Sesamoid Injuries

What the heck is a sesamoid? Or what’s that white circle on my x-ray by my big toe joint? These are probably the two most common questions asked in my office when people are diagnosed with a sesamoid injury.

There are two sesamoid bones in the ball of your foot

A sesamoid bone is a bone embedded in a tendon. In your foot, the sesamoids are two M&M shaped bones located in the ball of your foot, beneath the great toe joint. These act as pulley mechanism for the tendons and help you push off with your big toe when walking or running. They also serve as the weightbearing surface for the first metatarsal absorbing the impact placed on the ball of the foot when walking, running and jumping.

Sesamoid injuries which can involve the bones, tendons and/or surrounding tissue in the joint are often associated with activities requiring increased pressure on the ball the foot, such as running, basketball, football, golf, tennis and ballet. In addition, people with high arches are risk for developing sesamoid problems. Frequently wearing high heel shoes can also be contributing factor.

There are three different kinds of sesamoid injuries in your foot.

Turf toe: Turf toe is an injury of the soft tissue around the big toe joint. It usually occurs when the big toe joint is extended beyond its normal range of motion or hyperflexed. This is very common in football, soccer and tennis. This is a completely soft tissue injury but can involve the cartilage of the joint.

Fracture: A sesamoid fracture occurs when a sesamoid bone breaks. This can be either acute or chronic. An acute fracture is caused by a direct blow and you usually will have immediate pain and swelling. A chronic fracture is usually a stress fracture or hairline break caused by repetitive stress. These are common in runners, golfers and ballet dancers. A chronic stress fracture of the sesamoid causes a long-standing pain in the ball the foot and is aggravated by activity and relieved with rest.

Sesamoiditis:Sesamoiditis is basically an overuse injury with chronic inflammation, but without fracture. Sesamoiditis is actually tendinitis of a tendon that has a sesamoid in it. Sesamoiditis is caused by increased pressure to the sesamoids and is usually a dull, long-standing pain beneath the big toe joint. This pain usually comes and goes.

Diagnosis of sesamoid injuries

In order to diagnose a sesamoid injury, physical exam and imaging is necessary. There is pain upon palpation of the ball of the foot and there maybe swelling and bruising. X-rays are taken focusing on the great toe joint. Often times a stress fracture will not be revealed on a plain film x-ray and an MRI, bone scan or orthopedic ultrasound maybe more helpful.


Conservative treatment for sesamoid injuries may include one of the following options depending on the type of injury and the severity.

  1. Padding:a pattern maybe placed an issue to cushion the inflame sesamoid or two off wait it.
  2. Taping:a turf toe taping maybe utilized to stabilize the joint period
  3. Immobilization: the foot maybe placed in a cast or removable walking cast to stabilize the joint as well.
  4. Oral medications: A steroid dose pack or nonsteroidal anti-inflammatory drugs such as ibuprofen can be helpful in reducing pain and inflammation.
  5. Physical therapy: often times these injuries require physical therapy after a period of immobilization in order to strengthen an increased range of motion period
  6. Steroid injections: In some cases Cortizone is injected into the joint to reduce pain and inflammation. No more than three injections in a one year period are recommended.
  7. Custom orthotics: custom orthotics are often quite helpful to off weight the joint especially when it is a chronic injury. These will often decrease the need for surgical intervention.
  8. Surgery: surgery is usually reserved for severe sesamoid injuries that have failed to respond to conservative therapy. Often the sesamoid has shattered into many small pieces and needs to be removed.

Sesamoid injuries are unfortunate because they often take a long time to heal and have long-term consequences. Nonunion of sesamoid fractures (meaning they either take a long time to heal or never heal) are not uncommon due to the decreased blood supply to the sesamoid, because it is within a tendon. Bone stimulator’s can be helpful to try to avoid surgery. Even surgery is not an awesome option because it can destabilize the joint; and it’s difficult for some people to get back to running, jumping and playing with the other kids on a regular basis. If you suspect that you have a sesamoid injury please seek treatment early, because long-term consequences occur with prolonged inflammation causing joint dysfunction.

