Sesamoid Fracture with signs of Healing!!!!

Hi Dr Blake,

I wanted to respond to you and your readers with a hopeful update. Since I emailed you, I have had very successful healing that I’m sure will only continue to improve.

Dr Blake's comment: I have attached the original post that was sent and answered. 

http://www.drblakeshealingsole.com/2017/09/sesamoid-injury-email-advice.html

Per your advice, I began using a dancer’s pad (Dr Jill’s Sesamoid Gel Pads from Amazon) daily, icing my foot twice a day for 10 min, and contrast bathing with super elevation. After only a couple weeks I began to feel tremendous improvement.

I have begun walking in tennis shoes around the neighborhood to continue weight-bearing and re-teaching my foot how to walk again. Every week I am improving. I have not used the boot much at all in the past two weeks and instead use tennis shoes with the dancer’s pad. I can’t believe how much better I am feeling. I’m about 95% pain-free and continue to gradually increase the range of motion in my big toe.

The swelling is down - though not all the way gone - and I had my third visit to the podiatrist last week. She reviewed my newest X-Ray and said it looks like a “fibrous union” of the sesamoid bone has occurred/is occurring. I told her what I had been doing and she said to keep it up. 

It’s only been 2+ months since the initial injury and I feel I am well on the way to healing completely. (I don’t want to jinx myself, but want to give everyone a little hope if they need it!)

Thanks to you for this blog and all the tips. I’ll continue them and can’t wait to keep improving.

Thank you!

Talar Injury in Tennis: Email Advice

The dark area above sensor is injured part of talus extending into tibia above

Dr Blake,

I want to check in with you to confirm diagnosis and treatment you gave me this week.  Again I sincerely thank you for taking your time and listening which is something I normally do not see from health professionals.  Also, thank you for actually looking at the MRI which strangely most Doctors (except Dr Loosli) did not attempt.



Diagnosis:  Talus stress fracture

Dr Blake's comment: Yes, that is my diagnosis. Acute ankle pain, out of the ordinary on 6/27/17, which has hobbled you ever since. It is easy to focus on the wear and tear arthritis in your ankle, but something different happened that day, that is normally a stress fracture due to the impact of tennis and the over pronation of the ankle. 

Please confirm this diagnosis.  This is all makes sense now after researching normal symptoms.  Obviously 37 years of USTA competitive tennis and hiking Mt Diablo contributed to overuse.  This all started with a major ankle injury in 1963 playing basketball (stepping on top of players foot) in High School.  I have injured this ankle many times over the years, most significant 2009, and I only made stress fracture worse by playing on it for the last year or two.  I completely stopped playing tennis 6/27/17 and since then have only walked on a flat surface up to 45 min.  I have re-injured since 6/27/17  a total of 7 times due to things like gardening, using a ladder to install lights, light hiking, etc.  Right now it feels strong and I walk every day 45 min with no pain or discomfort.

Treatment:

1) ice 2x daily for 15 minutes with reusable gel ice pack,
2) alternating heat 4 min and ice 1 min, each evening, 
3) wear heel 1/2 inch inserts in shoes,

Dr Blake's comment: The ankle has the most pressure internally, exactly where his fracture is, when his ankle is at a right angle or bent forward (as in a squat). The heel lifts are to keep him slightly plantarflexed at the ankle not to crowd the joint. 
4) bone stimulator to increase healing twice daily, and 
5) continue walking flat surface using wrap around brace.

Please confirm above treatment or add or edit.  You told me it will take at least 1 year to heal and to monitor with another MRI in January 2018 and 6 mo later. 

Dr Blake's comment: Another MRI in January will tell us if you are healing, and by approximately how much. This will be 6 months from your first MRI. Each month you do more activity to test how it is doing. So, think about what you will add in November, and then in December, and then in January. We want to slowly stress the area and see how it responds. 

 You also suggested I take bone density test (scheduled tomorrow) and get you copy.  You also suggested I look at Vit D level and I believe calcium level.  I know Vit D level is good (47 Ng/mL).  Calcium 9.2 mg/mL on 9/20/17.
Dr Blake's comment: I know Vit D is 32-80  normal range, and calcium is below 10.1 over 40 years old. Which we both are!!

Questions:

1) Is there a way to speed up significantly the healing process?  For example, wear a boot or plaster cast for several weeks, then rehab?

Dr Blake's comment: Time, not irritating the tissue, bone stimulation, contrast baths for a deep flush, various braces and/or orthotics, and then a gradually ankle strengthening program. Immobilization always weakens the bones, so we need to create that 0-2 pain level and slowly increase function. 
2) What was your source(s) of diagnosis?  I believe you based on my symptoms and MRI.

