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The response to the question below was authored by Marc Mitnick DPM

sesamoiditis after bunion surgery

by Cheryl
(Eureka California )

After bunion surgery on both feet my right foot is not healing and with a compounded cream, anti-inflammatory and new orthotics. I was told I have sesamoiditis. I still have pain and swelling in my left that I could accept

that explanation for... but my right has always felt thicker and it feels like a bony mass on the ball of my foot. Supposedly the x-rays looked fine.
My right foot does not lay flat like my left. Like the tendon is shorter and
the toes are very difficult to move. I did bump it a couple of times very hard right after surgery. It just feels different structurally.
Is there any scan like an MRI that can tell if there is something else going
on? I am afraid I have made my Dr. mad continually asking that question. He said
he knows what it is and has seen it thousands of times. I just cannot explain to
him how different the structure feels and the pain is so much worse. It is like
I did not "develop" sesamoiditis over time....it has been like that ever since
surgery. Should I get a second opinion. I am worried it will effect my employment as I am a mail carrier. Thank You!

RESPONSE

Hi Cheryl,

I would tend to agree that ongoing foot problems will tend to adversely affect you as a letter carrier.

There are a few things I would have liked you to mention in your narrative. The first is how long ago you had your bunion corrected. There is acute sesamoiditis and there is chronic sesamoiditis, meaning that sesamoiditis can occur as a result of bunion surgery but how long it lasts is critical.

If you have only had it for a couple of weeks and your surgery is fairly recent, then I am not as concerned as I would be if you had your surgery months ago and the sesamoiditis has been with you for a long period of time.

The other
question I would have liked answered is the type of bunion procedure that you had performed on your right foot. If it involved breaking and resetting the metatarsal bone then there is a greater incidence of sesamoiditis with these procedures than other bunion procedures. If this happens to be the case, then there is the possibility that there was some damage done to the sesamoids themselves, particularly with the saw blade used to cut bone and I am not sure how quickly, if at all, the sesamoids will heal in spite of new orthotics and anti-inflammatory medication.

The other potential problem is if you have very little fat underneath the ball of your foot to begin with. In general those with a "fatty" forefoot tend to have less issues with sesamoiditis than those who have bony feet to begin with, where you can actually feel the sesamoid bone by pressing on the bottom of the foot.

You raise the issue of an MRI. In theory it might be helpful in determining how the structures of your forefoot line up and whether there is any damage to the sesamoids or to the ligaments that attach the sesamoids to each other and to the metatarsal bone. However, if you have any hardware implanted in the bunion site, like screws or pins, that could lessen the effectiveness of the MRI.

I would sum it up this way. If the surgery was fairly recent and you have been bothered by sesamoiditis for a short time, you might ask your surgeon to send you for physical therapy in addition to wearing orthotics and taking medication

If however, your surgery was at least five or six months ago and the sesamoiditis has been present for most of that time, a second opinion may be in order by someone who is unbiased. The fact that your foot does not lay flat and I assume prior to surgery it did lay flat, is a cause for concern to me.

Marc Mitnick DPM
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Mar 07, 2017
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Austin Akin Bunionectomy
by: Anonymous

Hi,

I had this procedure done in Dec.2016 and things appeared to be fine. I used crutches for a few weeks and then I started feeling pain in the ball of my foot. It feels like walking on a pebble constantly. I didn't have this pain prior to the surgery. I spoke to my doctor about the pain so he placed orthotic cushions in my shoes, which helped some, but that pain was still there. I've worn them for 3 weeks now and returned to the doctor. He recushioned them and said to wear them for another 3 weeks, which I'm still wearing now. Once I shower the shoes go back on. I wear the shoes until I go to bed. I still feel the pain and I can't walk bare foot at all. I've done a lot of research online and ran across toe spacers. After I placed my toe (the one I had surgery on) in what feels like the correct alignment, that pebble feeling goes away. Unfortunately, my toe doesn't remain in that position so I believe the sesamoid bones shift back to being out alignment causing this horrible pain. I am totally thinking about toe spacers to see if this will help with that alignment and stop this horrible pain. into good running shoes with cushions.

Oct 27, 2016
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2.5 years after surgery
by: cheryl

Hello ~ I am not sure if the same person will respond to this as it has been two years since I have posted a queston. All the pads attached to my orthotics have done little to help. Finally a year ago the Dr. took another xray. He remarked that there was a fracture but assured me it was there before surgery...yet this was never mentioned and the pain that would have caused that I have now was not present. He remarked at least 3 times during the office visit that he had xrays from before. I am highly suspicious. He remarked that he could remove the bone that my bunion would come back and my toe would not lay flat ( it does not now ) then a few months ago he remarked that maybe he could "plane the bones" in my foot. I wonder if an MRI or some other test would show what is going on. I do believe he pinned the bones during surgery so that may not be helpful. I could really use some guidance. I do not want this Dr. to touch my feet again. Problem is it is work related and no Federal DOL workmans comp doctors within 100 miles of our rural county. I want to retire in a year or so and would like to get some opinions. I am afraid a second opinion would require me to request my current Dr's xrays. I am also worried that he will drop me as a patient if he were to know I was getting a second opinion. Thanks for any reply. Cheryl
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Any doctor who fears a patient getting a second opinion probably has doubts about his own competency. Based on your narrative, I think a second opinion would be a good idea, even if you go to a local doctor and pay out of pocket for the visit.
I tend to agree with your assessment; if you had a fractured sesamoid before surgery, your foot would have hurt. He is correct in that removing the sesamoid might cause your bunion to recur which would then possibly require a fusion of the big toe joint, a procedure I do not particularly like.
"Plane the bone" might help but it would depend on how bad the fracture actually is.
Give some strong thought to getting a second opinion.

Marc Mitnick DPM

Oct 08, 2014
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answered questions
by: Anonymous

My surgery was May 1 , 2014 so over 5 months ago and it is not getting better. I do not have much fat on the ball of my foot. I had an Austin bunionectomies done on both feet. At least that is the type my Dr. said he was going to do. He did say the bone would be broken and moved. The toes of my right foot do not move very easily. The structure of the ball seems wrong...like I am walking on the wrong part of it because it is thicker and maybe the tendon was shortened?
This is a work comp issue and I am scared to death that I cannot make it another 3 years at work. If there is surgery that could help it I would go for it. I am a widow and making it three more years is very dire to my finances. I was told I might be able to get a second opinion but there are no doctors in my area that take Federal Workman's Comp. I thought maybe I could get a referral to a medical school in the San Francisco Bay Area as I am about 250 miles north of there.
Thank you so much for your reply!! Cheryl

Hi Cheryl,

The location of the bone cuts for an Austin bunionectomy are in the neighborhood of the sesamoids, so it is possible that some damage was done to the sesamoids either as a result of the bone cuts, or when the head of the metatarsal bone was shifted, to reduce the bunion deformity.

If you have little fat underneath that part of the foot, that would compound the problem.

Going to a medical school for a second opinion would not be a bad idea. If your insurance would allow it, I would suggest an MRI of the sesamoids (actually the whole surgical site) to see if there is any damage to the sesamoids such as fracture, or damage to one of the ligaments that attaches to the sesamoids.

Do not fall into the false assumption that there is a surgical answer to every foot problem that develops. I am not saying to rule out further surgery, but you should try every thing else available to you prior to consenting to further surgery.

If you have orthotics and they are not helping, ask the doctor to try a different approach in the padding of the orthotic. If you keep experimenting around with the orthotics you may reach a solution, although not ideal, will at least allow you to walk reasonably comfortable.

Marc Mitnick DPM

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