Are Custom Orthotics Worth It?

If you are a frequent visitor to Foot and Ankle Associates of North Texas in Grapevine or Keller, TX, you probably already know about orthotics. Maybe you have even purchased orthotics.  

Custom Functional Foot Orthotics

A foot orthotic is an insole placed into the shoe that helps control foot position. There are two main types of orthotics: Functional and accommodative. These can be prefabricated; like Lyncos that are popular at Healthy Steps or custom; which the doctor fabricates unique for your feet. A functional orthotic controls foot movement and helps a person walk in a way that best supports joints and muscles. An accommodative orthotic helps distribute foot pressure evenly over the bottom of the foot.  Most patients use a functional orthotic and usually these are custom for long term usage.  A functional orthotic can be useful for many problems and are used to balance the biomechanics of your feet. Think of them as an in-shoe tire realignment for your feet. Accommodative orthotics are very useful to distribute stress in the elderly, diabetic and arthritic populations.

In the foot care aisle at your local drug store or grocery store, you may have seen readymade orthotics for sale.  Does it really matter whether you buy store bought orthotics or custom orthotics from your podiatrist?   Well, some people may be able to get away with wearing store bought orthotics for a period of time. We even start with these type of prefabricated devices so we can get you on the road to better foot health quickly, but most patients do need custom for long term control of their foot type.

When you think about the long term health of your feet, custom orthotics are the way to go!  Store bought orthotics are made to fit many foot problems for a large variety of people; one size fits all usually means one size doesn’t truly fit anyone!  To be truly effective, an orthotic must be fitted for YOUR particular needs.  Wearing an ill fitted orthotic is not only a waste of time, but it can also make your foot problems worse.  Over time these problems can lead to leg, knee, hip, and even back problems. Store bought orthotics tend to not offer long lasting comfort. 

If you find yourself buying store bought orthotics every few months because of foot pain, it may be time to schedule an appointment to see one of the doctors at FAANT. Your podiatrist will produce orthotics that fit only YOUR feet.  The materials used will be those that are best suited for your walking and running needs.

Everyone deserves special treatment! With a real custom orthotic that is exactly what you have. Yes, custom orthotics can be costly, but so can surgery from walking incorrectly over the years.  I’m always amazed that insurance companies will often not cover orthotics, but will pay for surgery! Doesn’t make any sense!! Think of the orthotics as an investment and an investment in your health is one of the best choices you can make for yourself.

How to Stop a Running Injury Before it Starts!

Most consistent runners will relate that they have been injured at least once in the last 12 months. While there is no crystal ball to see the cause of every injury, there are things that you can do to try to prevent or at least decrease the severity of these sidelining injuries. Here are just a few tips to help keep you on the road and out of the doctor’s office. Think prehab instead of rehab!