Dr Blake's comment: The MRI can be read as stress reaction, stress fracture, bone bruising, arthritic changes, but the acuteness of pain on that one day is diagnostic for a fracture until proven otherwise. And, good medicine dictates that you need to treat the worse case scenario (in your case a stress fracture that could lead to a full fracture and major disability).  
3) Can special heel inserts be made for my shoes?  Can you do this?  Or perhaps another specialist you can refer?  I have seen Dr Jason Hiatt in Walnut Creek and 2 other Podiatrists.

Dr Blake's comment: The biomechanical change is simple, and most podiatrists, shoe repair cobblers, and running stores to give or make them. It is up to you to tell us if they help. 
4) Is my walking every day prolonging the healing process?  Should I just stop all weight-bearing exercises?

Dr Blake's comment: We have to create the 0-2 pain level, and or course, stop when the pain comes on with activity. Or, have the brace ready to put on. 
5) After my ankle heals, am I risking injury again by playing tennis?

Dr Blake's comment: So much depends on bone density, how hard you play, if you play with orthotics and a brace, etc. Let us see in 4 months how volleying leisurely feels with your wife or tennis partner first and go from there. Hope this helps Rich
Thank you for everything and you are the best!

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Painful Flat Feet: Email Advice

Thanks so much for your blog--I've learned a lot.

I'm a 60-year-old, 5' 8" guy.  I have had overpronation and "flattish" feet--if not exactly flat feet--all my life. Both my feet have problems, the right foot being worse.  (My right leg is a little longer and the right foot is more overpronated than the left.)  I have tried orthotics, but the only one that I liked is the "Dr Roberts Orthotics," which was discontinued 25 years ago.  (It corrected the overpronation by re-aligning the gait by putting pressure just behind the arch on the outside of the foot.)  If I had been able to wear these orthotics for the past 15 years, I might not be having these foot problems.

Seven years ago, I went for a series of day-long hikes and injured my feet.  I weighed 250 pounds back then; I'm under 220 now. Both my ankles were swollen at the end of the day.  

Now, seven years later, my right foot still hurts after I start walking a bit.  The throbbing pain is below the ankle on the inside and across the flat of the foot.  At first, an orthopedist thought that I had partially torn the post tibial tendon. He gave me a diagnosis of PTTD/flatfoot and thought that surgery would be required.  But the MRI shows that the tendon is "intact."   There is "mild tenosynovitis" of that tendon and others, as well as some beginning arthritis in the foot.   I'm attaching the radiologist's report and the X-rays in the following email.

My left foot isn't as bad but has pain in the ball of the foot. I suppose it could be the post-tib tendon here too.  I don't have any imaging of this foot.

Walking is one of my favorite activities, but long walks are no longer possible with the pain I experience from both feet.  I have tried physical therapy at a local place but didn't gain much benefit from that.  I also tried three rounds of shock-wave therapy for the sore tendon (in Canada) but didn't notice any improvement.  In addition to a few physical therapists, I have also seen: one podiatrist, a chiropractor, an acupuncturist, a chiropodist (in Canada) and a naturopath for my feet.  (The only thing that really helped me was a supplement from the naturopath, Ligaplex II by Standard Process.  This contains VERY high amounts of manganese, so I'm not sure how suitable it would be for general use.)  

From reading your blog, it seems that I need better orthotics and appropriate physical therapy to strengthen the tendon.  I'm in the Raleigh-Durham area of North Carolina and am not sure where to turn.  It's not difficult for me to get orthotics made (again) or find a physical therapist (again), but it's hard for me to know whether I chose the right people.  Is it possible that you know someone in my area who could help me?  Or perhaps it would be better to get the proper orthotics and do the tendon strengthening exercises that you've posted about?

Thanks!

Dr Blake's comment: Thank you so very much for emailing. Please first look for Dr Doug Milch in the North Carolina area. Also, contact the Root Functional Orthotic Laboratory and Richey and Company and see if these labs can give you recommendations of places and doctors that will design the Inverted Orthotic Technique for flat feet. 
     You have to make your feet better for the next 30 year stretch of life. That program should include foot strengthening, orthotics, taping at times, soft tissue work, flexibility work, and stable shoes when your activity demands. This is the program you need to work on the next year. The MRI and X-rays show nothing that serious, although minor things can be a bigger problem at times. Good luck. Rich

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Sesamoid Fracture: Email Advice

     Hello, I have been reading through all of your blogs looking for all wisdom you have shared regarding sesamoid fractures. 

     I am a 53-year-old male in good physical condition(ran 3 times a week prior to the accident and continue to lift though only upper body now). On June 19th of this year, I fractured my right tibial sesamoid when I jumped from a lift at work. The fracture was initially misdiagnosed as a normal bi-partite bone so no conservative treatment was administered. It was very painful and swollen bottom, top and side of the foot.

