Effects of sesamoidectomy on biomechanics?

Members do not see these Ads. Sign Up.

A question from a current medical student and aspiring orthopod. I have been dismayed at the answers and care from my current docs and physical therapists about the following. Perhaps you have some input?

My hx:
Starting when I was 22 yo, very active in sports (college volleyball, skiing, running) I fractured left medial sesamoid bone. After 6 months of "playing through the pain" and another year of "conservative treatment" (not running, waiting for health insurance to pay for surgery), I finally got surgery to remove a bone that had by this point completely deteriorated and was causing considerable pain.

Post surgery: No orthotics. Back to regular activity in 2 months.

Started training for triathalons exactly 1 year after having surgery. My running milage went from 5-10 to about 30 miles a week. I had a coach watching my stepping up of training, I had been already stretching my IT band fairly regularly, I had shoes that fit me well and were new, and I was keeping pretty good track of not over-training too fast. 6 months into training, I acutely started having severe IT band syndrome, mixed with hip and low back pain. The leg that is affected the worst (by far, though both are symptomatic) is the same leg I had the sesamoidectomy on.

Began resting, no running, only yoga and swimming, occasional failed "test runs." began physical therapy. Treated for weak hip abductors and back pain. Some relief, but worsens always when I have to study and sit a lot.

Now, 6 months later, still not able to run, STILL having pain, starting to get spasms and numbness and tingling down my legs when I go for a walk. I have a physical therapist and a sports doc who can give me no good solutions. The exercises that the PT gives me aggrevate everything and seem to only make things worse. Xrays show some lumbar vertebral disk narrowing, but not a lot. Right now, they think I have an irritated piriformis combined with some knee problems and possibly some radiculopathy (combined with, of course, the stress of medical school). I have been walking, mostly for stress relief, with mild to moderate pain, and am on high dose NSAIDs, but no other activity right now besides light stretching for fear of aggrevating whatever the heck is going on.

The million dollar question: Do you think a sesamoidectomy could throw off my gait enough to do all this? Anybody have any experience with something like this? Will correcting my gait (if it is indeed messed up), i.e. orthotics, help rectify this situation? How about chiropractics?


Please help! As someone who will be helping other people with these types of situations in the future, any thoughtful input is appreciated!

 

In 21 years of practice, I have never seen a medial sesamoidectomy cause the type of symptoms you are experiencing. However, that is not to say that the sesamoidectomy isn't at least part of your problem.

Is your sesamoid area symptomatic still? In other words, can you run and jump off of your first metatarsal head area without pain? If you can't put full weight on your remaining lateral sesamoid without pain, then you may be oversupinating your subtalar joint during running as a pain-avoidance mechanism which, in turn, could easily cause ITB syndrome.

Your best bet is to be evaluated by a sports podiatrist to see if he thinks foot orthoses are in order. (Tell me where you live and I'll tell you where you can go to get a good podiatrist to help you.) However, I tend to doubt foot orthoses will cure all your problems and you may want to change your seating position while studying to lessen the strain on your piriformis. By the way, I have been practicing with orthopedic surgeons for the past 21 years and wish you lots of luck in your quest to become an orthopedist.

 

I may be able to provide just a bit of insight into your condition. You ask about chiropractic treatment for your problem, and being a chiropractor I can comment on that, but probably more importantly I myself have experience with your problem as a patient.

My hx (if you will indulge a case study):
Like yourself, I was diagnosed with a fracture of the tibial sesamoid bone (comminuted). This happened in 2000 while I was training for a marathon, but my guess is that I was headed that way for years being as active as I was with the foot biomechanics that I now know I had. I was attending chiropractic college at the time and so naturally presented to the clinic for evaluation. After consultation with a DC/DPM, it was determined that the best course of action would be a resection. The surgery was scheduled accordingly.

