Diagnosing and treating difficult sesamoid pathology

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Dear all

I have a patient coming to see me who has some kind of 1st mpj/ tibial sesamoid pathology. I.E. the left 1st MPJ is very painful weightbearing there is some pain on the right also. She is 52 years old and has already seen many medical professionals in Belgium where she lives. She has had all types of imaging to get a diff Dx and several therapies including casting and orthoses. There is a table attached that outlines these and the various conclusions and diagnoses made. So far there has been no resolution of pain. She is reluctant to have surgery, partly because there are conflicting diagnoses between fracture and bipartite but also because of possible subsequent problems if sesamoid is removed. She is coming to see me in Folkestone UK in the hope that I may be able to help. (I'm internationally famous for my great fresh coffee and cracking sense of humour :dizzy

I have attached some MRI scans and the table mentioned above (comments are patient's) and wondered if you would be kind enough to have a look and make any comments regarding the trauma/pathology, treatment history, fracture or bipartite?, what next?. I don't have any biomechanical data yet.











Many thanks Dave Smith

 

Dave - I have a general rule regarding patients who send me vast information, prior to the consult, about past experiences in a tabulated form such as the one you attached - I find out when they are booked in and then I call in sick that day

Good luck with this one squire

 

Dave I know there was some discussion about fracture or bipartite in a thread a little while ago. It all came down to very hard to tell after time due to bone degeration which may occur to the fractured sesamoid. ie a fractured sesamoid may appear to be bipartial.

here the thread excuse my excitement- must have been a slow day at work -http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=42749

maybe ask if she has ever had her foot xrayed in her previous 52 years. She might have some old xrays ( she seems one who might keep stuff like that).

But in realitly what does it matter if she does not want an op. I did not see mention of CAM walker or Rocker bottom shoes maybe thats an option.

But I put my money on most surgeons saying pain gone on too long cut it out.

But maybe Ian´s advice is the best.

Good luck

 

My pound says she'll turn up in a pair of court shoes. She will not have had any orthotics previously that were designed to offload the joint, or if she had, she couldn't accommodate them in her shoes.

 

Dave:

If the patient has been put into a good orthotic with a sufficient Reverse Morton's Extension and with an inverted balancing position to increase the external rearfoot invesion moments in a proper shoe so that a good reduction in the pressure to the sesamoid has been achieved, and the symptoms still persist, then surgery is the best solution. Have cortisone injections been tried? You can assure your patient that medial sesamoidectomy is one of the least difficult surgeries in the forefoot to perform in the hands of a good foot surgeon.

 

Yes thanks for those quick replies


Ian, I see a challenge to find a solution to, not a problem to avoid.

Mr Weber - X rays she does have and bringing with her she is, (why did I break into Master Yoda speak there??) good idea about earlier x rays to compare, I'll see. I thought cam walker or rocker shoe too, she has already had casting although that was fairly short term. I intend to try a Jones technique which sometimes works like magic

Quote Craig Payne on Jones technique -http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=2374
"With one hand, apply a slight distraction force to the MPJ (grip the hallux IP joint and lift). Compress the painful sesamoid with your thumb of other hand. Rotate the hallux medially and laterally to end RoM's, then dorsifles and plantarflex until find least painful position during compression of sesamoid --- hold the compression on the sesamoid in this position for a minute or so without moving and see how it feels and maybe do it again. .... it is surprising how often it works dramatically on the pain - some have called this "turning the pain off" ... then again at other times it does not work - I have not seen any consistent pattern yet."

Simon That is a common scenario I agree but this lady sounds switched on and so I'm not expecting that. (then again nobody expects the Spanish Inquisition -http://www.youtube.com/watch?v=uprjmoSMJ-o )

Kevin From your experience of surgery what is the failure rate in terms of non relief of pain and or changes in joint position post surgery?

How often do you come across avascular necrosis of the sesamoid, does it always require surgery? (see attached paper)

Regards Dave

PS I'm not really famous this lady found my name on this forum.

