Symptomatic Hallucal Interphalangeal Sesamoid Bones Successfully Treated with Ultrasound-guided Injection - A Case Report -
A 29-year-old woman presenting with lower-extremity pain and walking difficulties was referred by the department of neuropsychiatry to our clinic. Her pain, which was in the toes, was described as continuous, throbbing, crushing, and burning, and its intensity was registered as 8 on the 11-point Numeric Rating Scale (NRS). At night, her pain was severe enough to wake her frequently.\nAccording to her medical history, these symptoms had arisen 9 months previously (3 months postpartum) and were accompanied by postpartum depression. Orthopedic, neurologic, rheumatologic, and endocrinologic examinations had been unable to reveal the cause of her pain. Eventually, she had been referred to a psychiatrist for a somatoform disorder and then admitted to the psychiatric ward. At the hospital, she had been treated for painful legs and moving toes (PLMT) syndrome, but the symptoms had persisted. As time passed, her depression had steadily worsened. The patient had then been scheduled for consultation with a pain specialist.\nAs a last resort, she visited our clinic. We reevaluated her problem, taking special note of the directionality of her pain, which originated at the great toes and extended to her calves (). On physical examination, there was tenderness at the base of the great toes bilaterally, and this tenderness increased, becoming pain, particularly during dorsiflexion. On the basis of an ultrasonographic foot evaluation, we found sesamoid bones on each interphalangeal joint of the hallux under the flexor hallucis longus tendon (), which had been overlooked on plain radiographs ().\nFurthermore, in a dynamic examination involving the application of a USG probe and passive extension and flexion of the hallux, we were able to diagnose the influence of symptomatic interphalangeal sesamoids on the flexor hallucis longus tendon. The patient was treated through an ultrasound-guided injection of 1 ml of 0.125% levobupivacaine (Chirocaine®, Abbott, Elverum, Norway) mixed with 10 mg of triamcinolone acetonide between the sesamoid bone and flexor hallucis longus tendon at each site. The patient's pain immediately subsided.\nThe following day, the patient reported no pain and, with her doctor's permission, went shopping. Subsequently, she was discharged in a state of complete remission. From that day to the present, her depression has also greatly improved.