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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.
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
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.
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.
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.
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.
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"citing an indisposition due to special circumstances"
I would like to understand more about this condition too.
This is what I posted in the other thread:
Quote:
I should have also added, that this whole technique does put a question mark over the diagnosis of 'sesamoiditis' (at least in my mind).
To start with, it never really is a 'sesamoiditis' (as the sesamoids do not get inflamed) - its probably really a 'peri-sesamoiditis' (as its the peri-sesamoidal structures that get inflamed). The standard treatment is to off-load the painful structures and the inflammation generally goes down and patient gets better.
Since using the Jones technique, I question the diagnosis of 'peri-sesamoiditis' and start to wonder if we are really dealing with some sort of first MPJ and/or sesamid-met head joint dysfunctions in many or some of the cases. In thoses when the Jones technique does not work, maybe it is a true 'pressure' related peri-sesmoiditis..... ... or it could be that the peri-sesamoiditis in some induce some sort of joint dysfunction that the off-loading does not address.. or
What say you?
__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________ God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University This is where I am, where are you?
Since using the Jones technique, I question the diagnosis of 'peri-sesamoiditis' and start to wonder if we are really dealing with some sort of first MPJ and/or sesamid-met head joint dysfunctions in many or some of the cases. In thoses when the Jones technique does not work, maybe it is a true 'pressure' related peri-sesmoiditis..... ... or it could be that the peri-sesamoiditis in some induce some sort of joint dysfunction that the off-loading does not address.. or....??
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
Chondromalacia
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?
__________________
"citing an indisposition due to special circumstances"
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
Chondromalacia
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?
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.
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
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.
Quote:
Originally Posted by Levin Kirby
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.
Thanks for this Kevin - 'fraid I missed this too.
Cheers
Mark
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"citing an indisposition due to special circumstances"
Sesamoiditis or not?
... or it could be that the peri-sesamoiditis in some induce some sort of joint dysfunction that the off-loading does not address.. or 
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