  1. Don’t Binge Exercise! The most common cause of running injuries that I see is “too much, too soon, too fast” syndrome. We get so excited to get out there that we too much all at once. Our bodies get stronger with small increases in stress over time. We break down with big increases in stress in a short period of time. Although there is no good scientific evidence validating the 10% increase per week rule; it works! Meaning do not increase your mileage more than 10% per week and do not increase you distance and pace at the same time. Work on either speed or endurance; but not both.
  2. Strength Training. Strength training is a great way to prevent many injuries. Almost every runner I see with plantar fasciitis (arch pain) has tight hamstrings and a weak butt. Integrating a total body strength workout at least once or twice a week in your routine can really help balance your core muscles and decrease injuries.
  3. Replace Your Shoes Regularly. This is the one preventable thing that I see the most often in my office. Worn out shoes are like worn out tires on your car. They lead to all kinds of repetitive stress injuries. The rule of thumb is to replace your shoes every 400-500 miles or every 6 months; whichever comes first! If you are running more than 3 days a week, you should be rotating two pairs of shoes.
  4. Socks Matter! A lot of people will just go running in their daily wear socks. Socks do matter and wearing a wicking sock like dry-weave or cool-maxx will help keep your feet cool and dry. This decreases blisters, calluses and athlete’s foot fungus.
  5.  Massage. A regular deep tissue massage or habitual foam rolling will help increase blood flow to your leg muscles and break down any scar tissue. A massage is not a guilty pleasure, it’s a great way to stop a niggling injury in its tracks! If you can’t justify the expense, invest in a foam roller and use it regularly. 
  6. Check your Iron levels. No one likes to go to the doctor and have their blood drawn, but fatigue from iron deficiency is a common cause of injuries especially in women. Simply adding an iron supplement can ward off these types on fatigue injuries.
  7. Listen to your body! It’s always amazing to me how many people push through the beginning stages of an injury and make themselves 10X worse! If you have pain on the run, STOP! Take a few rest days or cross train. You know the difference between the achiness of fatigue and the pain of an injury. When in doubt, shut it down for a few days and rest, ice, compress and elevate! R.I.C.E. If the pain persists more than 4-5 days, you’re hurt. Forget the denial process and find your way into your favorite doctor’s office.
  8. Sleep!This is also one of those things that we as Americans are really bad at. Actually sleeping 8+ hours a night. Just like the fatigue of anemia, going out running when you haven’t had adequate rest will cause you biomechanics to break down and can lead to an injury. If you are tired, it’s OK to skip a run; just remember that lazy and tired are two different things!
  9. Hydration.Why do so many of us run dehydrated? Especially in hotter climates we require at least half of our body weight in ounces each day. Your muscles need the water to process lactic acid and your body will thank you. As a bonus, well hydrated skin actually looks younger! It’s a win:win.

These are just a few tips to keep you on the road towards your fitness goals!

Happy Running!

Children’s Shoes

I have made it a personal and profession mission over the last 5 years to replace all the children’s flip flop sandals in the world with more sensible shoe gear. Summer is here again and I am on the lectern at my office preaching about the injuries associated with constant flip flop wearing. Is anyone listening? Not really. I have been on major network and cable television, in USA Today and over 50 smaller newspapers, more blogs and internet sites than I can count….yet…. Flip flop sandals have been increasingly and immensely popular in the last 7 – 10 years and have even been worn to the White House and the prom.

This constant flip flop sandal wearing has led to a significant increase in Sever’s disease (pediatric heel pain) and plantar fasciitis (arch fatigue) in children and in numerous adults. The only more offending shoe is the stiletto! (Of which I give up trying to get woman not to wear them, now I preach high heel survival tips!)  Since I cannot convince people to throw out their flip flop sandals, I propose a more ergonomic alternative….Crocs! A good alternative to the traditional flip flop and actually has scientific studies revealing it as a great ergonomic alternative that is actually good for the developing foot.

Let’s send our children out for summer fun and sports protected against overuse injuries that seem to plague our active youth. There is no better way of doing that than ensuring they have the right shoes.

Why are the right shoes important?

Shoes that fit are vital to a young child’s rapidly growing feet. By the time a child reaches the age of 12, his or her feet will have reached about 90 percent of their adult length. Therefore, development of a child’s feet is especially important in these first 12 years of life and it is the reason podiatrists consider the early years to be essential in the development of feet and foot problems. Hence why flip flop sandals should be banned! Children who continuously wear incorrect shoes can develop many problems in later life and exacerbate inherited foot problems. Common problems such as hammertoes, heel pain, Osgood Schlatter’s disease (pediatric knee pain), “growing pains”, corns, and ingrown toe nails can be prevented by selecting the right shoe. Remember, foot pain at any age is not normal! Some children have foot problems that cannot be corrected by shoes and need custom orthotics. If your child is wearing appropriate shoes (not flip flops!) and is still having foot and leg pain, a visit to the podiatrist can be quite helpful.

How do I choose the right shoe?

