Archive for August, 2010

Sesamoid Disorders and its Treatments

August 26, 2010

Almost all feet have two sesamoid bones found on the bottom of the big toe joint.  These two sesamoids are oval, seed-shaped bones. Their purpose is to absorb weight-bearing forces to protect the tendon that runs on the underside of the big toe. They elevate the big toe, which is also known as the hallux, thus assisting in increasing the mechanical advantage of the tendon that bends the hallux toward the floor.

Anatomy of the Sesamoid

Each of the two sesamoids found under the big toe joint have specific names. The sesamoid closer to the little toe side of the foot is termed the fibular sesamoid, and the sesamoid found on the big toe side of the foot is called the tibial sesamoid.  If one of the oval shaped bones is in two pieces, it is termed bipartite and if the sesamoid is found in many pieces, it is termed a multipartite.  Finally, the sesamoids are anchored to each other, also to the hallux and the first metatarsal by various ligaments and tendons.

Symptoms of Sesamoid Disorders

The most common disorder is called sesamoiditis.  This is inflammation of the sesamoid bone and is usually caused by repetitive trauma. It is commonly seen in young adults, athletes, dancers and women that wear high heel shoes. Most of the time, the pain from sesamoiditis is worse with shoes when weight bearing. The pain is located directly under the sesamoid where swelling and redness maybe noted.

Diagnosis of Sesamoid Disorders

To diagnose sesamoiditis the doctor will press on the bottom of the foot in the area of both sesamoids. If pain is elicited when one or both of these bones is palpated the doctor will know that the patients pain is coming from an injured sesamoid bone.  An important part of diagnosing sesamoiditis is to evaluate the bones with X-ray imaging.  Sesamoiditis cannot be seen on x-ray.  The x-ray is used for ruling out other conditions in this area such as fracture, bone tumor or arthritis.  If on the x-ray image the sesamoid appears fragmented and the pieces have sharp edges with wide separation relative to each other, it may be indicative of a sesamoid fracture.

Non-surgical Treatment of Sesamoid Disorders

Before surgical treatment is considered, non-surgical treatments are always tried. If the pain on the sesamoids is due to the presence of callused skin, the podiatrist may remove the callus with a scalpel.  In the case of sesamoiditis, the first line of treatment is to get the pressure off of the bone.  This can be accomplished by applying a Dancer’s pad to the foot.  This is a pad made of felt or silicone; it has a curved cut out to allow the sesamoid to float. In the case of fractures or dislocations immobilization of the sesamoid is essential for healing.  Depending of the severity of the sesamoid disorder, the immobilization can be accomplished with the use of a CAM or boot walker to decrease pressure to the sesamoid.  Treatment using ice and non-steroidal anti-inflammatory medication may also be recommended. If the padding helps relieve the pain custom orthotics can be made to off-weight the sesamoids. Corticosteroid injections to the joint can also help alleviate pain.

Surgical Treatment of Sesamoid Disorders

If the sesamoid pain is not alleviated by non-surgical care, then surgical treatment is considered. The most common surgical procedure for sesamoid disorders is a sesamoidectomy (removal of a sesamoid).

Recovery after Sesamoidectomy

After a sesamoidectomy, it is recommended that the patient is non-weight bearing with crutches for 2 weeks, followed by 4-6 weeks in a post-op shoe with protected walking.  The podiatrist may recommend joint exercises to prevent stiffness in the joint and custom orthotics to decrease pain and maintain function of the foot. Since sesamoids are important in the function of the big toe, sesamoid removal can change the mechanical balance in the foot. Therefore, removing the sesamoid can result in a decrease of hallux strength, limited big toe joint motion, and positional changes of the big toe.


Treatment and Cause of Ganglion Cyst

August 23, 2010

What is a ganglion cyst?

It is a single or multi-chambered soft tissue mass with thin walls that is filled with high-protein fluid. The fluid color ranges from amber to clear and located beneath the skin and can be attached to muscle tendons, joint capsules or nerves.

What causes a ganglion cyst?

The causes of ganglion cysts are still unknown. However, it is suggested that they are caused by repetitive trauma or joint fluid projecting out of its contained area. In the case of repetitive trauma, ganglion cysts may form if there is friction or excessive rubbing between a bone and/or shoe against a tendon.

What are the symptoms of a ganglion cyst?

Ganglion cysts can be found all over body. Most commonly, on the hand and wrist, then followed by the foot. In the case of the foot, ganglion cysts are the most common soft tissue masses found in the foot and ankle; in addition most are located on top of the foot. When a ganglion cyst becomes large, it may appear frightening and worrisome because patients may believe they have developed a cancerous growth. Fortunately, ganglion cysts tend to be harmless and painless and may even resolve on it’s own.  However, if the ganglion cysts become large enough, it can begin to cause pain. This is because the enlargement produces increased pressure on the surrounding tissues such as skin and nerve.  Additionally, large ganglion cysts can interfere with shoe gear.

How do you diagnose a ganglion cyst?

Ganglion cysts are usually diagnosed clinically. The podiatrist will test if the soft tissue mass has characteristics of ganglion cysts. These characteristics are that the mass is movable and soft.

X-ray studies are occasionally used in examining a ganglion cyst. The cysts are soft tissue and do not appear on x-ray, however, x-rays can rule out other diagnostic possibilities, such as calcified masses or bone invading tumors.

Diagnostic ultrasound is inexpensive and very effective at diagnosing and revealing the nature of the ganglion cyst.  By studying the cyst with the ultrasound, the doctor can see the size, shape and the number of chambers in the mass.

MRIs may also be requested usually to determine the size and the degree of how much soft tissue is involved with the ganglion cyst. This is an expensive test and is most often used for surgical planning.

How do you treat a ganglion cyst?

Non-surgical treatment:

It is often difficult to treat ganglion cysts without surgery. However, non-surgical treatment can help relieve pain and symptoms from the ganglion cysts. Padding may be placed around the ganglion to decrease pressure and irritation to the area. Change in footwear may also be suggested to reduce friction and pressure to the area as well.

Aspiration of a Ganglion Cyst:

This is done by first numbing the area with local anesthesia.  Next, the site of aspiration is cleansed with antiseptic skin cleaner. Then, using an empty syringe and needle the fluid is pulled out of the ganglion cyst. After aspiration of the ganglion cyst, a syringe with steroid maybe injected. Also, it must be noted that there is a high risk of recurrence of the ganglion cyst after aspiration.

Surgical treatment:

Surgery as a treatment for ganglion cysts is only considered if conservative treatment failed, the ganglion is recurring, or there is significant pain. Surgical removal of a ganglion cyst consists of removing the entire ganglion wall and surrounding soft tissue that is associated with the ganglion cyst. Since surrounding soft tissue needs to be removed, the incision site will need to be longer then ganglion cyst. Pain, swelling, numbness, or tingling may occur after the surgery. As with aspiration procedure noted above, it must be noted that there is risk of recurrence of the ganglion cyst after surgery as well.