     On Aug 3 was released from care by the "work care' Dr. and told that the swelling and pain was most likely gout.  On Aug 30 after a very painful flare-up went to urgent care center suspecting gout. Uric acid test, as well as fluids drawn from toe joint, showed no sign of gout.

     Saw a podiatrist on Aug 31 who took another x ray of the foot as well as an x-ray of the left foot for comparison and she confirmed the fracture. Was placed in an air cast rocker boot and told to restrict activities. Had another x-ray on Sept 30 (at the four-week point in boot cast) Podiatrist said she saw little if any healing.   
Dr Blake's comment: During the initial stage, if though gout was misdiagnosed, were you able to get fairly pain free for healing? X-rays are very poor to follow the progress of sesamoid, or any bone, fractures. 

    Started using a bone stimulator (first a borrowed Orthofix for a week, then for the last week I have used an exogen 4000 each day. Had a cat scan on Oct 11 that notes say bone is in the healing stage. Saw my podiatrist on Oct 14. She said upon examining the cat scan the two fragments were healing and would continue to do so but they would not fuse back together but that was fine it shouldn't be a problem. After all, many people naturally have bi-partite sesamoids. 
Dr Blake's comment: We see a ton of sesamoid injuries, most have healed enough that the patients are back to full activity with initially some protection of orthotics, dancer's padding, cluffy wedges, and spica taping. If we forced all of these patients to x-ray, even when clinically they have had a full recovery, the x-rays or CT scan would only show partial healing. It is the internal strength of the healing fracture that matters, and of course, some probably develop a non-painful non-union. This is why I like MRIs to follow sesamoid injuries. MRIs tell the amount of bone healing, and comparisons say 6 months apart, can really give us an idea how the healing is going. I get CT scans when I am worried about avascular necrosis or first metatarsal bone problems. 

    From the countless blogs and articles I have read this doesn't sound like the optimistic report that she is giving me. Can a non-union fractured sesamoid continue to function properly? 
Dr Blake's comment: Very individual. You would assume that the higher level of activity an athlete does, the less chance that would be comfortable. There are too many ifs, ands, and buts in your case. Get an MRI soon, and be ready to get another one 6 months from then to check on healing. The MRI is so sensitive to how sensitive the bone is now by the bone edema noted. Unfortunately sesamoid bones, since weight bearing, can be very sore, even when technically healed, due to nerve hypersensitivity, inflammation in the bone as in presses against the ground or first metatarsal, and from mechanical pulling of the tendons, the bending of the toe, the foot pronation force,etc. They can be so easy to teach, and then some are very challenging. 
     I currently don't have pain in my sesamoid area. I am however still in the walking cast boot. In addition I have a pre-existing bunion on this foot that has never presented any symptoms prior but now seems to become red, swollen and very tender a few times a week. When it does this there is also pain in big toe joint when moved. I am committed to using the bone stimulator for as long as necessary, do contrast baths once a day, ice once or twice daily. I also take calcium, a multi vitamin and vitamin D. I have attached a copy of the CAT scan report. I also have disk with images of all x-rays and the CAT scan in my possession. Any advice is greatly appreciated and much needed.Thank you very much for reading this.
Dr Blake's comment: You have a great attitude since you want to keep that sesamoid. Please get the MRI (do not need contrast dyes), and then send the discs and I will be happy to review. Good luck. Rich The CT Report sent:

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Sesamoid Injury in a Young Athlete: Email Advice

Hi Dr Blake –

I wanted to thank you so much for all the information on your amazing blog – it has been such an incredible resource as I have been trying to help my 13-year-old daughter (gymnast and ballet dancer) with a sesamoid injury (stress response versus stress fracture). 

I was wondering if you would have time to provide some input on her case.  We live in Denver, but would be happy to arrange payment to you for your usual office fee for you to read through my email and provide a general response to some of my questions.   Or I would be happy to make a generous donation to support your blog J.  I would even consider flying out with my daughter for a visit if this is something you would suggest after reading my email.   I myself have had foot pain for 18 months  - probably hallux limitus after reading your blog – and could benefit from a visit as well!.   We have an HMO type plan so it would not be covered but would be happy to pay out of pocket.  I can also send x-ray and MRI images on disc if you think this would be helpful. 

Dr Blake's comment: Thank you for your kind words. Please email the disc to me at Dr Rich Blake 900 Hyde Street, San Francisco, CA, 94109. It is a free service so no money is expected. 

I have tried to inform myself as much as possible by reading your blog prior to emailing.  Also – if feel this may help others I am also happy to have you post this on your blog (perhaps minus my full name)

     13-year-old very active female PMH significant for Severs Disease on and off since age 8.    Competitive gymnast (3 hours, 5 days/wk, year round) ballet dancer (on pointe since age 11, usually 1.5 hrs/wk year round and up to 3 -4 hrs/wk  week when rehearsing for a show) and swimmer (2 month summer season only, stops dance during this time).  

