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Medial Sesamoid problems or Compressed Nerve?

Discussion in 'Ask your questions here' started by Walter, Jun 17, 2008.

  1. Walter

    Walter Guest


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    Help - I have two different diagnoses for pain/discomfort under the great toe on my left foot. One is sesamoiditis, the other a compressed digital plantar proper nerve? How do I get this problem diagnosed correctly? This discomfort has been driving me crazy for years. By the way, my right foot is fine.

    I have had this problem for 3 1/2 years, with little relief except for a month or two. The pain is worse in tennis shoes and least in sandals and hard-soled shoes. I have gout which is now under control with allopurinol. I have had x-rays, CT scan and an MRI on my left foot. One doctor is now recommending a bone scan on my left foot to confirm a medial sesamoid problem. Any ideas? Thank you in advance.
     
  2. FootDoc

    FootDoc New Member

    DISCLAIMER:
    THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
    ***********************************************************
    As both diagnoses mentioned are most often clinical in nature, meaning that they are likely based entirely on patient's descriptions and complaints rather than visual or test evidence, it would require the skill and experience of the examining doctor to differentiate which, if either, is correct. Short of nerve conduction testing and/or clear evidence of electrical type symptoms, numbness or paresthesias, entrapment of small nerves is particularly difficult to conclude. Sesamoiditis is merely a catch-all term which has come to mean pain in the sesamoid area, but does not indicate a specific cause. Without knowing the details of what diagnostic methods have been attempted and their specific results, I really cannot offer a road map to an accurate determination. It might be helpful if you could think over what, if any difference, there might have occurred which could have contributed to the relief you received during the month or two of remission which you mentioned.
     
  3. Walter

    Walter Guest

    Foot Doc - thank you for the feedback. Attached are results from an MRI and CAT on my left foot. The pain is exclusively near the medial sesamoid, plantar proper digital nerve, FHL, etc. Any other thoughts?

    MRI - Marrow edema and subchondral cystic change within distal aspect of lateral sesamoid, apparent overlying chondral loss and prominent osteophytes arising from the plantar aspect of the of first metatarsal head, are indicative of advanced osteoarthropathy of sesamoid joint. Medial sesamoid appears bipartite. Small focus of subchondral edema within base of first metatarsal and larger regions of edema within base of second metatarsal and within medial cuneiform appear related to advanced to osteoarthitis of tarsometatarsal joints. Considerable fluid present within flexor longus tendon sheath proximal to Knot of Henry. FDL, peroneus longus and extensor tendons are unremarkable. Intrinsic muscles of foot are normal.

    Impression
    1. Advanced Osteoarthrosis of lateral sesamoid metatarsal joint and first/second tarsometatarsal joints.
    2.Tenosynovitis of FHL tendon proximal to Knot of Henry.


    CAT lower extremity

    A fragmented medial first metatarsal sesamoid bone is present, likely a bipartite sesamoid, although an incomplete fracture of the proximal component cannot be excluded. Recommend clinical correlation with point tenderness. Of note, the right sesamoid bones are intact and no bipartite sesamoid bone is identified within the visualized right foot. There is joint space narrowing of the metatarsal-sesamoid articulation involving both the medial and lateral sesamoid bones, consistent with osteoarthitis. Mild subchondral lunency within the lateral articulation is demonstrated. There is also is first metatarophalangeal joint space narrowing with small marginal spurs. No prominent spur is present off the medial base of the proximal phalanx. A mild hallux valgus deformity is present, although the foot was not imaged in standard radiographic projection for this assessment.

    Impresson
    1. First metatarsal-sesamoid and metatarsophalangeal osteoarthitis, moderate in degree. No large plantar spur identified.
    2. probable bipartite medial sesamoid with a fracture felt less likely, but recommend clinical correlation with point tenderness.
     
  4. FootDoc

    FootDoc New Member

    DISCLAIMER:
    THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
    ***********************************************************
    In my opinion your MRI and CAT reports represent the typical shot-gun, often unfocused impressions which, because of their impressive language, tend to make, especially the patient and often the doctor think that they supercede old fashioned diagnositic ability. It seems often the case that the radiologist tends to attempt to justify his/her value by citing any and all abnormalities seen, whether or not they bear significantly on the patient's complaints. For that reason, I generally read my own tests in addition to receiving the narrative from the radiologist, as I know exactly what I am looking to rule in or out and don't have to bother with extraneous information which often simply muddies the waters. I note in particular that you mentioned that your doctor suspected a problem with the medial (tibial) sesamoid. The MRI report finds problems with the laterial (fibular) sesamoid, while the CAT report states that that same sesamoid is fine. Seems to substantiate the waste of money that these tests often wind up being. Many are preformed because the doctor may not possess the necessary diagnostic skills, and/or because the patient both expects and is impressed by such tests. But all that being said, I see no information regarding the alternative diagnosis of a possible nerve entrapment. I can't tell you what your diagnosis is, but I'd bet dollars to donuts that with a good old-fashioned physical examination, I could give you one.
     
  5. Walter

    Walter Guest

    Foot Doc - thank you for the feedback. I am more confused than ever. Would a bone scan be helpful to diagnose my problem? Do you know a podiatrist, orthpedist, etc. in Denver that you trust? Where are you located?
     
