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Sesamoiditis or not?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by podomania, Jul 27, 2006.

  1. podomania

    podomania Active Member

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    Dear all.
    I need some help on the following case.
    Goalkeeper, with high arch profile on both.Supinates during the whole of stance phase, maybe comes up to neutral during "foot flat". Last year he presented with no symptoms to me, but he insested that the Dr. of his team recommended some orthoses since he is a pes cavus foot type.So i gave him some EVA prefab with an arch support and nothing else, so that he could have some more support during the gait cycle. However he wore the orthoses only in his every day shoes and not in his football boots and he found them great. After a years time he told me he injured his foot during beach soccer and now he gets some pain under the "ball of the right foot". The pain starts during activity but disappears after the warm up!!!???. However it is aggravated when he puts all the weight on the right foot,for example when he needs to pass the ball (he is left footed) or when he swings to the right and all the weight is forced on the right foot. Clinically the 1st MPjt does not look inflammed and the x-ray does not show a fracture. The range of motion on the 1st MPjt is normal, neither the patient feels any discomfort when i dorsi or plantarflex the hallux.
    Please give me some thoughts about diagnosis and treatment.
    Thank you in advance
    p.s. Excuse my English, I am Greek.
  2. Admin2

    Admin2 Administrator Staff Member

  3. Craig Payne

    Craig Payne Moderator

  4. Atlas

    Atlas Well-Known Member

    I would like to understand more about this condition too. The paradox is, that the more ideal we correct/facilitate in biomechanical terms, the greater the load on the sesamoids. Plantar-flexion of the 1st ray would drive the sessamoids into the ground!

    Do we use 2-5 met bars? Do we incorporate plantar wing covers? Do we go easy with PF 1st ray and move the peak of the arch distally?

    As for Dx, I would have thought palpation was quite reliable.
  5. Asher

    Asher Well-Known Member

    Apart from the above, if the gastroc / soleus complex is tight, there is more and earlier loading of the forefoot, therefore gastroc and soleus stretches required.
  6. Good points. Initially take three xrays - AP lateral and axial - and perhaps scan to ensure there is no avascular necrosis. In acute stage RICE principles apply. If the injury is not too severe local deflective padding with 2-5 met bar/ plantar wing will assist, but you may wish to incorporate rigid strapping to plantarflex the hallux which prevents extension and reduces the strain on the flexor tendon. In severe cases, a BK Wilson's cast with 10 degree ankle plantarflexion for 6 weeks, then where the aetiology has been mechanical, FFO's to prevent recurrence.

    If there is a fracture, Wilson's cast as before and review for non-union after removal. Bone scan is preferred as sometimes stress fractures will not be obvious on xray. With non union or avascular necrosis, sesamoidectomy should be performedas soon as possible.
  7. Craig Payne

    Craig Payne Moderator

    This is what I posted in the other thread:
    What say you?
  8. I propose that sesamoiditis should rank alongside metatarsalgia in the podiatric non-specific -ambiguious-terminology hall of fame. First MTP Joint pain can be incredibly complex to diagnose and treat when there has been repeated trauma over a period of time. I currently have a patient with 7 degree forefoot valgus and a history of severe joint pain >2 years but can recall repeated episodes dating back to her early childhood. There is no fracture but the pain is of such severity that even the lightest touch over the tibial sesamoid can elicit an extreme reaction which she describes as being similar to an electric shock. Even with two months of 10mm deflective padding and taping of the hallux in a plantarflexed position and strict adherence to RICE principles, recovery is not sustainable - the pain returning within 30 minutes of weightbearing. She is presently in a BK Wilson's cast for 6 weeks and if there is no improvement, she will require bone scans and MRI.

    I agree with Craig in that there are a number of differential diagnoses; Perlman (1994) suggested ten -

    Vascular claudication

    Acute disruption of sesamoid ligaments

    Avascular necrosis osteochondritis

    Stress Fracture

    Neoplasm of bone and soft tissue.

    Tendonitis of FHL or adductor hallucis

    Osteitis or inflamatory bone disease


    Normally occurring bipartite sesamoid

    Sesamoid gout

    I would be interested to hear of any experiences, particularly where there has been disruption of the inter-sesamoid ligament. Is surgical repair possible?
  9. Scorpio622

    Scorpio622 Active Member

    What is a Wilson's cast???

  10. Joplin's neuritis/neuroma can cause medial-plantar pain with "electric shock" symptoms. These patients will generally have decreased sharp/dull, light touch sensation on the medial-plantar aspect of the hallux and have a palpable "cord" which is the medial-plantar proper digital nerve to the hallux that has been "walked on". This diagnosis is commonly missed by many podiatrists since they forget that this nerve may be very plantarly located in some individuals and that many individuals propel off their medial-plantar 1st MPJ and hallux.