Here's where my story differs from yours. The day before my surgery I consulted with my biomechanics professor and we discussed the biomechanics of the sesamoids and the rationale for removal. The concern at the time was that without surgery bone fragments could enter the MP joint space and cause hallux rigidus, thus turning me into a swimmer (this explanation seems odd to me now given that the fragments were probably contained within the tendon of the FHB). Anyway, I ended up deciding that I liked my sesamoids and that I would keep them for a while. Surgery cancelled.

I agree with Kevin (and he would have much more experience with follow up on sesamoidectomies) that it would be tough to blame all of your symptoms on the absence of sesamoids. Of interest, here is a study that would support minimal change in the mechanical advantage of the FHB with a medial resection, but significant change with a bilateral resection. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7820237&dopt=Abstract

So I still had my sesamoids and the pain, and was cast for a specific type of orthosis to facillitate MPJ motion. Interestingly, the theory behind the orthosis was not to shift weight laterally away from my pain, but to evenly distribute weight during toe off and was cast in a maximally supinated (not a subtalar neutral) position. I know when I mention the name of the company it will spark debate here (sorry Kevin), but I think it’s important for this case that you know there are a few different theories out there with regards to the goals of a custom foot orthosis. The orthosis was a Sole Supports device, and my disclaimer includes the fact that I now work for the company because of my personal success with the device.

Back to the story: I did have some low back pain, and left SI pain with my sesamoid pain and was treated with manipulation for that problem a few times with resolution. To make a long story short, I successfully trained for the Chicago marathon the next season and continue to be an avid runner and marathon coach. I do have some residual stiffness in my MPJ after long runs of over 20 miles, but I am keeping an eye on it.

A few comments on your more proximal pains. I would suggest an evaluation by a provider (dc, pt, dpm) with a sports focus. The piriformis symptoms, IT band pain and low back pain can be consistent with SI joint dysfunction in runners. If your PT has not already looked at it, might I suggest an evaluation for functional vs. anatomical leg length deficiency. This can often result in the types of muscle imbalances you describe. A debatable topic for sure, but one that I have had great success with clinically when dealing with runners. If you let me know where you live, I might be able to recommend someone.

I hope that provides some help (and hope) to you.

Stu

 

Thanks for the advice!

I am curious about the fact that you decided to keep your sesamoid, despite being fractured. Not sure if you mentioned this, but was it necrotic at all? How did your fracture resolve? Mine was clearly deteriorating, and I'm not sure that keeping it was an option. Anyways, you have probably saved yourself some future pain and aggrevation, and possibly bunion surgery, which is most likely in my future at this point.

I am also surprised that you were placed in a maximally supinated position. Because I had been going for awhile in pain, it felt like I was supinating naturally for pain avoidance. I've also still got more calluses on my lateral foot, suggesting the same. However, according to my PT, my current injuries and Q angle of 20 suggest that I'm now more prone to a knock-kneed pronator stance (a year before my injury, I was analyzed as compeltely neutral).

Re: the paper you cited: While excision of sesamoids in cadavers may not change moment arms and effective forces, the real life situation involves scarring and gradual deformity, which DOES effect ones ability to flex one's big toe (and one's ability to balance, I might add-- it took me awhile to be able to do the same one legged balancing poses in yoga that I used to have no problems with.). While I'm sure this is a scar tissue problem and not a joint disease problem, I hope that hallux rigiditus is not in my future given my already decreased range of motion.

Anyways, I'm pretty positive that the surgery has changed my gait significantly, as I now have a totally different callus pattern(mostly on the operated foot, but definitely has changed in both), a different wear pattern on my shoes, my feet have gone from normal-high arch to borderline flat(this could also be because of the 10 pound weight gain since injury, I'm also guessing), and the tip of my big toe on the affected foot has deviated laterally about 2cm compared to my other foot (umm, if that makes sense-- sorry, I'm still in school and I haven't yet read the "How-to-describe-a-bunionesque-deviation-Chapter")

Thanks for the advice. It's nice to compare notes with others with the same injury. I live in Sacramento, if you happen to know of a good chiropractor there.