  6. FootDoc

    FootDoc New Member

    DISCLAIMER:
    THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
    *********************************************************** I don't believe in blindly jumping fromn one high-tech diagnostic modality to another unless one know what he is looking for. This business of substituting these techniques for basic diagnostic skills derived through experience, I believe, is a flawed concep,t and simply relegates the practice of medicine to a machine rather than a person. So, it depends on what your doctor is thinking and what he/whe is looking to rule in or out as to whether a bone scan might be helpful.

    I cannot help you with selection of a podiatrist in Denver, and I don't make such referrals through the Internet anyhow. It is my firm policy not to personally treat or become diectly involved with anyone to whose questions I've offered general opinions in this forum, There are too many doctors everywhere who use forums such as this for their own financial benefit and I won't be one of them.

    I've covered my recommendations for the basic selection of a podiatric surgeon on this forum on many occassions. Look at:
    http://anonymouse.org/cgi-bin/anon-...ad.html?id=18028&thread=17982&f=1&u=epodiatry
     
  7. Walter

    Walter Guest

    thanks again for advice - I agree with most all of your thoughts. I've seen two orthopedists and three podiatrists in the Denver area, all of who came highly recommended. I do not believe any of them has accurately diagnosed my problem. I recently saw the two orthpedists because of my frustration at not getting help from the podiatrists. So far, every podiatrist has made a vague diagnosis of sesamoiditis, even though my pain is nearer to the first MTP joint. They then recommend a standard regimen of orthotics, which has not proven helpful. One orthopedist thinks I have a compressed proper plantar digital nerve (and he wants to decompress the nerve), and the other wants to have a bone scan to check for a medial sesamoid problem. In your experience, how useful is a bone scan in detecting a sesamoid problem?
     
  8. FootDoc

    FootDoc New Member

    DISCLAIMER:
    THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
    ***********************************************************
    Bone scans can be useful in detecting fractures which may not be evident on standard x-rays, arthritis and diseases of bone, but there are many cases of sesamoiditis which do not feature any of these problems and positive results (hot spots) on scans are not uncommon in cases where there is no sesamoiditis present. As with all tests, bone scans are an adjunct to diagnosis and not the end-all of diagnosis
     
  9. Walter

    Walter Guest

    thanks again for your response. I am determined to get this foot pain resolved, and you have been very helpful! My left MTP joint has very good flexibility (the same as my right foot) with no pain with any movement. Also, I have no pain over the medial or lateral sesamoid. My pain/discomfort is very specifically in the area between the 1st MTP joint and the proximal phalanx of the hallux. Today, I had an injection of 1/2 cc of lidocaine, 1/2 cc of marcaine and a small amount of B12 in this area to see if would help the discomfort and be diagnostic with respect to digital proper plantar nerve pain. I have a bone scan scheduled for later this week.
     
  10. Walter

    Walter Guest

    I recieved the injection a week ago today, and it was not helpful. I also have the results of a bone scan, which were negative as follows:

    Findings; Flow portion of the study, if anything, shows more flow through asymptomatic right foot than to the left, possibly due to overuse of the right. Blood pool images show show no abnormal activity on either side.

    Delayed images show mild increased activity at the base of the first metatarsal bilaterally and likely due to some mild arthitic change. No abnormal activity is seen about the first metatarsalphalangeal joint or in the region of the sesamoid bones of the left foot.

    Impression: Minimal increased activity, base of the metatarsal of both feet and likely due to mild arthitic changes. No other abnormal activity is seen in the region of the left metatarsophanangeal joint of its associated sesamoid bones.

    A physical therapist I am seeing is convinced I have a tendonosis (degeneration of the tendon) of the FHL tendon. Does that sound possible?

    I also understand that bone scans can be negative even though one has AVN of one or both of the sesamoid bones.

    Any thoughts?
     
  11. FootDoc

    FootDoc New Member

    DISCLAIMER:
    THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
    ***********************************************************
    As I attempted to point out previously, test such as MRI and scans are often not helpful when they are used primarily in the hope that they will reveal some diagnosis which was not substantively suspected as a result of basic old-fashioned diagnostic skills. Certainly the local anesthetic injection could have offered some degree of short-lived temporary relief if the locus of the problem were in the area of the injection site, but I would not have expected the vitamin B-12 to have had any real effect even if it were a nerve compression. But having had no opportunity to examine you or to elicit a detailed and targeted history, I would have no further thoughts as to what may have been missed or what appropriate treatment simply hasn't worked.
     
  12. Walter

    Walter Guest

    I have learned my lesson - I will ask you no more questions. See ya.
     
  13. FootDoc

    FootDoc New Member

    walter wrote:
    -------------------------------
    I have learned my lesson - I will ask you no more questions. See ya.
    ======================================
    Not sure what lesson you mean. If by "lesson learned" you mean that you now understand that high-tech tests are generally not a substitute for good diagnostic skills, then . . good for you. But if your comment was a "dig" at me for, at no cost, trying over the last two weeks, but not coming up with an answer to your problem, when those whom you have paid for same have done no better, then I would consider that rather ungrateful of you.

    See ya.
     
  14. Unregistered

    Unregistered Guest

    i get like a need to pop the big toe, and it can drive me nuts, i can't wear tennis shoes either, I can't nice dressy shoes, or none of that.
    an x-ray shows I have a large cyst in the medial sesamoid. that could expalin my problem,but doctors ignored it.
     
  15. Guest

    Guest Guest

    Any answers? My symptoms are almost identical to what you describe above w/ the addition of a snapping feeling in the arch.
     
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