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Chronic Sesimoiditis
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Chronic Sesimoiditis - July 26, 2008 3:45:46 PM
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NPPT
Posts: 4
Joined: July 1, 2008
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Hi PT's,
I am seeing a 21 y.o. female who has had sesimoiditis for 2.5 yrs. Her foot problems started when she says she diagnosed with a cyst on the dorsum of her foot that was caused from repeated blows because she is a college lacrosse goalie. She says that it got better, but soon after developed sesimoiditis. I can't find a solid reason as to how the two could be related other than the "cyst" changed the way she walked and predisposed her to developing the sesimoiditis. Before she came to see me she has had 3 cortizone shots, none of which has helped, has been in a walking boot, which helped a little, has had custom orthotics with a metatarsal pad made, which helped a lot as far as her day to day pain goes, but still does not allow her to run or walk very far without pain. She has seen two different ortho's, one who told her she had arthritis, and one who told her nothing was wrong. She claims she has an x-ray that shows that one of the sesimoids is actually broken in two, but has yet to bring in the films or report.
She habitually walks on the lateral border of both feet to avoid the pain. She says that it causes her so much pain, that if she had to run to catch the bus or get out of the rain, she would choose not too because it would hurt too much later. She says the only thing that seems to keep the pain at a manageable level is taking glucosamine.
I think her discomfort is completely related to cushioning. After walkng on the lateral boarder of her feet for so long, her pad over her sesamoids does not seem very thick. A reverse Wolf's Law happening. If I ask her to concentrate on walking "normal" for a couple of days she says that it hurts too much.
Anyone have any suggestions for this patient? I am also trying to find an orthotic that would be thick enough in that area that I could carve out a place to sit her sesamoids.
She has seen at least one other PT and she says I am the first health care practitioner of any kind that has said this may be something that she willl have to learn to live with and figure out different ways to manage it, instead of just telling her that they were sure they could fix it.
First post on this forum, thanks for reading this whole thing, any suggestions would be appreciated.
Thanks,
Joel Eaby PT, DPT,ATC
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RE: Chronic Sesimoiditis - July 26, 2008 8:49:27 PM
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PTupdate.com
Posts: 1477
Joined: October 8, 2001
From: Pittsburgh, PA USA
Status: offline
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Joel,
Besides all the usual stuff for controlling her inflammation, restoring normal flexor tendon movement, first MTP mechanics, etc., you may consider this product:
http://www.hapad.com/hapadpro/dance.shtml
Cheap, easy to use and works quite well. At times I have had to also put on top of a half turf toe liner (steel insert for shoe that prevents motion of forefoot). I get a lot of athletes due to our participation in numerous ATC programs, and this one is common during hoops season. Consider it!
_____________________________
John M. Duffy, PT
Board Certified Orthopaedic Clinical Specialist
www.PTupdate.com
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RE: Chronic Sesimoiditis - July 27, 2008 1:56:47 PM
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NPPT
Posts: 4
Joined: July 1, 2008
Status: offline
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Thanks John!
That looks like a great product and I will give it a try. Its nice that it is inexpensive so the patient can use it long term in needed without spending a lot.
Thanks again,
Joel
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RE: Chronic Sesimoiditis - August 7, 2008 1:55:21 PM
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grifffdog
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Joined: July 22, 2008
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Joel
Look and see if she has cuboid restriction(s). The distal attrachment of the peroneus is on the distal 1st ray near the sesamoids and is almost always sore to palpation if the cuboid is restricted and pulls on the peroneus longus back up the line. Mobilize the cuboid(s), see what happens. I find the tenderness under the great toe goes away almost immediately if the cuboid is the culprit. Quick and easy to try, won't hurt anything if not the answer.
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RE: Chronic Sesimoiditis - August 10, 2008 2:34:54 AM
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gomez2
Posts: 51
Joined: May 5, 2005
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I have treated PF both directly and indirectly by addressing and correcting hip alignment and effiency through a series of progressive exercise routines, mostly hips but overall body as well. My goals are to establish bilateral muscular activation throughout the body, establish proper AROM, proper muscular balance and postural re-alignment and then begin re-educating proper muscular coodination through full ROM then add demand to reinforce the new proper biomechanics.
My demo for my clients to illustrate the importance of hip function to the allignment and function of the knees and ankles: stand and lock the knees tight, rotate the femurs in towards each other then outwards. As the hips are IR the feet pronate creating a "flattening" stress on the arch, as the hips ER the feet supinate decreaseing stress on the arch allowing the interosseous nuscles to re-establish the arch.
I have had clients work themselves out of custom orthotics as they re-establish proper hip then foot alignment, also clients have had to get new shoes as they go from severe supination and pes cavus to proper foot alignment and their feet WB properly and the feet acually get larger.
Look at the client's posture in all 4 directions for alignment as well as gait. I would bet she is IR in 1 or B hips
Lifts and supportive shoes would work but is really not addressing the origin of the problem, it is bracing and bandaging the pain.
www.adapttraining.com
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RE: Chronic Sesimoiditis - August 12, 2008 10:20:37 AM
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NPPT
Posts: 4
Joined: July 1, 2008
Status: offline
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Thanks Griff and Gomez!
Mobilizing the cuboid sounds like a good option, especially since she has been walking on the lateral edge of her foot for the past two years. I will also take another look at her hips using the methods you suggested Gomez.
Unfortunately she is on vacation this week and I probably will only be able to see her one more time before she heads back to school in another state.
Overall, she is feeling a little better as we figure out ways to manage her symptoms and correct her gait compensations.
Thanks,
Joel
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RE: Chronic Sesimoiditis - August 12, 2008 2:23:45 PM
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bonez
Posts: 232
Joined: August 29, 2007
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I think that you may benefit from looking at her mechanics as a goalie. Many stand on the ballls of their feet slightly pantar flexed ready to drop into the "butterfly" position. this likey has added to her predisposition for this problem.
Bipartite sesamoids are a common variant of normal, a nice well corticated margin would likley ddx it from a fracture.
Once the mechanical tx is established, review plantar fascial issues connecting to the first ray as well, consider a full length shock absorbing foot bed that you have modified to not allow contact with the sesamoids directly onto the bottom of the shoe. ( a cut out hole) The windlass affect on the sesamoids plus lack of padding locally likely cause a "bottom out" of the bone triggering the inflammatory process over and over.
Just my two cents.
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