Jewish World Review March 27, 2003 / 24 Adar II, 5763

Big toe, big pain and a big problem if left untreated

By Marlene Cimons | The worst thing you can do if you feel pain under your big toe is to ignore it. Yet this is what many athletes do.

Pain under the big toe could mean you've injured one or both of your sesamoid bones (so named because of their resemblance to sesame seeds, although they are actually the size of pebbles). The two tiny bones are located in the ball of your foot, right under the big toe, and act as a fulcrum -- a pulley system -- for the flexor tendon, which runs down the inside of the leg and along the bottom of the foot to the big toe.

Injury to the sesamoid region frequently occurs among high-intensity runners, dancers, football players -- and racehorses.

Such an injury can mean a fracturing of the bones, an inflammation of the surrounding tissue or both. The important thing to remember is this: If you feel pain under the big toe, don't dismiss it as a stone bruise or something equally benign. Seek professional help immediately. This is not an injury that can be neglected.

"The biggest problem is delay of diagnosis of a fracture,'' says Sheldon Laps, a sports-oriented podiatrist in Washington, D.C. "Most runners feel a little pain under the big toe and think it's going to go away, so they continue to run and don't come in.''

This is can be a serious -- and permanent -- mistake.

Because the sesamoids have a poor blood supply, they can suffer irreversible damage if a fracture is left untreated or is misdiagnosed: Chronic pain, arthritis within the toe joint, even bone death can result from a fracture that does not heal.

"I knew what it was, but I didn't realize the severity of it, how badly it was fractured,'' says Donna Gievers, a podiatrist in private practice in Silver Spring, Md., who fractured a sesamoid in her right foot about six years ago. She didn't treat it aggressively because she was reluctant to disrupt a scheduled trip to Africa.

The bone has since "died,'' and she lives with chronic pain. "My advice is, don't ignore it,'' she says.

Sesamoid injuries can result from overuse -- repetitive stress -- and most frequently occur among athletes who push off from their toes, over-pronators (pronation is the flattening out of the arch when the foot strikes the ground), those who run or compete on uneven surfaces and athletes with high arches.

But anyone, even non-athletes, can have a bad landing -- and it only takes one. Step in a hole, miss a stair or hit a stone or rock -- and you can fracture a sesamoid.

It is not uncommon in runners to see problems related to the sesamoids. Because of the critical position of the sesamoid bones under the first metatarsal head (the big toe, ball of the foot area), the sesamoids modify pressure, alter the direction of muscle pull of the muscles of the foot -- important in push-off -- and diminish friction under the first metatarsal head area.

Dr. Richard T. Braver, a sports podiatrist in Englewood, N.J., says. "Sesamoid injuries can certainly be a nuisance. The problem is that these two bones are encased in the flexor tendon to the big toe. So any time you bend the toe up, the sesamoid or soft tissues surrounding this bone get stretched or pulled apart.''

There is very little that can be done to prevent a sesamoid injury, short of wearing well-padded shoes and sticking to even surfaces when running or playing your sport.

If you feel this pain in the big toe area -- which can be mild, intermittent and dull, like a stone bruise, or severe and throbbing, with swelling -- you should see a foot specialist. This is important because a specialist will order the correct kind of X-ray -- one that positions the foot in a way that the sesamoid bones can be seen more easily.

It's important to take what we call an axial/sesamoid, or "ski jump,'' view, where a plexiglass plate is used to bend the toes out of the way so you can see the sesamoids.

Most hospitals don't take that X-ray view, he warns. "Usually, it's taken from the top of the foot, and they shoot through the first knuckle, so you can't clearly see those bones,'' he says. "A radiologist will know what to do, but a physician will have to request it.''

Sometimes adding to the confusion is the fact that a small number of people are born with "bipartite'' or "tripartite'' sesamoids, which, on an X-ray, "mimic'' a separation or fracture -- another reason why it is essential to have a specialist diagnose the problem.

If a fracture is diagnosed early, most doctors will recommend that the foot be immobilized in a cast, which means no running for six to eight weeks. Unfortunately, "most of the time we don't see patients until it's been three or four months,'' Laps says.

For fractures that do not heal, experts often prescribe the use of a bone stimulator to promote healing. This is an electronic device that looks like a Velcro cuff and is strapped around the foot; it must be used for 10 hours every 24 hours for at least three months, sometimes longer.

"You wrap it around your foot and connect it to the wall when you go to sleep -- it's like charging a cell phone overnight,'' Laps says. "I have my patients use it for eight hours overnight and then an additional two hours during the rest of the day, in any increments, for a total of 10 hours. Used this way, for 10 hours a day for three to four months, it has a success rate of 85 percent.''

It is covered by most insurers, but only for fractures that have failed to heal using conventional treatments. Most of the time, you can only get this machine through a doctor and you have to prove to your insurer that everything else has failed.

If a fracture still does not heal, surgery to remove all or part of the bones is a last resort.

Inflammation alone -- when the soft tissue surrounding the sesamoids hurts, but no fracture is involved -- is treated with rest, protective padding or orthotics to "float'' the painful area and correct "overloading.'' Doctors may also recommend non-steroidal anti-inflammatory drugs or cortisone injections. Women should avoid high heels. Also, a running shoe that is very stable in the forefoot may help relieve stress in the sesamoid area.

One prevention tip from Dr. Braver: "'If you start to develop a callus under the big toe joint, this is usually a sign of increased pressure or friction,'' he says. "Use this as a warning sign to purchase more cushioned shoes or use a replacement insole to better disperse pressures away from the sesamoid area.'' That could prevent more serious trouble later on.

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