     She first noticed some “big toe pain” during gymnastics competition season in the winter of 2017.  Very mild, mostly with vault. Was able to dance en pointe in a spring ballet show in June 2017 without significant pain.  

     In late June 2017 developed progressive pain in balls of both feet while vaulting and doing vaulting drills (sprinting down the minimally padded vault runway in bare feet with ankle weights).   The pain was up to a 6-7 when vaulting, but had minimal pain on other events and only intermittent mild pain when not at the gym (though noticed pain with flip turns at swimming).  Did not dance at all during this time as she said she was sure pointe would hurt.  After a few weeks, she stopped vaulting/running but now had pain on other events at the gym, especially when going into releve on beam (high toe).  In mid-July took a week off gymnastics to see if the pain would resolve but continued to swim and started PT (massage, ROM, ultrasound).  The pain was mild and intermittent mainly just with flip turns at swimming but PT found a very tender spot on the ball of the right foot so I took her to see pediatric sports medicine specialist in late July 2017. 

Here a separate on the tibial sesamoid is noted. Bipartite? Fractured?

You can tell by the smoothness of the separation of pieces probably bipartite. However, you can fracture the loose junction of material between sesamoid pieces in a bipartite sesamoid. 

The right side also has this smoothness between the parts of the tibial or medial sesamoid. 

     On exam, she was tender over her medial sesamoids in both feet.    Bilateral foot Xrays read as “no foot fracture or dislocation visualized” (x-ray of the left attached below my signature, I cannot access images of the one of the right or the MRI but I have them on disc) but the sports medicine doctor noted she had bipartite medial sesamoids in both feet. He diagnosed her with sesamoiditis versus stress response and suggested bilateral walking boots or casts for 2-4 weeks.  We chose to start with the walking boot as we leaving for vacation that day.   I requested an MRI to try to differentiate between sesamoiditis and stress fracture which showed the following:

Dr Blake's comment: With the symptoms she had, and the bipartite nature, you have to put her on fracture protocol (treat the worse case scenario). Typically this is 3 months of restriction of toe bend and off-weighting plantarly. More later. 

     7/28/17 MRI right foot:  The medial bipartite sesamoid at the first metatarsophalangeal joint has abnormal signal and abnormal adjacent medial collateral ligament and superficial plantar soft tissue. In comparison with the medial bipartite sesamoid of the left foot in the same location, the appearance is asymmetric. The distraction of the fragments with edema and abnormal adjacent medial collateral ligament appearance is more concerning for the potential of fracture/chronic distraction stress injury upon the fragments rather than simply sesamoiditis.

Dr Blake's comment: What side is worse? I am confused since they are talking about the right foot, but then the left sesamoid? 

     7/28/17 MRI left foot:  Bipartite medial sesamoid at the left great toe with mild marrow edema representing sesamoiditis versus stress reaction.  No definite fracture line visible.
Dr Blake's comment: If I am reading this correct, the right is the worse by far. Is that the way it is clinically? 

     She wore bilateral boots for 1 week while we're on vacation with a reduction in pain.  Based on the MRI report he said he did not see fracture line to suggest stress fracture but that the bone was very inflamed and he suggested bilateral walking casts as the quickest way to get this to resolve.  The expectation was that this would give her the fastest healing and allow her to return to her activities ASAP. 

Dr Blake's comment: This is a doctor who wants her better, has compassion, but most sesamoid patients should be told 6 months from the get-go, and if it goes faster, great. This time frame is hard for docs to do. Even yours truly!!

    Bilateral permanent casts were placed when we got home from vacation on 8/2/17.  She had difficulty walking in the casts as they were up to her knees and had to use crutches and swing her feet so I would say she was also partially non-weight bearing during this time.  She remained in the casts for 2 weeks on the left and about 3.5 weeks on the right.  She had a lot of heel pain in the casts which were attributed to her Severs but her sesamoid pain seemed to decrease and perhaps even resolve completely during this time.  She wore a Hoka One One shoe (Bondi 5) on the left until the cast on the right came off and then wore the Hokas on both feet.   She continued to do upper body conditioning at the gym but no impact other than walking while in casts.

Dr Blake's comment: One of the reasons I hate permanent casts is that you can not really work on the inflammatory pain or the neuropathic pain which develops. You need to be icing, contrast baths, pain-free massaging, even pain-free PT at times. The casts ruin that option. Not to say it was not the right thing to do that this time. 

     After she came out of the casts she had severe heel pain on both sides attributed to a Severs flare.  It was so bad there was a concern about CRPS as she had some color changes and a bit of swelling around the Achilles insertion on the right but that seemed to resolve with ice, stretching and PT.  (After reading your blog I now realize the importance of making sure she was in a “pain-free environment” in regards to her sesamoids while transitioning out of the cats into her Hokas, but I did not realize this at the time -  I thought the casting had treated the sesamoid issue). 