    Sesamoid problems generally are relieved by a combination of an orthosis/insole that causes a rearfoot supination moment and increases the GRF plantar to the 2nd-5th metatarsal heads and decreases the GRF plantar to the sesamoids. However, I may also inject cortisone, use icing therapy, or use a cam-walker type brace. I may even surgically excise the sesamoid or perform a dorsiflexing osteotomy of the first ray if the patient is resistant to conservative care. Careful examination combined with appropriate x-rays (sesamoid axial views are critical), bone scans and MRI scans are often necessary to pin down a diagnosis.
  11. Nick

    It is a corrective Total Contact Cast (TCC) in this case modified with a depression over the 1st MTPJ and the ankle & hallux held in 10 degree plantarflexion.
    Thanks for this Kevin - 'fraid I missed this too.

  12. RobinP

    RobinP Well-Known Member

    Sorry to take this a little off thread but having read this description, I have just picked up a lady who would appear to have Joplins Neuritis. The nerve is quite palpable toward the plantar surface and if i palpate and move the nerve, the patient gets all the symptoms desribed - electric shock etc.

    Kinematically, she is quite pronated at terminal stance although curiously she has a laterally deviated STJ axis and actively pronates at midstance. My plan is to shift the centre of pressure laterally at terminal stance in order to facilitate 1st ray plantarflexion. Doing so, I would hope that there is less propulsion off the medial aspect of the hallux and 1st MPJ, which is where the nerve resides. I have also advised icing the area to reduce any potential inflammation. I was going to provide a silicone bunion protector just to reduce the nerve irritation.

    Am I doing the right thing? I would appreciate any guidance. Once again Kevin, thanks for pointing out another pathology that I would otherwise have failed to diagnose.

    Kind regards,

  13. More beers.....I hope.:drinks

    Pay close attention to the late midstance pronation. This needs to be resolved with the foot orthosis. Generally the best way to get rid of the late midstance pronation is to use a nicely fitting orthosis in the medial longitudinal arch, no medial heel skive, and then use also a 3 mm korex reverse Morton's extension to the sulcus. Ice therapy, 20 minutes, twice daily, also helps.
  14. efuller

    efuller MVP

    It's important to understand the cause of late stance phase pronation. Often you will see some contact phase pronation, then it stops when the forefoot becomes loaded and then pronates further throughout the rest of stance. The first stopping of pronation, i'm theorizing, is where the foot initially reaches equilibrium. As tension in the Achilles tendon shifts the center of pressure forward, it also increases supination moment directly at the STJ axis. If the foot has a laterally positioned STJ axis the direct supination effect from the Achilles creates a greater supination moment than the pronation moment from the anterior shift of the center of pressure. So, if left alone the STJ would supinate. However, this would lead to sprained ankles, so the person chooses to use the peroneal muscles and this creates the pronation moment that causes the late stance phase pronation. So, if this is a muscle caused pronation it is ok to have the orthotic increase pronation moment. The high use of peroneals will cause the foot to evert to the point where there will be high forces under the first met head. The high pronation moment from the muscles will also make the windlass create a higher plantar flexion moment at the hallux. This is what could create what in gait is a functional hallux limitus in a foot that in static stance can have an easy hubscher maneuver or an easy supination resistance test.

    So, if there is a laterally deviated STJ axis, it's ok to add a lateral skive and intrinsic forefoot valgus post. Just don't try to evert the foot farther than it can go.

  15. Lee

    Lee Active Member

    I agree with Kevin. I also use a similar foot orthosis with a forefoot extension 2-5, sometimes full length, sometimes sulcus length depending on tolerance and footwear. Along with this, if you do suspect a Joplin's neuroma based on your clinical exam, you can get an ultrasound scan to confirm it before combining your orthosis with an injection or get a guided corticosteroid injection. I don't see too many Joplin's neuromas, but I have seen 2 cases in the last week. One was a review following orthoses and injection, which thankfully settled the pain, the other has been sent for an ultrasound scan to confirm (or otherwise) my clinical diagnosis. I haven't had to operate on one yet.
  16. RobinP

    RobinP Well-Known Member

    Yes, i think that is more than likely :drinks

    My proposed prescription was to be in line with what Eric is suggesting. Given her cavus foot shape, laterally deviated sub talar joint axis and active midstance pronation, I felt that reducing the peroneal requirement was of paramount importance. Until I could eliminate/reduce this active contraction, I would be unable to see if there was any other reason why there should be marked pronation moments at terminal stance. Shifting the COP laterally in terminal stance via a reverse mortons extension or a FF valgus extension was my plan to reduce the direct pressure on the neuritis. I have the typical fear of over increasing the pronation moments so I will be very careful to not pronate the foot further than it can can go.

    Many thanks for this Lee, I was about to ask about diagnostic imaging and injections but you have preempted this.

    Gents, many thanks for your considered responses.



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