- The 3 forces that lead to
stress in the sesamoids commonly are: tight achilles tendons that must be
stretched out, pes cavus feet with high metatarsal declination angles that
need to have the re-balanced, and plantar flexed first rays that must be
off loaded
What Phase of
Rehabilitation?
- Immobilization (but non-weight bearing
with crutches can intensify the swelling accumulation and make the patient feel worse than they actually are)
Should We Image?
- X Rays and MRI already done
- I always look at the first MRI
as just that “The First”
- I will get another MRI in 6
months to see how the healing is going
First Decision: How to
Reduce Pain 0-2
- Minimal to No Crutches as non
weight bearing increases swelling to a localized area like this
- Build an accommodation of at least ¼
inch adhesive felt inside of the removable boot (normally up to ½ inch)
Second Decision:
Inflammation Concerns
- No NSAIDs due to bone problem
- Ice Packs or Soaks 3 times a
day
- Begin Contrast Bathing each
evening to get rid of the bone edema
Third Decision: Any
Nerve Component?
- Assume that nerve
hyper-sensitivity begins 3 months after a problem like this.
- Start treating with ice for
only 5 minutes, warm compresses, non painful massage, topical gels or
patches (like Neuro Eze lotion or Lidoderm Patches)
Fourth Decision: Initial
Mechanical Changes
- Get the boot comfortable so
that we know we have a healing environment (make an internal float)
- Order a 9 month course of
Exogen Bone Stimulator
- Begin designing or ordering off
weighting pads like Dr. Jill's Dancer’s Pads of a ¼ inch thick
This
particular patient did well with conservative treatment over the next several
years and was back running. The mechanical list from Chapter 6 (Book 2 of Practical Biomechanics for the Podiatrist) is so long due
to the long period of experimentation needed for a patient like this. I have
starred all the ones used for this particular patient as we moved him through
his rehabilitation.
Common Mechanical Changes at the First
Metatarsal Phalangeal Joint
- Spica Taping*
- Bunion Taping
- Toe Separators
- Dancer’s Padding*
- Cluffy wedges*
- Morton’s extensions
- Orthotic Devices for Weight
Shift with no extrinsic post*
- Orthotic Devices of Stability
only with no extrinsic post
- No Heel Lift*
- Zero Drop Shoes*
- Rocker Shoes*
- Bike Shoes with Embedded Cleats
- Cam Walkers or Removable Boots*
- Stiff Shoes (including post
operative shoes)*
- Flexible Shoes
- Forefoot Padding
- Skip Lacing*
- Deep Toe Box*
- Wide Toe Box
- Shoe Stretching
- Carbon Plate Full
- Carbon Plate Morton’s Extension
- Carbon Plate Dancer’s
Modification
- Proximal Padding Dorsal or
Medial
- Metatarsal Padding sub 2nd
through 4th or 5th*
- Self Mobilization for Hallux
Limitus
- Metatarsal Doming*
- Abductor Hallucis Strengthening
- Flexor and Extensor Hallucis
Longus Tendon strengthening*
- Night Splints and Yoga Toes
- Correct Toes
- No Achilles Tightness*
- Avoid Excess Toe Bend*
I saw this patient once
a month for a year to progress the rehabilitation. He was in the boot for
almost 3 months from the day I first saw him. While in the boot, he was working
on bone health with diet and bone stimulator, and he was working on the
inflammation and nerve sensitivity 5 separate times each day. I should have at least got a Vit D blood level, as transient vitamin D deficiencies can lead to bone issues and prevent or slow down healing.The 2nd 3 months
was still partial boot as we weaned him off the boot and into Hoka One One
Shoes 1 size bigger and the widest one on the market. I needed room to build
things for him. It was at 9 months along our rehab course when he had built up his pain free
walking to 5 minutes, that he started the 10 level Walk Run Program. At one
year from the start of seeing him, he ran a slow 10K in 73 minutes. In the
shoes that he ran in were Hannafords (full length soft based plastazote custom
inserts). I had made him a pair of Root Balanced plastic based orthoses due to the lateral column
support I needed to get (high everted forefoot deformities) which worked best as
scaled down dress orthotic devices. I had made him an Inverted Pair, but he was
too laterally unstable as he began to walk and run. I also think the
arch began too high in the Inverted pair, so the metatarsal declination pitch became too high.
However, rehabilitation of these conditions, with all the modalities at our
disposal is pretty awesome.
