Nick’s Pain at his Big Toe is called Sesamoiditis

Meet Nick

We first met Nick in February 2017. He is a 31 years old, works as an accountant, is healthy and active – at least he wanted to be! Nick came in with pain at the ball of his left big toe that had been persisting for over a month. He described the pain as coming and going on different days but being particularly worse during exercise.

Nick enjoys walking with his wife and on the weekends when they go for longer walks or hikes, the pain would flare up and continue to linger afterwards. Nick had recently started running too with the intention to run a half marathon towards the end of the year if the running went well – and it didn’t get off to a good start. He first started getting the pain during a run. The pain then began to always present during running so he had to stop. He came in feeling frustrated that the pain was not settling and was instead getting in the way of doing the things he enjoyed.

Clinical Assessment

The assessment with one of our Podiatrists found that Nick’s left big toe joint was somewhat swollen. Feeling around the joint and moving the toe up and down did elicit significant pain and tenderness. The pain did not radiate into the tip of his big toe or to any of the other joints, it was well defined to the big toe. Nick graded his pain that day an 8/10. On walking, Nick’s gait was altered due to trying to avoid pressure on the big toe. The range of motion at the symptomatic left big toe still remained fairly similar to that of the non-symptomatic right. Nick also had some callous at the painful area and on the side of the toe. Nicks’ Foot Posture Index test showed he had a moderately pronated foot type.

We tested the range of motion through all Nick’s joints of the feet and legs and tested his muscle strength. All appeared normal except for tightness through his calf muscles and a slight weakness in his flexor muscles beneath the big toe. While we would normally analyse Nick’s walk and run on the Zebris gait analysis system, the severity of his current pain meant that this would not be a safe tool for the first appointment. Nick had not brought his running shoes to his appointment but did know they were Asics and was advised to bring them next time.

Diagnosis – Sesamoiditis

From our extensive clinical experience in working with forefoot injuries, we diagnosed Nick with Sesamoiditis for which he has all of the classic signs and symptoms. Sesamoiditis describes the irritation to the small sesamoid bones located beneath the big toe joint causing inflammation and tenderness.

Treatment

Treating sesamoiditis is relatively straightforward and we have great results and success in doing so. Treatment involves a combination of:

• Footwear Advice – The goal is to reduce irritation and pressure from the joint
• Joggers – Even though Nick had good Asics joggers, it turned out that they were over 18 months old and the resulting wear pattern was encouraging his foot to roll in and onto the big toe
• Work dress shoes – These had a slightly pointed forefoot which was rubbing against both sides of his feet and contributing to the problem
• Hiking boots – we went over the important features of having a forefoot rocker, stiff sole and good ankle support
• Sesamoid Pad – We placed a pad inside Nick’s shoes to immediately start offloading the joint and relieving pain and continued to do so until the joint had settled and he had his custom orthotics
• Taping – Using sports tape we supported and helped offload the joint and taught Nick how to continue to tape at home as needed and when doing certain activities
• Custom Orthotics – We created custom orthotics made from a 3D impression of Nick’s feet to improve his foot mechanics and address the original cause of his pain. After Nick’s pain had settled, we analysed Nick’s feet on our Zebris gait analysis system and captured a 3D impression of Nick’s feet. Combined with his biomechanical findings, we crafted the perfect custom orthotics for his feet.
• Exercises – We prescribed exercises to strengthen the flexor foot muscles as well as stretching to help increase the range of motion through the affected joints and muscles

We applied these treatment variable in a specific and timely manner to maximise Nick’s comfort and rate of recovery. We don’t just treat symptoms, we identify and address the original cause – as otherwise it will just happen again.

The Outcome

From the moment we inserted the padding into Nick’s shoes at his first appointment, he felt some long-awaited relief. With ice and some anti-inflammatories, he was able to get the pain right down by the end of the next day. We created and distributed Nick’s orthotics at his next appointment one week later so that this new pain-free state could become permanent.

2 weeks later at his check, Nick’s left big toe was not red or swollen but a regular, healthy joint. Nick was stoked. He reported wearing his orthotics daily in both work shoes and joggers, though having missed a day at work and feeling some discomfort at his big toe that evening as he could feel more pressure through the toe as he walked without support.

Nick has now started running again and it’s going well – he’s ensuring to continue to strengthen and stretch to help prevent problems from recurring as he increases his load through running.

Nick is booked in for a 6-monthly follow-up and we can’t wait to hear the things he will have accomplished in that time.