Dr Blake's comment: So happy it did not develop into CRPS. Casts are notorious for that. 

    For the next 2 weeks, she did a lot of PT –balancing, hip strengthening, foot strengthening.  She would complain of pain in the ball of her foot between her first and second toe, but her PT said her sesamoids were not tender to the exam so he was not worried about this pain and thought it was tendon pain related to casting/disuse.  

Dr Blake's comment: Why am I not hearing about dancer's pads, with and without, arch supports, to protect the sesamoids? This is crucial. Even as the sesamoid heals, it can be very sensitive, so protection, massage, anti-inflammatory is crucial. 

    After 2 weeks of PT (around mid-September), she progressed back to some light activities  (cartwheels, walkovers, light jumping, yoga) initially in Nike frees and then in bare feet but always on padded surfaces or trampoline.  I also let her wear shoes other than the hokas a few times for a few hours…   Initially, she did ok but gradually her pain in the ball of her foot increased and the  “sesamoid pain” on the lateral side of her big toe returned in both feet.   She stopped all activity, went back to wearing the Hokas full time but the pain persisted. 

Dr Blake's comment: You have to get back to square 1 with the Immobilization Phase. Back into the removable boots to calm things down quickly. Up the anti-inflammation measures, and add the massage for the nerves.  

     We went back to the sports medicine doctor on 10/1/17.  We were told that this is a very difficult injury to heal and many kids have to give up their sport because of this injury.  He advised backing off on activity for several weeks to give it more time to heal but no other specific therapy.  He did not want to put her back in the boot because of how difficult a time she had coming out of the casts.  We left the visit under the impression that she would never dance or do gymnastics at a competitive level again.  It was a rough day and she was very sad and frustrated.

Dr Blake's comment: But, does not make hearing the news better, but you know better. The length of immobilization to create the healing environment needs to be longer. Hopefully, some healing has occurred, but this rush to get her well attitude is actually slowing her down. If she would be in my office now, back in the boot, design inserts to off weight, start more anti-inflammatory, plan on re-MRI in 3 months (but I have not seen the first one). 

     We sought a second opinion from an adult foot and ankle orthopaedic surgeon on 10/2/17.  He reviewed her MRIs and history.  On exam, he felt her medial sesamoids were tender but not exquisitely so (3-4/10 pain with pretty deep palpation).  He obtained additional foot x-rays (single view) which are attached below my signature and were read as follows:  

10/2/17 XRAY Left foot: Single sesamoid view demonstrates normal medial and lateral sesamoids with normal articulation between the sesamoids and the metatarsal head.  Soft tissues are unremarkable.

10?2/17 Xray Right foot: Single sesamoid view demonstrates subtle irregularity at the deep margin of the medial sesamoid without joint abnormality.  The lateral sesamoid is normal.

      He felt we had not given the sesamoids adequate time to heal and suggested 6 more weeks of no gymnastics/dance.  He also thought that some of her ball of foot pain in the middle of her forefoot  may be from atrophy/disuse after being in the casts and not doing enough PT (though I thought she had done a fair amount of PT…) He wanted her to continue wearing the Hokas and obtain a custom orthotic to “float the sesamoid”.  He also ordered an Exogen bone stimulator and suggested calcium and vitamin D supplements  (vitamin D level was normal).  He also wanted her to continue PT for hip, core, foot and ankle strengthening.   Currently, she says she is probably at a 3 in regards to her pain which is in both feet and mostly in the middle of her forefoot between her 1^st and second toe  - rather than more medially over where I think it would be from the medial sesamoid.  She also says she notices it when she is at rest as well as when standing/walking.  After reading your blog, we are also going to start contrast baths and try spica taping her big toe and dancers pads to get her pain down until we receive the custom orthotics.   

Dr Blake's comment: This doctor could be my brother. Same thought process!! Create the 0-2 pain level with whatever it takes, and gradually add one activity at 70% force at a time (typically every two weeks you make a change). 

I have several questions I was hoping you could provide guidance on:

1)      At this point, can she continue in the Hokas or would she get better healing in bilateral walking boots?  (I am worried about the boot causing heel pain and muscle atrophy…)

Dr Blake's comment: She should be in whatever enables 0-2 pain for her present school and home activities. The Severs should have an insert like the red Sole which can go into the boot or Hokas. It may even need a gel heel cup on top of. 

2)      I am trying to understand her injury/imaging.   It sounds like sesamoiditis/stress response in the left medial sesamoid but more like a stress fracture (or at the least severe stress response) in the right medial sesamoid?  (Though the sports medicine doctor and orthopedist say they do not see a stress fracture on the right on the MRI…)

Dr Blake's comment: I would interpret a bone bruise left sesamoid and stress fracture right, but I know you are sending me the MRIs. Definitely, the right sounds worse, and will probably need more overall protection and take longer to heal. 