Here are some useful tips for parents buying shoes for their children:

  • Take your child with you to go shopping. Do not rely on the size from their previous shoes! Every brand fits differently.
  • Go shopping in the late afternoon. Our feet swell during the day and especially in the summer.
  • Try shoes on with socks that will be worn with the shoes.
  • Stand-up to tie laces and check width.
  • Check length from the longest toe – not always the big toe.
  • Never buy a shoe for a child to ‘grow into’.
  • Ensure the shoe is flexible at the ball of the foot.
  • Never wear hand-me-down shoes – they are worn in to someone else’s shape and can cause problems.
  • Try both shoes on – very few people have two feet with the same width and length. Buy shoes for the larger foot.
  • Never buy shoes that aren’t comfortable right away! You should not have to “break in” properly fitting shoes.
  • Perhaps the most important advice for parents is to visit a reputable shoe store where sales assistants are trained in correctly fitting shoes.

How long should the shoes last?

Children grow at different speeds and wear shoes down at different rates. But there are some important things to do once you have selected the right shoe.

First, ensure you check the fit regularly. Children’s feet grow quickly and, since shoes up to two sizes too small may not cause a lot of discomfort for the child, you may not even be aware a new pair is needed. Kids tend not to complain unless their foot feels like it is squished!

It is also important to regularly check the shoe for wear. Shoes that are worn down badly can cause as many problems to a child’s feet as improperly fitting shoes. Excessive abnormal wearing of the shoe may indicate a foot deformity that should be evaluated by your podiatrist.

Bottom line: fit your child for proper shoes before summer play. Barefoot and traditional flip flop sandals can actually increase their chance of foot and ankle over-use injuries. A good, fashionable, and ergonomic alternative to sandals are Crocs and most kids will wear them!

Does Running Cause Arthritis?

Is it a foregone conclusion, that if you run for years, you will have arthritis? Many of my patients are concerned that the aches and pains that are inevitable from distance running are actually harbingers for the future aches and pains of arthritis. This fear is even strong enough to get older runners to quit and start a lower impact exercise regimen like swimming and cycling. Is this a reasonable fear? Yes and No! Running by itself does not cause arthritis; improper biomechanics coupled with the rigors of running can cause arthritis.

Consider the stress of running on the joints for a minute. The foot hits the ground and the bones and joints experience force up to six times the runner’s body weight at impact. The joints are being asked to move and glide efficiently and smoothly while enduring this stress. In the event of a misstep or stumble, the joints need to continue to be stable to maintain their perfect alignment.

Osteoarthritis, a.k.a. “wear and tear arthritis”, is what runner’s dread. This is degeneration of the articular cartilage which absorbs shock, distributes stress and allows the joints to glide smoothly. The ability to run pain free depends on the health and integrity of this cartilage as we age. In osteoarthritis, the surface of the cartilage becomes roughened, fissured and even starts to shred into small fragments. These fragments “float” around the joint and cause more damage. The bone tries to protect itself by producing small bony prominences called osteophytes which actually in the end make the joint damage and pain worse.

Any kind of sports participation can increase the incidence of osteoarthritis due to increased twisting forces, high impact, muscle weakness or over-development and joint instability which causes abnormal peak pressures and greater stress in certain areas of cartilage which can lead to osteoarthritis. Nevertheless, for normal joints , there is no scientific evidence that simply the action of running, even over a long period of time, causes permanent joint damage or even a predisposition for osteoarthritis.

What is the risk of osteoarthritis in runners? Many studies of long-term runners show no increased incidence of osteoarthritis in these competitive runners. Some studies did show more evidence of osteophytes, but no correlation with joint pain or instability. Confusing the issue for many runners are the numerous incidents of misdiagnosis of repetitive stress injuries like patella-femoral syndrome as arthritis. This is reversible and caused by abnormal tracking of the kneecap, which is treated with physical therapy and orthotics.

Joints are in fact strengthened by activity and damaged by inactivity. Studies have shown that the articular cartilage actually thins and becomes more fragile with inactivity, therefore increasing the risk of arthritis. Joints adapt to the stress of exercise and become stronger and more able to endure the long term stress of running. Remember the doctor saying to increase slowly? This is why. Ligaments and muscles, which support the joints, are strengthened and reinforced by the stresses of the running activity, improving joint mechanics, if the joints are properly aligned.

