Persistant sesamoiditis

by Catie
(Seattle)

I have been suffering from sesamoiditis for almost a year. It started in the right foot whenI tripped in heels, but I now have it in the left, as well. I have seen two GPs, a podatrist, a physical therapist, and orthopedic doctor, an acupuncturist, and a reflexologist. I have changed shoes (probly not soon enough), tried 4 different insoles, quit my cafe job, stopped walking my dog and exercising (except swimming), taken nsaids, worn a boot for 8 weeks; I kneal when I cook and sit to get ready in the morning. With everything I've done, they just get worse. I've been told I have hypermobility, but PT didn't see any improvements, so they gave up on me. I also have high arches and chronically cold feet. I haven't tried custom orthotics, b/c they are so expensive, but I'm going in for an MRI and if the bones aren't dead, I will give orthotics a shot. I feel like I am at the end of my rope. My husband is not convinced I even have sesamoiditis. He thinks it's a nerve issue. Is this a possibility? Are there any other underlying health issues that could cause this?

RESPONSE

Hi Catie,

Although a nerve involvement is certainly a possibility, based on your narrative, I am leaning more to sesamoiditis based on the description of your foot type. Additionally, if you can press into a specific area and this causes pain, then it is likely more a sesamoiditis than a nerve entrapment.
If you have a high arched foot there is a tendency towards irritating the sesamoid bone which of course would be aggravated by wearing heels, particularly heels with thin soles. Aggravating the situation where there is a hypermobility of the big toe, because as the big toe bends upward that too puts more pressure on the sesamoid bone.
Additionally, if you do not have much fat on the ball of your foot this further exposes the sesamoid bone to excess pressure and thus pain.
The real problem here is that once you aggravate the sesamoid bone it becomes very difficult to remedy the problem. I would have thought that wearing a boot might have helped as that should have given the sesamoid bone time to heal.
I think the MRI is a good idea to make sure you have not fractured the sesamoid bone, which would change the dynamics altogether.
Assuming there is no fracture you basically have two options as I see it.
You could try a prescription orthotic because unlike orthotics you buy in a drug store, a prescription orthotic can be built to adequately support the arch thus taking pressure off the sesamoid bone. Additionally, various types of cushioning or accommodative padding can be added to a custom orthotic in an effort to further reduce pressure on the sesamoid bone.
If custom orthotics do not work out, then you are faced with having the sesamoid bone removed. This is generally a surgery we try to avoid because it can have adverse effects on the big toe joint, but if the pain is as great as you describe, then the risk reward ratio may favor removal of the bone. This is a discussion you would need to have with your doctor who can better explain the potential pitfalls of surgical removal of the sesamoid bone.

Marc Mitnick DPM
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