3)      How can you tell the difference between a bipartite medial sesamoid with a stress reaction/stress fracture versus an overtly fractured sesamoid (i.e. that was not bipartite before the injury)? This seems to be an important distinction for treatment duration and prognosis (let me know if you would like me to send her MRI).  If it helps, I have a bipartite medial sesamoid in both my feet on x-ray/MRI

Dr Blake's comment: First of all, bipartite sesamoids can get injuries like stress fractures. The x-rays look like normal bipartite sesamoids, so it is the MRI that is crucial. Again, you have to treat the worse case scenario until you get an MRI, assuming the symptoms warrant that (and she was totally disabled for what she wanted to do), and treat it as a stress fracture within the bipartite. I think bipartite sesamoids are more prone to injury than solid sesamoids, and their injuries cause much more disagreement about what to do. The junction between the pieces of a bipartite sesamoid should be smoother edges than a fractured sesamoid that started out whole. 

4)      I recall seeing on your blog that a bipartite sesamoid can fracture within the connective tissue bridge and that this type of fracture does not heal.  Is this something we need to consider in her and if so what is the prognosis/long-term consequences of this?
Dr Blake's comment: The connection between the parts of a bipartite sesamoid can be fibrous, cartilaginous, or osseus. I was probably talking about a fibrous bridge that torn, like an ankle ligament. These may not heal, but do not generate bone reactions on the MRI. I do not think she has this. Typically this sprain of the tissue between the sesamoid pieces, if immobilized, have nowhere to go, and should scar in. 

5)      Are there benefits/potential risks of “Shock Wave” therapy  i.e. Extracorporeal Pulse Activation Treatment (EPAT) for this condition?  Our orthopedist thought it could help but after reading the one post on your blog about this I have some concerns…

Dr Blake's comment: The idea behind this is to break apart the scar tissue and fragile bone cells, that seems to be not healing, and sort of re-breaking the bone. So, you are starting again, and the 3 months of immobilization should begin again. It will break down unneeded scar tissue, that may be getting in the may, but is worth starting afresh? 

6)      How much PT should she be doing right now– she says that theraband foot strengthening exercise cause “soreness” in her big toes so should she avoid these for a while? 

Dr Blake's comment: She could easily be in therapy 2 days a week, even 3, to work on all the body parts that are deconditioning. Definitely, I am not a believer in pushing through pain so I would not do what hurts today for one month, and then retry. A good therapist can set benchmarks for you of what to do and not do, and make changes as things change and symptoms improve. I know children are less discerning about pain levels, but they definitely know 0, 5, 7, and 10 in general. You want no limping, and as close to 0 as you can. Sharp pain that last for 3 seconds then goes away is fine. 

7)      Do you think she could (with time) get back to a high level of gymnastics or dance? She has been out since July and is devastated and feels like she is getting behind and wants to get back to both ASAP.  I know from reading your blog we need to be patient and not put a timeline on this but for her planning, it may be helpful to have a sense of what a timeline for a 13-year-old might look like, especially as many of the recommendations on your blog pertain to adults.   She has Nutcracker performance in Mid December though her teacher is willing to significantly modify her choreography and allow her to do it on flat rather than pointe and  without jumps or leaps.  Her gymnastics season begins in January and goes through April. 

Dr Blake's comment: There is nothing in this injury that normally does not make full recovery with full activity. So, that is my expectations. You seem so very knowledgeable, which is so wonderful, and you are asking the right questions so I will pose one to you: Why do you think she hurt herself in the first place? The answer may shed some light into how to rehab this injury better, and also how to prevent future injuries. I have some ideas but want to hear your thoughts. If any of my readers are going through this, what comments can you leave that may help in the future. 

8)      Finally –Do you have thoughts as to which activity (dance versus gymnastics) would be less likely to cause re-injury?   Her sports medicine doctor suggested that she would have to pick one activity, that she could not continue to do both. Gymnastics seems to be associated with higher impact (especially vault) and this was likely the trigger for her injury.  However, at least there is some padding at gym… and she could wear a light gymnastics slipper with a dancers pad for vault.  With dance, everything is done on a wood floor and pointe work puts a lot of stress on the foot. She had a bone age done recently and her growth plates are still open so after reading your blog I have some concerns about her going back to en pointe form that perspective.  She is a good swimmer and I guess that would be an option but her heart is in gymnastics and dance…