 

I'll believe it when you see it Make sure she brings her previous orthoses with her. £10 says they don't have the modification Kevin listed. Photographic evidence please.:drinks
P.S. taking a photo of a random pair of devices with these mod's doesn't count!!!

 

Dave:

Surgery for a "sick sesamoid" generally is much better for the patient than the multitude of postural complaints and weakness that often results from the chronic oversupinated gait pattern that these patients adopt to compensate for a painful medial forefoot.

 

Good point well made!!

I'll prescribe some of Roberts special inch thick soft and squishy technology orthoses and some Doc Martins.

Cheers Dave

 

Waiting with baited breath!

 

Dave:

Here is a nice article by Eric Heit and Rich Bouche on sesamoid pathology from Podiatry Today. Rich coined the term "sick sesamoid", as far as I know and lectures quite a bit on the subject.

http://www.podiatrytoday.com/article/2442

There was also an article on treating fractured sesamoids by removing only one half of the fractured sesamoid (i.e. dividing the sesamoid at the fracture line) in athletes as an alternative to full sesamoid excision that reported good results. Don't have the reference at hand currently.

In the few sesamoid excisions I have done in these cases, the patients have done well and are happy with the surgical results. Another surgical alternative that I have seen work is a dorsiflexing wedge osteotomy of the first metatarsal to reduce the ground reaction force plantar to both sesamoids. Of course, this transfers the ground reaction force in the forefoot toward the 2nd metatarsal head which could become sore later on after the surgery.

The key for the clinician, when treating women of this age group, is to focus on shoes and their importance (as Simon alluded to) and how the right shoe and righ orthotic can help them avoid surgery. I tell them if they are not willing to change their shoes, or not willing to avoid barefoot, then surgery is definitely in their future, but if they willing to wear the proper shoe 95% of the time, then they may avoid surgery. One of my favorite questions I ask these patients: "Sometimes, in life, you need to choose between vanity and pain. Don't you think, after all these years of wearing these uncomfortable shoes to look pretty, that you now deserve to wear shoes that allow you to be comfortable?"

You would be amazed at how many women have come back for their next office visit after asking this question to them about their foot health and shoewear and thanked me for asking them that question since it made them change their attitudes about the importance of them wearing comfortable shoes more often and wearing fashionable shoes less often.

Hope this helps.

 

David:
You have a pt. with chronic sesamoiditis, probably a separated bipartite, not responding to conservative Tx.

Remove it.

Steve

 

Steve, Don't beat around the bush get to the point man

LoL Dave

 

Dave I found this abstract no full text sorry.

Might help (might not but thought I would share) , if the patient is at the point where she takes Steve´s advice.

 

NIce pair of Orthoses should do the trick:

try functional hallux wedge with arch support maybe a plantar met pad with lateral stabalisor give the lady a full on treatment you cant make the pain worse offloading and redistributing in simple form always does the trick. Good luck

Regards
Sofina

 

Hi all

Saw this lady before Easter. She had 3 pairs of 'orthoses', 2 of which only had a 1mm-2mm deep cut out filled with eva under the 1st MPJ and all had a deep winged met bar extended to far forward so they were uncomfortable to wear. One had a deep cut out but the foam was far to soft to maintain the depth on weight bearing. They did not have any design to address other biomechanical variation of the feet and lower limbs, which it turns out were important considerations. She did have very good shoes, good fitting with stiff rocker soles similar to Dr Comfort.

The 1st MPJ/sesamoids of both feet were extremely and exquisitely tender to the lightest pressure and any attempt to touch or flex the 1st MPJ resulted in jump response.

Her gait was completely antalgic, she walked on he heels and inverts the foot, with a high knee lift to avoid any forefoot push off pressure and used hip extension for propulsion. She had made her own insoles from felt cut out at the 1st MPJ, she felt these gave the most pain relief compared to the ones she had previously been prescribed.

Her right forefoot was valgus and the 5th ray very compliant to GRF. The left foot was extremely inverted in STN but no other biomechanical variations. Both feet the hallux RoM was extremely restricted but this may have been antalgic response. The right hip was much lower than the left, the Ankle RoMs and all other foot RoMs were very good even slightly compliant/hypermobile.

