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I have a 33 year old construction worker with chronic right foot sesamoiditis. He had his right knee scoped "a number of years ago", has knee pain, 1st step pain and more particularly, plantar right 1st met head pain. His foot type is cavus, there is a positive anterior drawer test on the right lateral ankle, a 7 degree forefoot valgus with neutral rearfoot. Orthotics were made with minimum arch fill, 2 degree rearfoot varus with the forefoot balanced. An additional 1st met shaft pad was added to offload the 1st. He has had a cortisone injection, physiotherapy, massage. X-rays are unremarkable from all views, ultrasound was also unremarkable for soft tissue, although there is diffuse swelling over and around the joint plantarly. I have taped his foot very tight to offload, he has used topical anti-inflammatories, all to no avail.
Any suggestions would be helpful. Thank you

 

Which sesamoid?
Did you view the xrays personally? If not I would take a look. Radiologists are not into the "finer" points of evaluating sesamoids.

Anterior drawer sign? Really? (although I do not quite know what you are referring to by "positive...... lateral ankle"

This means he has a rupture of at least his ATF ligament.

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My treatments for Chronic sesamoiditis are, in order:

Assess activity that may be causative factor; Biomechanical and or off load; Injections: PT: Excision.
If the first ray is rigidly plantarflexed you may need one of several types of dorsal wedge osteotomies.


Good luck

Steve

 

Yes viewed the xrays. His complaint is with the tibial sesamoid. The only view not taken was axial. He had a severe inversion injury playing football so the ATF was ruptured causing his lateral ankle instability.

 

Can I just ask if any other areas were painful on palpation- especially FHB, Ab Hal, 1st IM space and around dorsal cuboid joints?

 

Nothing remarkable, however is compensating by inverting and increasing lateral pressure. No real pain noted or suggested.

 

Thanks Hauckpod- bang goes that idea!

 

Has pain on hallux extension but only in the medial sesamoid region. Plantar flexed and swollen with full RoM.