Cheers,
Krista

 

Krista,

I know a good podiatrist in Sacramento. Kevin Kirby

 

WOW, you should have given up running\impact movements after the sesamoidectomy. That procedure severly alters the stability of the #1 MTPJ not to mention claw toe and drift. Didn't your doctor counsel you on that.? I'm sure he\she did. If you don't have any foot pain at this point I would say your lucky.!
I would advise you to sadly, move into a different lifestyle as you have undergone a significant foot altering surgery. Not many doctors want to do this procedure as it will alter the foot. Its used as a last resort.
With the significant loss of stability a tibial or medial sesamoidectomy yeilds, I cannot for the life of me conceive that your Doctor did not counsel you on the effects of the procedure and that you should be more gentler on that foot post surgery. I also find it astonishing, that your foot held up through the hell you put it through post surgery.
It's sad, but our bodies breakdown and in some cases ( Yours and mine) the part that breaks forever changes our lives. I had a torn plantar plate #2 left foot. The hammer-toe procedure failed and created additional pain in # 2 joint, as well as torn plate had significant facia (scar tissue) buildup making weightbeaing a level 8 pain. Had to have the toe amputated and then the dr excised the facia from the plantar plate leaving me very little to knone of the "Fat Pad" cusioning the #2 MTPJ. THis was a life altering surgery as I cannot walk much on that foot.
While in P.T. for that, the therapist had me do a move that Fractured the sessamoid in my GOOD REMAINING foot. Almost 12 months now and only got worse.....I live on a couch, can't go out much, and have no social structure in my life anymore. Left hip clicks, and hurts quite a bit since favoring the Right foot now. When this all happened I was a 6'2 210 lb 3 day a week gym nut. Now I ride a couch and tv....

Please take care of that foot by not impacting it as you have. You'll need it as you get older.

Good luck.!

 

Why would you see a chiropractor about your foot, when you've got Prof. Kirby in your city? Who knows, you might even get an education on foot and lower extremity biomechanics within the price of your consultation.

 

SkiDoc

My History: (without reference to sesamoid surgery)
Started training for triathalons. My running milage went from 5-10 to about 30 miles a week. I had a coach watching my stepping up of training, I had been already stretching my IT band fairly regularly, I had shoes that fit me well and were new, and I was keeping pretty good track of not over-training too fast. 6 months into training, I acutely started having severe IT band syndrome, mixed with hip and low back pain. It is the left leg that is affected the worst (by far, though both are symptomatic).

Began resting, no running, only yoga and swimming, occasional failed "test runs." began physical therapy. Treated for weak hip abductors and back pain. Some relief, but worsens always when I have to study and sit a lot.

What would you think was the aetiology of your symptoms now?

Just because there are two unusual events in a scenario doesn't mean that one is causal of the other. (Had a short lecture on heuristics at the weekend so I'm feeling like a clever dick)

Without the benifit of a gait and postiure analysis, Kevin seems to have picked out the most likey candidate IE aggravating sitting position. And as RJS said you just may not be suited to long distace running. I always get hip and ITB pain when running distance on roads. So I don't do it. If you want to be really fit do Judo, a proper mans sport.

Cheers Dave Smith

 

I think you'll find that the proper "gentlemans" sport is rugby.

 

Sorry Krista, I don't know of one personally in Sacramento; however, if you find yourself in the bay area you might try a good podiatrist/chiropractor by the name of Steven Subotnick.

http://www.drsubotnick.com/about.html

Stu

 

Simon

True but notoriously hard on the knees by my experience.

LoL Dave

 

Skidoc2b:

I agree with what others have said in this forum regarding doubt that the surgery is what has affected your current symptoms.

You have a gait related disorder that may have put you in a position where your tibial sesamoid was stressed and then fractured.

