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bipartite or sesamoid fracture?

Discussion in 'General Issues and Discussion Forum' started by ltracy, Aug 18, 2011.

  1. ltracy

    ltracy Member

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    bipartite or sesamoid fracture?


    hello all-

    I'm a clinical researcher trying to understand a case of 36 yo avid runner (>45 mi/week) complaining of sharp pain on the top of her first metatarsel near the distal joint. She has no pain upon palpation on the dorsal side of toe near sesamoids, no swelling nor redness. Pain on top of metatarsel joint mostly when walking. Right foot xray suggested sesamoid fracture. Left foot image obtained for comparison. Appears patient has bilaterial bipartite medial sesamoids but seeking input from podiatry experts on this forum.

    Both images in the attached document.

    thank you in advance
  2. Hi L

    Its quite hard to tell from the x-rays.

    If the left side is bipartile then there is a very good chance the right is as well.

    The symptoms of the patient also do not suggest a sesamoid fracture but suggest something dorsal.

    There is some saying - if you hear the sound of hooves hitting the ground think horses not Zebras - or something like that.

    With the limited information we have I would suggest dorsal lipping associated pain or Extensor Hallucis Longus tendon irritation - but these would be wild guesses in the dark.
  3. G Flanagan

    G Flanagan Active Member

    " She has no pain on palpation on dorsal side of toe near sesamoids " come again?

    As Mike suggested from the low def x-rays it looks like a normal well corticated bipartite sesamoid, however the x-ray quality is low.

    Again as Mike alluded to, the patients symptoms don't relate to a sesamoid pathology anyway, I can't see any obvious osseous abnormailty at the joint. ?capsulitis? secondary to ........................

  4. Tracy, perhaps you could provide us with some greater detail of your symptoms. The first thing you should do in terms of treating your symptoms is to stop running. With painful hallux limitus in patients I have had good success using foot orthoses with a full length forefoot extension with a cut out to the 1st MTPJ or a reverse Mortons to off-load the 1st, if that doesn't work ~(it usually does) I'll go for a Mortons extension or a varus posted forefoot extension with the aim of jamming it up.

  5. ltracy

    ltracy Member

    Hello all-

    Thank you for your thoughts. Allow me to provide a bit more information and a few more images of the right foot-lateral and oblique. There is NO pain nor tenderness/redness on the plantar (bottom) (note: my apologies in reversing plantar w/ dorsal in original post) side the foot at or around the sesamoids, which is usually present if a sesamoid fracture exists. Instead, the runner has sharp pain on the dorsal side of the first metatarsel at or near the MP joint. This pain is more evident when pushing off with toes and walking downstairs. Also, prior to injury, the runner complained that she was making holes in her shoes w/ first toe-too much dorsiflexion?

    MRI report of the right foot indicated:

    FINDINGS: The medial sesamoid of the great toe appears fractured, with angular
    margins. Additionally, there some marrow changes within the more distal
    fragment suggestive of fracture. There is a small amount of marrow edema in the
    adjacent great toe distal metatarsal. No other areas of marrow signal
    abnormality. No joint effusion is identified. Tendons appear intact. No
    abnormal fluid collections are seen.

    The soft tissues are normal.

    IMPRESSION: Fracture of the medial sesamoid with a very small contusion at the
    adjacent great toe metatarsal.

    So, I am baffled. If sesamoid fx, then why no symptoms on the plantar side of the foot!? The MRI notes a small contusion....could this be the source of the pain? Seems to coincide with excessive plantarflexion running technique.

  6. Griff

    Griff Moderator

    Don't treat the imaging - treat the patient.

    I suspect this may be a bipartite sesamoid (given that it appears to be present bilaterally, and given the absence of any pain on palpation) and focusing on it will put you off the scent regarding the actual pathology causing the symptoms. Instead focus on the dorsum of the toe and the things that you do know: (1) Pain on end range dorsilfexion. (2) An X-ray which shows a slightly sclerotic region at the base of the proximal phalanx. What might these sort of things tell you?
  7. efuller

    efuller MVP

    Where was the hole? Was it plantar or dorsal to the hallux (big toe).

    Another vote for not treating the x-ray, but rather treating the symptoms.

  8. ltracy

    ltracy Member

    Very valid point to not treat the image but rather the symptoms! Too bad, radiology doesn't see it that way!! Yes, the noted hole is on top of shoes right above the big toe! Thanks again all!
  9. efuller

    efuller MVP

    So, if the toe sits flat on the ground in relaxed stance, this person would have to be using their extensor tendon a lot to put a hole in the top of the shoe. The pain may in fact be the extensor tendon. But the question is still why are they using the tendon that much. This is consciouis or sub conscious motor control. They must be avoiding something.

  10. ltracy

    ltracy Member

    Eric-you're on to something there! The runner has high arches (as shown in images) and likely deficient in another area such that she is pulling too much with her feet. Also, prior to this issue, she suffered from a possible stress fx of lower anterior tibia. Patient used to wear custom orthothics but d/c them for OTC high-impact Sofsole inserts. Cheers!
  11. Weak tib ant. recruiting long extensors to assist. On resisted dorsiflexion bet movement is initiated with ext. hallucis longus. Muscle imbalance tib ant versus gastroc /soleus.
  12. efuller

    efuller MVP

    If they didn't do the bone scans and just said stress fracture, it could have been a painful EHL muscle belly. Simon's point about weak ant tib muscle is a good one. When docs are thorough and not sure of a diagnosis, or when they are less thorough and lazy, they may just pin the diagnosis on a tissue in that location. I've done it myself.

  13. kirstyq

    kirstyq Member

    You may need to read "Myofascial Pain and Dysfunction - The Trigger Point Manual". EVERY PODIATRIST SHOULD READ THIS BUT VERY FEW HAVE!!! pg 474 shows how an active trigger pont in Extensor Hallucis Longus can refer pain to the dorsum of the hallux.
    So interesting to think outside the square.......so often orthotics are not needed.....just massage and mobilisation.
    Best wishes.

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