Here is the truth about foot biomechanics. Proper biomechanics during the strengthening process is essential for joint health. Improper biomechanics can increase the stress on the joints in an abnormal fashion and actually increase the incidence of osteoarthritis and hasten joint damage.

Bottom line? Running does not increase the incidence of osteoarthritis unless the lower extremity biomechanics are faulty. In fact, almost 75% of Americans over the age of 65 experience some symptoms of osteoarthritis. This is not increased in runners. In fact, running may actually help with the symptoms of osteoarthritis.

The benefits associated with long distance running profoundly overshadow the risk of osteoarthritis. In runners, orthotic devices to correct their biomechanics early in their training may actually decrease the stress associated with increased osteoarthritis. If you have joint symptoms, see a sports medicine podiatrist today and have your gait realigned. Your joints will thank you. Remember, your feet are meant to carry you for a lifetime. Don’t let the fear of osteoarthritis rob you of the joy of a lifetime of distance running!

All About Bunions

Hallux Abducto Valgus, better known as “Bunions”, is a condition where the big toe is pointing away from the mid-line of the body towards the second toe.  As a result, there is a boney bump right on the inside of the foot, where the big toe attaches to the rest of the foot. Truly this is not extra bone, but a subluxation of the joint.

A bunion can become irritable when the bump rubs against a shoe.  This prominence usually becomes red and, at time, swollen, which in turn can cause increased pain.  There may even come a point where the bunion is chronically painful.  Any shoe at that point can be a constant irritant.

Because the toe is deviated in the wrong direction, the joint itself moves out of alignment.  When this happens, there are areas of increased pressure in the joint which causes the cartilage to wear down over time. 

When enough of the cartilage has worn down, the joint becomes arthritic.  It is at this stage when the bunion becomes painful not only at the bump, but inside the joint as well.

Causes of a bunion are debatable.  Most doctors agree that this condition is congenital for the most part and biomechanically induced.  This means that you were born with the foot type to develop a bunion and the way your particular foot moves when it walks can speed up the formation of the bunion.

There are cases where a bunion can be accelerated in its formation by the types of shoes worn.  Any shoe that has a point at the toe, a higher heel or one that is very tapered at the toes, can worsen a bunion and its symptoms.

Diagnosing a bunion and its severity requires a detailed exam which includes x-rays.  X-ray images of the foot are important because your doctor will be able to tell just how far along your bunion has progressed.  The joint can be properly accessed.  Any irregularity in the joint, (where the surface of the bones on each sides of the joint look uneven), is a sign that arthritic changes are taking place.  The joint itself may still be asymptomatic at this stage.   Joints are also expected to have a certain degree of space with in them.  If the joint appears narrow and there is very little space between the bones, arthritis may be getting to a point where it is noticeably painful.  Your doctor will take into account your pain, the severity of the bunion and activity limitations when deciding on how to treat your condition. 

For those bunions where the pain is very occasional, usually caused by inappropriate shoes, recommendations are made for wider, more accommodative shoe and padding the area on a more regular basis.  There are cases where the pain is not daily by any means, but is occurring more often and more consistent.  In other instances, a new activity such as a new exercise program, a new job, or a recent trip can cause pain to a previously non-painful bunion.  There are also cases where a change in shoes is not possible because of certain work environments.  In those situations, a cortisone injection may help to reduce the inflammation that occurs in and around the joint.  Oral anti-inflammatories and icing and resting the area can help as well.  Physical therapy is another good modality using ultrasound to penetrate the joint reduce the tenderness.  Splinting the big toe is yet another option to calm down the symptoms. 

Those conservative treatment options may help to address the painful symptoms of a bunion, but none of those treatments will make the bunion go away.  Bunions are a structural condition, meaning the change is in the skeletal location of the bone itself.  The only way to make a bunion “go away” is to change the shape of the bone by surgically moving it back in its place.  This is very effective!