I used the Jones technique on both 1st MPJs, applying very light pressure and small stretches at first and then building up to full pressure and stretching/flexing of joint and soft tissues. After that I mobilised the hallux / 1st MPJs to get about 30dgs RoM on each. I then padded with about 10mm of SA felt with cut out and met bar and the right foot felt lateral f/foot wedging.

I reviewed the gait, which had become somewhat propulsive from forefoot push off, however after many months of antalgic gait she needed retraining to walk properly. Although her muscles were all strong they were not firing in the correct sequence, especially the left foot. The left ant tib did not fire at heel strike which resulted in foot slap, the peroneals were not stabilising the supination / applying supination moments at the right time and the Hip internal rotators made her internally rotate the leg at heel strike. This was made worse by the posterior position of the heels of the shoe relative to the TC joint. Her hip abductors were weak and she dropped onto the left foot and rocked sideways over the left leg. All this resulted in foot slap and supination, which made her very unstable to the left.

I got her to think about consciously pronating the left ankle complex at heel strike and added a bar under the heel below the TC joint and a lateral f/foot post in the shoe. This considerably improved the foot action. I then mobilised the ankle and massaged the insertions and origins of the ITB and its tricep of gluteals and TFL muscles. This considerably improved the hip abductor strength and significantly reduced the side to side rock and drop onto left side.

I reviewed the next day and the right 1st MPJ was pain free and the left was also pain free over the sesamoids but there was a new, but reduced pain just posterior to the met head. She said the right felt as if the pain had just "switched off". I did some massage and stretching of the soft tissues there and this pain mostly resolved. The gait had improved more and the foot slap was almost gone and she did not become unstable and wobbly to the left side. The gait had become significantly more propulsive off the forefoot although she still had some residual of the old gait style left.

I made temp orthotic insoles with 10mm right heel lift and valgus f/foot posts both feet. Plus deep cut outs with grey poron pads and met bars, plus medial rear foor posting on the left. I gave stretching exercises for Hammies ITB and Achilles/GSC. Advised icing for 1 weeks 2 x daily 20 mins on both 1st MPJ. She did not want me to make proper bespoke orthoses yet as I advised but she may return for them later. She left walking fairly well but needing to keep training the gait to walk properly.

Just thought you might like to know:dizzy:

Dave

 

Hi Dave:
So, she went from "exquisitely tender to the lightest pressure" to pain free after one manipulation type treatment.
Hmmmmm

I think I'll have to refer back to Ian's post of March 25..................

"I have a general rule regarding patients who send me vast information, prior to the consult, about past experiences in a tabulated form such as the one you attached - I find out when they are booked in and then I call in sick that day"

Steve

 

Steve

I know what your saying but I can only report what happened. This lady was quite
hopeful about this Jones Technique when she first contacted me and quite believed it might work for her.
She wasn't completely pain free on the left foot but was able to weight bear, the addition of temp orthoses that can actually do something such as off loading properly and balancing the gait and allowing a more normal function was helpful. How much of the result was real (physical) and how much placebo (which is still real) I may never know but at the end of the day she hobbled in and walked (ish) out. I predict that within a couple of weeks she will be walking perfectly normally. If she returns from Belgium I'll let you know.

Cheers Dave

 

PS The Jones technique can be extremely effective and it has worked in this way many times before and in fact three times last week. I wasn't exactly confident that it would work in this case but it did appear to. Don't forget that I did also enable proper walking to with other manual therapy type techniques.

Dave

 

Nice work that man !!

Thanks for letting us know how it all went.

 

Thanks for letting us know - time to read up on the Jones technique !

Robin

 

I have seen patients get spectacular results with foot manipulation. The problem is that the pain comes back fairly soon especially when real pathology is present. Who would not be surprised that this patient will be back with recurrence of pain?

I too would not want to treat this person as a patient as there are other underlying psychological issues that most likely need to be addressed. This is also a patient that I would never take to surgery no matter how straight forward the procedure is. I do not think this patient is playing with a full deck.

Time to get back to reading my article on "Why do ineffective treatments seem helpful?

Steven