Regardless, more than likely you have a limb length discrepancy, an ankle joint equinus and functional hallux limitus on the side where the sesamoid was removed.

Let go of the surgery being the cause of these problems and instead focus on improving your foot and Lower Extremity function and you will see tremendous improvements.

I would do in-shoe and video gait analysis when treating you to gain as much functiona information as possible. Not everyone has that equipment in there office. Dr. Kirby would be a great place to start regardless.

Good luck.
Sincerely;
Bruce Williams, D.P.M.

 

>>>>>>>>>>That procedure severly alters the stability of the #1 MTPJ not to mention claw toe and drift. Didn't your doctor counsel you on that.?<<<<<<<<<<<

ABSOLUTELY not TRUE.

Removing one sesamoid is incredibly common. I've done (as Kevin probably has) literally hundreds of these over the years. If a patient is prone to metatarsus primus adductus and a Tibial sesamoid is removed it may accelerate the progression.

I have never seen a biomechanical problem with a post Tibila sesamidectomy.

Gotta run
Steve

 

Steve and Colleagues:

In the sesamoidectomies I have performed, I have yet to see either a hallux abducto valgus or hallux varus deformity develop, but I have seen these complications from other doctor's sesamoidectomies. Therefore, I advise patients of these potential complications when performing sesamoidectomies, but definitely, like you, would try to avoid a tibial sesamoidectomy in someone that already has an increased 1st intermetarsal angle.

And thanks to Drs. Fuller, Spooner and Williams for their confidence in me. I greatly appreciate it.

 

One thing I'd like to add ( I was rushing out the last time I posted) - if you were to excise BOTH sesamoids.....then you may have a problem and will most likely need to do an IPJ fusion.

Complications can always occur - no matter what the procedure, but that's not the point here. What we ARE discussing here, sesamoidectomies, should be viewed as having a very very high success rate.

All things being equal (re: the Kirby doctrine - we have to assume it's being done correctly)
I would never hesitate to remove a sesamoid.



Steve

 

I guess someone recently replied to this, as I just got an email about it, so I thought I'd give an update. And I'd like to apologize for such a lengthy, whiney original post--I think I posted in a fit of frustration one night long ago!:boohoo:

Update:
I'm running again! up to 30 minutes, but at most 4 days a week, thanks to a small circular theraband that goes around my ankles as I walk around my house. La Foot did a gait evaluation and determined that I was indeed heel-whipping and supinating on the affected side, but not horribly and not in need of orthotics. The thing that helps most is just staying focused on my push-off and using my left big toe, and only running on treadmills and perfectly flat surfaces(no roads) for now.

I still get pain in my hips and knee on the affected side, but less severely and--yes, fairly proportional to the amount of stress, and studying I am currently doing! I do not deny the mind-body connection. I also get point tenderness over the areas of my piriformis bilaterally, somewhat helped by stretching, and aggrevated by standing, but not running neccessarily.

I'm a third year, so not a whole lot of time for getting new referrals, but as soon as I've matched next year, I'll make an appointment with Dr. Kirby as he comes so highly recommended! Thanks for all the help!

 

Hi SkiDoc

In your first post you mentioned the Xray and Lumbar Disc narrowing, and that your pains worsen with study (Sitting). an Xray will not rule out sciatic Nerve impingment, however your piriformis syndrome and lateral leg (ITB) and knee pain can all be related back to your Lumbro-sacral Plexus. I had a similar story for years until it all fell in a heap and I finally got an MRI and the Disc Bulge at L4 L5 S1 was huge so finally after years of GP's, Sports Physicians Physios, Chiros, Self Treat Excercises, I had an answer, Funnily enough after it all went belly up (Got really bad) it is now the most managable its been in 20 Years Yippee!!!

MRIs help you know exactly whats going on at Spinal level and ease your mind, so you can work productively around your injury. Im probably preaching to the converted

I suppose one way to check if its neuropathic pain is try codein instead of NSAIDs for the pain?



All the best