A 43 year old female presents to the clinic with pain in her “bunion” on the right foot, but indicates the painful area is on the bottom of the foot behind the big toe. She is 5”4” tall, 130 lbs, moderately active and dresses as a professional for her work as a clerical worker. Her medical history is unremarkable and non-contributory. She reports the condition has been for several months, gradually worsening, with no recollection of trauma. She states pain is worse barefoot and in dress shoes, and is somewhat less with athletic and casual footwear. Pain is partially relieved with OTC Ibuprofen, and OTC pads in her shoe.
Physical examination reveals intact neurovascular status of both lower extremities, no unusual skin lesions other than semi-circular hyperkeratosis under the second metatarsal head and a superficial heloma durum of the 5th toe of the right foot. There is mild Hallux Abducto Valgus deformity of both feet, right worse than left, reducible contracture of lesser digits right greater than left, adequate range of motion of ankle, subtalar and midtarsal joints of both feet, mild genu valgum bilateral, no limb length discrepancy is noted. Gait is antalgic, with late midstance pronation, extensor substitution, flexor stabilization, and delayed heel lift and abductory twist present. Palpation of the medial and dorsal eminence of the 1st metatarsal head is non-tender and no erythema or edema is present. Range of motion of the 1st MTPJ is adequate, no crepitus is present, however some pain is elicited at the extreme dorsiflexion end of range of the joint and tenderness of the Tibial sesamoid is present. Weight bearing x rays of both feet, reveal mild increases of both the intermetatarsal and hallux abductus angle, a congruous joint with no joint space narrowing, no signs of arthritic changes in the 1st MTPJ, an elongated second metatarsal, slight contracture of lesser MTPJs with rotation of the 5th digit bilateral. The Tibial sesamoid is centrally located relative to the 1st metatarsal head on the A-P view, but sesamoid axial views reveal the sesamoids located in the anatomical grooves on the plantar surface of the 1st metatarsal with intact crista and adequate joint space of the 1st metatarsal-sesamoid joints bilateral. An elevated 1st metatarsal relative to the second metatarsal is noted on the lateral view.
A diagnosis of sesamoiditis is made at the time of initial visit. The possibility of stress fracture, aseptic necrosis of the sesamoid, as well as soft tissue injury of the joint complex is presented to the patient, as well as the possible need for further studies and tests to rule out less likely causes of the condition. The decision is made to initiate treatment on a biomechanical basis, by using a low-dye strapping with dancer’s pad applied to both feet, the patient is instructed to continue her present routine and report back to the office in one week. She is also advised that if successful, this treatment would be followed up by use of functional custom foot orthotics, and she should bring three pairs of her favorite shoes with her. If not successful then other treatment options would be available, both conservative and surgical.
The patient does return for a follow up appointment the next week, with her shoes, and happily reports complete relief of the symptoms with the padding and strapping. We decided to proceed with creating custom functional foot orthotics for her. Next week's forum post will discuss the process during the follow up visit in determining which type of orthotic to use, and why, in order to successfully treat this condition.