Dr Blake's comment: This is a question in my mind for the short term. We modify to allow activity, in order not stress the sesamoids too much initially. Monthly you add another task as she survives the first. This is the best way to succeed, but it is also the best way to avoid giving up on something she loves. Unless we find out that her bone density is poor (a good idea now is to ask her doc how you should assess her bone strength), she should completely heal. It is October in San Francisco, so this has only been going on 3 months. Nothing really. I remember a patient of mine broke her ankle and did it heal slowly. Initially, the docs thought it was tendinitis, so one year went by before I saw her and got an MRI diagnosing the fracture. The delay forced her to miss her Junior and Senior years in college of gymnastics. Except, the only thing she could practice since she remained on the team was the parallel bars with no dismounts. For about one and one-half years she practised and practised, but never dismounted. She healed the break finally, could work 3 months on the dismounts and won the league finals in parallel bars. She helped her team to the Championship. And, she would admit, that was her worse event in her Freshman year. Circumstances forced her to adapt. You want the physical therapist, doctor, and coaches of these sports, to know what is going on, and gradually add more and more and more. That is the fun part. If she plateaus at some point, more decisions are to be made. 

9)      After reading her case, do you think it would be helpful to arrange an in-person consultation with you?  Or is there someone you would recommend in Denver that could help guide her rehab?

Dr Blake's comment: I know Dr William OHalloran in Denver. Let me look at the MRIs you are sending. Sounds like the doc is spot on, need an orthotic maker there, need a good physical therapist (the gymnastics center or dance people may know someone). Yes, you can come here, but I need a week to make orthotics, etc. I am happy whatever seems right. Good luck!

Thank you in advance from the bottom of my heart for any assistance or advice you can provide.  Scroll down for images below my signature. 

Warm regards,

The patient's mom responses:

Dear Dr Blake –

Thank you so very much for your detailed and thoughtful response in regards to my daughter on your blog.  You are so kind and compassionate and I wish I had come across your blog sooner.  The disc with her MRI's should arrive today. 

I have tried to answer the questions you posted below.  Please feel free to post this on the blog along with images from her MRI if you feel they are informative to the community or let me know if you would like me to post this in the comments on the original post.  (When I tried to post directly the bold font did not show up and I think it is helpful…).    

1)      You are correct that it was the right sesamoid that was worse initially - both clinically and on the MRI.  Although currently her pain is intermittent and seems to be more on the left then the right.  She had only a total of about 3 weeks immobilization on the left and 5 weeks on the right with the initial boot/casting in August – far short of the 3 months you feel is ideal for a sesamoid stress fracture.   As far as her current pain level with everyday activities I would say she is definitely not a 5, but not a zero either – probably a 2-3 when she has pain which is not all the time.  Overall, she is doing better in regards to pain over the past week since she has stopped activity and started wearing the Hokas full time.  Her Severs heel pain is gone.  Perhaps after you look at her MRI you can provide thoughts about whether the Hokas will provide enough immobilization for healing at this point or whether a boot would provide a better healing environment.  And whether we are back to square one in terms of 3 months of immobilization from now, or whether she can get any “credit” for the initial immobilization period. 

Dr Blake's comment: I reviewed the MRIs showing injury to both tibial sesamoids, right greater than left. The right also has some first metatarsal involvement, which will make unprotected weight-bearing uncomfortable for quite a while. I know you will create the 0-2 pain level, and Hokas are fine if we can keep her protected with orthotics and dancer's padding. See if the rest of October, with the Hokas, she can stay in the 0-2 pain level. We have to wait until Jan 25th, 2018 to repeat the MRI and see how things are going, before we really feel comfortable about the healing. That will be 6 months post first MRI. That does not mean she is not going to be progressing, with each month doing more than she did the month before. Is she riding a bike or swimming now?

2)      We started the Exogen bone stimulator 2 days ago.  Can the bone stimulator impact pain levels in people with sesamoid injuries?  After using it on her right foot only the first night she had no pain in the right foot the next day.  The next night she used it on both feet and it seemed to cause some discomfort on the left (but not on the right – which was the more injured bone, but also the one that was immobilized longer). 

Dr Blake's comment: Bone stim increases circulation, and swelling can hurt. So, like contrast baths daily, the bone stim may be giving a good flush to the tissue. 

3)      You also mention anti-inflammatory several times in your response – are you talking about NSAIDS or ice/contrast baths?  I would be interested in your thoughts on the role of NSAIDS in sesamoid injuries?  I have avoided giving them to her as I do not want to mask pain, or potentially impair bone healing. 

Dr Blake's comment: Ice/contrast baths. No NSAIDS in bone injuries. 

4)      We also saw an orthotist yesterday.  I have a pair of custom orthotics with an arch support and cutout under the first metatarsal to offload the sesamoid that I do not wear as they never helped me (my problem is not in my sesamoids).  However, I brought them to the visit and the orthotist said they fit my daughters arch/feet perfectly!  My daughter tried them in her Hokas but did not like the way they felt.  The orthotist took them out, and next tried a firm approx 1/8 inch thick pad about 3 inches long and 1 inch wide glued to the bottom of her Hoka insole to limit the movement of her big toe.  That seemed to be more comfortable so she said to try it for a few days and if it worked she could build a custom orthotic with arch support using this strategy.  Is this right time to obtain a custom orthotic? 

