Treating Chronic Sesamoiditis With ESWT

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Author(s): 
David Zuckerman, DPM, FACFAS, Lee Cohen, DPM, FACFAS, and Sharon Monter, DPM

These authors discuss the use of ESWT to treat a professional football player who previously failed various conservative modalities for chronic sesamoiditis.

   Sesamoiditis is inflammation and/or degeneration of the flexor digitorum brevis tendon as it passes through the sesamoid bones in the foot. Sometimes, there is a stress fracture involved and/or a tear of the tendon and/or capsule structures. Foot structure and type can contribute to this pathology.

   Standard evaluation consists of X-ray, MRI or utlrasound depending upon the presentation and the response to non-surgical treatment. The differential diagnosis may include a stress fracture of the sesamoid bone, tear of the flexor digitorum brevis tendon, capsulitis, tear of the intersesamoid ligament, and/or hallux limitus with biomechical involvement.

   Typical treatments include physical therapy, local steroid injections, padding, NSAIDs, orthoses, non-weightbearing or, in cases of failed conservative treatment, surgical excision of the tibial sesamoid. Complications arising from surgical excision may include infection, nerve damage, tendon tear, hallux abducto valgus deformity and/or other biomechanical events.

   We have used ESWT for chronic tendinopathies and sesamoiditis for many years and have achieved excellent resolution of the pain without the need for surgical excision or any type of surgical repair.

   In this particular case study, a professional football player had failed conservative therapy for chronic sesamoiditis. Failed conservative therapies included orthoses, taping, stretching, heel cups and deep tissue massage. His last episode of sesamoiditis was six weeks in duration and he was unable to play football without pain.

   Upon the physical exam, the patient had pain with deep palpation of the tibial sesamoid and ambulation. The neuro-vascular status was intact. There were no signs of infections

   We decided to try ESWT. We did not use an anesthetic nerve block for the ESWT treatment. We used the Dornier Epos Ultra (Dornier Medtech) to identify the flexor tendon at the level of the tibial sesamoid bone. We treated all hypoechoic areas at 0.21mj/cm2. The total joules applied were 960 joules. We performed two ESWT sessions with the sessions being two weeks apart.

   After the first session, the patient was 50 percent better. After the second session, the patient had complete resolution of pain. The patient was subsequently able to return to the field at full capacity.

Final Notes

Chronic sesamoiditis is a very difficult problem to resolve, whether it is in a professional football player or anyone with this very painful pathology. It is important not only to determine time frames for ESWT treatment but the history of the complaint. Was the problem off and on for years? What were the responses to treatments aimed at the inflammation? One would typically confirm the diagnosis with either MRI and/or diagnostic ultrasound.

   ESWT is a time-tested modality that clinicians can use to treat plantar fasciosis, Achilles tendinosis, posterior tendinosis and chronic sesamoidititis. I have found that clinicians have long used ESWT to treat non-unions so one may also consider this modality for non-union of the sesamoid bone. We believe that ESWT can be very effective in the treatment of chronic sesamoiditis with very little downtime and very rare complications. A study on the use of ESWT on a large pool of patients with chronic sesamoiditis would be a very exciting venture to be undertaken at one of the podiatry schools.

   Dr. Zuckerman is a Fellow of the American College of Foot and Ankle Surgeons, and Director of ESWT Services Excellence Shockwave Therapy in Woodstown, N.J.

   Dr. Cohen is a Fellow of the American College of Foot and Ankle Surgeons. He is a podiatric consultant to the Philadelphia Eagles, the Philadelphia 76ers and the Philadelphia Wings. He is in private practice in Cherry Hill, N.J., Ridley Park, Pa., and Devon, Pa.

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