How far do your feet take you in a day, 3 miles or 10? Did you think about any of those steps? Most of us do not think about our feet until something goes wrong. Foot pain can be quite debilitating and limiting. When something goes wrong with out feet every step can be painful, especially the first step in the morning.
I recently saw a 40 year old female who had been running 35-40 miles a week for five months. She started feeling mild soreness on the ball of her foot by her big toe. The pain would be sharp with her first step out of bed. After 5-10 minutes the pain would be mild when walking, and it was tender to the touch. The pain continued to increase in intensity for several weeks.
She stopped running for two weeks and the pain decreased. It was less sharp and sore, but still tender whenever she rubbed her toe. She realized her running shoes were getting old and replaced them with new shoes. On her first run in two weeks she felt the pain within a mile, and it became very tender by the end of the night.
Reading information on the internet can make a person well informed or just nervous. She was afraid that she would not be able to run for months because she had either developed gout or turf toe. She came to the office with pain under her big toe that was very painful to the touch. The rest of the toe did not appear swollen or discolored. She was able to flex and extend the toe without pain.
Underneath her toe was a very tender spot that she described as painful for weeks. This area of the toe contains two small bones that are embedded in a tendon under the big toe. These small bones are called sesamoids in the flexor hallucis longus tendon. The sesamoid bones provide leverage when the big toe "pushes off" during walking and running. They also absorb some of the weight of the ball of the foot when jumping, running, or walking.
Sesamoid bone pain is more common in runners, sprinters, and jumpers because of the increased impact placed upon them during those activities. It can occur in women who wear ill fitting high heel shoes.
There are several types of sesamoid injuries that include a form of turf toe, fracture, and/or sesamoiditis.
Turf toe is an injury of the soft tissue surrounding the big-toe joint. It is a common football injury that occurs when the toe is extended beyond its normal range. The excessive extension motion strains the ligaments that support the big toe. The ligaments are stretched with every step and can take months to heal.
To read a greater description of the big toe sprains see our Turf Toe Page.
Any bone breaks, and sesamoid bones can fracture either by acute trauma or chronic repetitive stress. Acute fractures tend to produce immediate pain and swelling at the site of the break but does not affect the entire big-toe joint. Chronic fractures produce long standing pain that tends to come and go. It gets aggravated with activity and better with rest. X-rays will be needed if a fracture is suspected. The x-rays may also show some arthritic changes to the joint, which will complicate the recovery.
Sesamoiditis is an overuse injury involving chronic inflammation of the tendon and sesamoid bones. It is usually associated with increased pressure to the sesamoids that creates the dull, long standing ache underneath the big toe. The pain can be increased with certain shoes or activities. Wearing high heel shoes can trigger the sesamoiditis.
Treatment options for the above conditions involve reducing some of the pressure of the toe and decreasing the inflammation. Protecting the toe can involve modifying the insoles of your shoes. Cut out a small section under the big toe to reduce pressure. Pads can also be added to take pressure off the toe. There are some modified rocker shoes that change your gait and reduce the pressure that crosses the big toe while walking.
Sesamoiditis and some cases of turf toe respond to therapy treatments to increase blood flow, and decrease pain and inflammation. Ice, electric therapy, ultrasound, and cold laser are commonly used treatments. Anti-inflammatory meds or injections are also utilized to decrease the inflammation.
Severe cases and fractures may require 4-6 weeks of limited walking or use of crutches. Special boots are available to take the weight off the foot while walking. Modified orthotics can then be used after the boot to continue decreasing the pressure on the sesamoid bones. Some severe cases may require surgery if they do not respond or have other complicating factors.
In our patient X-rays did not show a fracture and her examination findings indicated sesamoiditis. During the exam we also found a mild case of plantar fasciitis that she had forgotten has been bothering her a few months before the toe. In retrospect she probably had been running a little different to protect the plantar area, which may have increased the stress on her toe.
She responded very well to treatment for three weeks. We negotiated the use of an elliptical instead of running for the first two weeks. She did have the option of pool running to maintain her fitness, but hated the experience. The physical therapy modalities quickly decreased the pain. We worked with a podiatrist who made her custom orthotics that fit great and helped her foot pain. Exercises and stretches were performed to increase her foot strength, endurance, and flexibility. Considering her recent plantar fasciitis pain, she was showing early signs of foot and leg weakness that would probably cause her more injuries in the future if it not properly addressed.
Sesamoid pain can be successfully treated after determining a proper diagnosis. Turf toe, fractures, and sesamoiditis need specific modifications in treatment, and the recovery time is very different. Getting the diagnosis correct sends you down the proper pathway. Then proper treatment and consistent home care makes for faster recoveries.
To read more about plantar fasciitis visit our Plantar Heel Pain Page