What about slowing down the progression of a bunion to avoid having to have surgery? 

If your bunion is only a slight annoyance, it can be controlled to a certain extent by placing your feet in a better position.  Better positioning is accomplished through the use of an orthotic.  An orthotic is a custom insert that goes into a shoe and helps to properly align your feet.  The stresses and strains that occur are more evenly distributed across the entire foot with regular orthotic use.  This proper alignment can actually slow down the formation of a bunion to where it may not worsen beyond where it is now.

Discussing these options with your doctor will help give you piece of mind that you are making the best decision for your feet right now and for their future.

Posterior Tibial Tendon Dysfunction (Adult-Acquired Flat Foot)

Noticed that your foot is getting flatter and more painful? Do you have difficulty walking or performing exercise activity without leg and arch pain? Have you heard the term “fallen arches”? All of these things refer to a condition known as posterior tibial tendon dysfunction. This is an inflammation and overuse syndrome of one of the long tendons that pass from the leg around the inside of the ankle and attaches to the inside arch of the foot. The posterior tibial tendon’s job is to help support the arch and allow for more efficient gait.

PTTD is most commonly seen in adults and referred to as “adult acquired flatfoot”. Symptoms include pain and swelling along the inside arch and ankle, loss of the arch height and an outward sway of the foot. If not treated early, the condition progresses to increased flattening of the arch, increased inward roll of the ankle and deterioration of the posterior tibial tendon. Often, with end stage complications, severe arthritis may develop.

How does all this happen? In the majority of cases, it is overuse of the posterior tibial tendon that causes PTTD. And it is your inherited foot type that may cause a higher possibility that you will develop this condition.

Non-surgical treatment includes rest and reducing your activity until the pain improves. Orthotics or bracing help support the tendon to reduce its pull along the arch, thus reducing pain. In moderate to severe cases, a below knee cast or walking boot may be needed to allow the tendon to rest completely and heal. Physical therapy is an integral part of the non-surgical treatment regimen to reduce inflammation and pain. Anti-inflammatory medication is often used as well. Many times evaluation of your current shoes is necessary to ensure you are wearing appropriate shoe gear to prevent re-injury.

For those patients with PTTD that have severe deformity or have not improved with conservative treatments, surgery may be necessary to return them to daily activity. Surgery for PTTD may include repair of the diseased tendon and possible tendon transfer to a nearby healthy tendon, surgery on the surrounding bones or joints to prevent biomechanical abnormalities that may be a contributing factor or both.

Posterior Tibial Tendonitis

Many people have begun a vigorous exercise program to start their New Year’s resolution of losing weight and getting in shape. But with this, comes unexpected pain that stops the workout sessions and ultimately prevents them from fulfilling their goal. Most often this is due to “too much, too soon, too fast” syndrome.

Pain along the inside of the ankle that extends to the inside arch is often due to strain of the posterior tibial tendon. The main job of this tendon is to prevent overpronation of the foot and stabilize the arch and ankle. Overuse of this tendon, particularly in people with flat feet, causes the tendon to swell and become painful so that exercise activity is not possible. Ultimately, this type of injury can lead to tear of the tendon and possible surgery. The pain is often sharp, stabbing and radiates along the course of the tendon. Often the entire ankle will be swollen.

Treatment for this begins with rest. This doesn’t mean you have to stop exercising, but no weight bearing exercise until the pain subsides. Ice daily and apply compression to reduce swelling. When pain is gone, then gradual return to an exercise program with appropriate shoes and brace as needed.

A complete lower extremity exam will help determine what types of shoes are best for your workouts and what type of inserts can prevent recurrence of the pain. Often with flat feet, custom orthotics are the best devices that support the ankle and arch and prevent overpronation, thus reducing the likelihood that the pain will return.

If left untreated, posterior tibial tendonitis leads to tear of the tendon (a.k.a. Adult-onset flat foot) and often extensive foot and ankle surgery. It is best to treat this pain as early as possible.