A 35-year old mother of three children recently reached out to me online, noting that she has “hit a wall” with continued pain after suffering a sesamoid fracture. She sustained the fracture when her four-year-old twins ran over her feet while riding in their Power Wheels vehicles.
She originally wore a cast boot for immobilization for two months but serial X-rays failed to show signs of healing. A subsequent referral to an orthopedist yielded a recommendation of orthotics but the patient states her pain worsened. A third referral to a podiatrist led to a return to the cast boot along with around-the-clock taping of the great toe and monthly serial X-rays. There were still no signs of healing. This podiatrist did also administer a corticosteroid injection. The patient called the injection “horrendous” but did acknowledge that the injection calmed the area down for a few weeks.
At the end of October, this patient continued to tape the toe and stay in the boot at all times except to sleep. However, she relates that now her entire foot is swollen and her pain now extends across the toes, the top of the foot and wraps around the ankle to the Achilles area and medial plantar arch. She also notes “bruising” throughout the foot and ankle.
This patient shares that the pain in the ankle and Achilles tendon areas is unbearable in and out of the boot. She states that her current podiatrist would like to obtain magnetic resonance imaging but the patient says this has not been scheduled as of yet. Since the month of June, the patient has elevated the foot every night and uses ice packs. She is unable to take non-steroidal anti-inflammatory medications due to an allergy. The patient notes oral prednisone did not provide relief and, in fact, caused a cardiac arrhythmia. She shares a history of Graves’ disease (controlled with medication) and denies diabetes. The patient also had a hysterectomy and takes hormone replacement therapy.
She says she is extremely frustrated and worried at this point. The patient is inquiring if it normally takes this long to heal a sesamoid fracture and if the other symptoms are normal. She feels her doctors are downplaying her most disturbing symptoms of extreme pain and swelling.
Initially, the treatment focused on a sesamoid fracture, whether healing or non-healing. However, now, I do not feel this is the primary concern. The primary concern should be the pain and swelling out of proportion to the injury. I think it is possible this patient developed complex regional pain syndrome (CRPS) from chronic pain and prolonged immobilization. I encouraged this patient to immediately seek treatment based on her history and photos showing mottling of the skin, which is consistent with CRPS as well.
In this particular case, this patient may need a sympathetic block in her back. I developed CRPS personally after herniating a disc in my back and literally rushed to get the injection. She may need to go to the ER to start this workup. If this patient indeed suffers from CRPS, the sooner she can obtain treatment, the better.
When you suspect CRPS, all icing, compression and immobilization should stop. Typically, the podiatrist can make the pain management referral, call the ER to inform them that an acute CRPS patient is on his or her way and even start the patient on gabapentin, pregabalin (Lyrica, Pfizer) or duloxetine (Cymbalta). One referral should be to a physical therapist with neurologic experience. Due to the pain, this patient is protecting the sesamoid at this point, barely able to walk. Be the patient’s ombudsman as it is a scary time for him or her.
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. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at www.bookbaby.com.
Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.