A 39-year-old lifelong runner contacted me recently with questions surrounding a complicated sesamoid injury. Seven months prior, she received a diagnosis of a medial sesamoid fracture. This was two months after running a half marathon. Despite good knowledge of proper training and working with a physical therapist during her preparation, she still sustained this fracture.
After the diagnosis from another physician, she did receive treatment, which included wearing a boot for five weeks. However, the pain persisted and imaging revealed a delayed union. Continued offloading helped but the pain returned after she resumed activity. Concerned about her continued pain, she asked about treatment recommendations as well as the potential risks of surgery.
Her MRI revealed the following impressions.
1. The runner had a non-displaced fracture of the medial sesamoid bone with persistent diffuse bone marrow edema, findings that were similar to a previous MRI. The fracture line is still visible on MRI but computed tomography (CT) would be best to assess the degree of fracture healing if it is clinically indicated.
2. Cystic intraosseous lesion within the medial first metatarsal head likely represents an intraosseous ganglion cyst related to the proximal medial collateral ligament origin. This has decreased in size due to bony ingrowth proximally but there is persistent moderate bone marrow edema within the medial head of the first metatarsal similar to the previous MRI.
3. A persistent increased T2 signal and thickening of the proximal fibers of the medial collateral ligament are likely due to a partial tear of that ligament.
4. A full-thickness chondral loss in the first metatarsal-medial sesamoid articulation remains unchanged from the initial MRI.
5. There is a full-thickness chondral loss in medial aspect of the first metatarsal head at the first MPJ.
The runner had quite the injury involving at least three structures. My primary recommendations would be to rest and minimize bending of the great toe for the next year. I know this sounds like a lot to any patient and of course, one should evaluate things monthly. There is a lot of pathology present that this patient needs to heal and she ultimately should give herself the time to do so.
At some point, she abnormally loaded the big toe joint, injuring the medial sesamoid, first metatarsal head and medial collateral ligament. If she were to elect surgery, she may have a medial sesamoidectomy, microfracture surgery on the first metatarsal head and repair of the medial collateral ligament. She would need to use crutches and scooters for months. This is not desirable as that medial collateral ligament needs motion and may scar down to the bone if immobilized. She would also still need proper shoes, orthotics, dancer’s pads, spica taping, etc., to protect the joint for a year post-surgery.
I would suggest using an Exogen 5000 bone stimulator twice daily and getting into some bike shoes with embedded cleats or other stiff-soled shoes. I would also recommend the use of spica taping and dancer’s pads. The spica taping is actually very helpful when the ligaments are involved. Massage with oils or gels twice daily for desensitization could help. Icing for five minutes twice daily and contrast baths for deep bone flush each evening are also indicated.
As the year goes on, this patient may be on the fast side of the expected healing time range, and shoe restrictions could lessen. She would benefit from a vitamin D blood test and a bone density scan to rule out bone health issues as I see many surprises in these tests.
Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. He recently published “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet.” One can find the book at www.bookbaby.com.
Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.
I am curious how this treatment worked out? How is the patient doing? Certainly a very challenging case.
Doug, thanks for the comment. This patient contacted me on my blog www.drblakeshealingsole.com on Feb 8th 2020. We only had the one email exchange. Sorry. I know this will be fascinating to see how it progresses. The original link to my blog is attached. Rich