Sesamoidits Swelling

by Frustrated
(California)

The episode involving pain and swelling in the ball of my right foot started with me feeling a very slight pain when taking walks in dress shoes. It wouldn't last long and I thought then I just needed new shoes. Then during one walk it felt like I had a pebble under the ball of my foot.

Because of that, I started to cut back on walking. Too late. I noticed I had swelling of the ball of the foot and big toe. I read about this and found out about the sesamoids and, because of the potential for a stress fracture, blood supply issues, etc., went to see a podiatrist and got in about 1 month after everything first started.

The podiatrist took x-rays and the lateral sesamoid didn't light up as much as the medial. Also, he thought maybe he saw a line in it, so he ordered an MRI to determine if there was a stress fracture. There was a delay with the office, but I eventually got the MRI about three weeks after the initial visit. The MRI came back inconclusive, saying there was edema at the lateral sesamoid and 1st metatarsal head. After that, the podiatrist said wait three weeks, continue wearing a metatarsal pad with a cut out, and see if the swelling would subside. The pain associated with the injury has been low -- tenderness mostly -- and the main issue is swelling and limited range of motion for the big toe and pain behind the big toe on the top of the foot when the big toe flexes upward.

At the three-week follow up to the MRI results appointment, it was decided to send me out to physical therapy. Then there was another delay of a week as the PT set up slipped through the cracks. Because of the office's tendency to forget to do things, I went to another podiatrist for a second opinion. They took a more comprehensive set of x-rays and said that the sesamoids were not fractured; the entire foot lit up the same. However, there was bone loss from having guarded the foot and trying to stay off of it. The second podiatrist also ordered PT. He also gave me a cortisone shot, which didn't accomplish much.

I have had one session of PT so far. After that session and after activity the main issue is that the swelling increases quite a bit; the big toe really swells and can barely move. The area also changes color to purple. If I massage the foot, the color goes back to normal and with ice and elevation, the increased swelling subsides to the original level of swelling.

I just want to see what someone else thinks about the swelling. I ask about it but no one so far has given me a good answer explaining why the swelling won't respond to any treatment and why it increases so readily with activity.

Hi "Frustrated",
As my article on sesamoiditis states, this can be a very troublesome problem because of the nature of where the pain is coming from. Every time you walk, you are basically re-injuring an injured area so naturally there is going to be a delay in healing. Another factor is how much fat you have on the bottom of your feet. I find people who had a lot of plantar fat (fat on the bottom of the foot) tend to do better than those that have bony type feet.
Has your podiatrist discussed the shoes you should be wearing and the shoes you should be avoiding?
Are you still wearing some kind of protective padding on the bottom of your foot?
If the answer to both questions is yes and along with physical therapy,(I would hope PT is only doing therapeutic treatments like ultrasound and not range of motion exercises) are not improving, then your next option would be to wear a walking cast that would accomplish two things. One, it would not allow your big toe to bend upwards which aggravates the sesamoid bones and two, it would keep pressure off of the sesamoid itself. That is the only way your are actually going to be able to rest the bone so that it can heal itself.

Marc Mitnick DPM

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