Dr Blake's comment: Yes, a lot of experimentation may be needed. It is important to note that dancer's pads off weight but allows motion. The type of insert you mentioned immobilizes the joint and works like a little cast for the toe. It is not to be used when the gait gets better and push-off improves. 

5)      As far as WHY she had this injury – my first instinct is that she has a bipartite sesamoid which you mention is more susceptible to injury coupled with doing sprints on the vault runway in bare feet with ankle weights which placed an incredibly high load on the sesamoid bones.  This may alone have been enough to cause the injury, but I do think her long history of Severs heel pain may have played a role as well in that 1) she learned to train through foot pain and 2) she may have learned to run, tumble, and land in a manner which placed less impact on her heel (to avoid pain) and thus more impact on her forefoot?  I am very interested in your thoughts on this, as well as any possible contribution from pointe work. 

Dr Blake's comment: That is fascinating and may be the reason she got both sides. Typically in landing with the vault in gymnastics, are you taught to stick it with both feet at the same time? 

If you only have time to answer a few questions you can focus on the first paragraph.  I have also tried to pose the questions in a way that would be helpful to the community as a whole rather focus solely on her specific case. J 

And once again, thank you for your knowledge and insight!!!

Another correspondence:

Thank you SO much, you are an angel for all the help and insight you have provided, it has given me hope that she will heal but also realistic expectations both about the time course and the importance of being patients as well as thinking about how to prevent re-injury. 

It seems that sesamoid injuries are so poorly understood my many. 

I will respond to your questions  in the comments on your blog – but yes, vault in women’s gymnastics  a two footed landing.  It also invokes about a 20 yard all out sprint in bare feet down  the vault runway (basically a carpeted wood platform with minimal padding) and a 2 footed punch off a springboard onto the vaulting table.   

Here is a video from you tube of what it looks like – the landing is usually pretty padded but the run and punch off the springboard is where I think a lot of the impact occurs.   

https://www.bing.com/videos/search?q=you+tube+usag+level+7+vault&view=detail&mid=60DCA3918BC5089AC94B60DCA3918BC5089AC94B&FORM=VIRE

Thanks so much!

Sesamoid Injury: Email Advice

Hi Dr Blake. 

I am from China. I am happy found your youtube video about how to treat the sesamoid fracture. I have this on-going pain on the joint of the hallux on my right foot.

https://youtu.be/8cwW2Bmcc0E

The story is, I hit my toe on a rock in 2015 Oct when jogging. It was extremely painful for 10 minutes and then the pain reduced a lot, I didn't do any treatment, and I kept dancing on high heels. 

A while later, I found the pain didn't go away, nor increase. I changed into flat shoes and reduce dancing, and keep massaging. 

However, it seems improved slowly yet, 2 months ago, the joint got swollen and burn, for 2 days, then it reduced again, and 2 weeks later, it happened again.

I took an X-ray,  the result says my bones are complete and fine.  Later on, I took CT (not sure if it is MRI) is says my sesamoid is the problem, the doctor says it is broken/inflamed, he said I need an operation to take that out. That sounds scary and the pain is on-going but not that huge, however, the operation is the only option the doctor gave me. 

I just wanna ask if you have any suggestion how can I treat the problem without going through an operation. 

You may take a look at the attached file for reference.

By the way, i

Very appreciate your time reading all this, I hope I can hear back from you soon. 

Best wishes. 

Dr Blake's comment: Thank you for sending the email and the images. The images look like the tibial sesamoid was injured, but it is healing fine. These bones bear a lot of weight and need protection. See if you can make a dancer's pad to off weight, and daily ice for 5 minutes twice a day. The dancer's pad we make is out of 1/8th adhesive felt so it can stick to shoes or inserts putting weight around the sore area. You need to create the 0-2 pain level, which is increased with just the above 2 treatments. Let me know how you are doing after one month of that. 

                                                                                      Dancer's Padding 

Turf Toe: Very Disabiling!!

Hi!  I found you through Youtube and have spent some time on your website.  The more I read, the more I realize I am in trouble.  I do not know if you still answer emails, but I thought I would send this.  I have nothing to lose, only to gain; right?
Dr Blake's comment: Hopefully, right?:)

So...  A year ago, I had a serious "Turf Toe" type injury, resulting in two fractures at the top-side of both joints of the big toe, one fracture, each.  I had ligament, tendon sprains, and nerve injury.  Eventually, it began developing into possible CRPS symptoms, which a physical therapist noted and got right on top of.  (I am very happy to report that those symptoms have been resolved.)
Dr Blake's comment: That therapist needs to be in your will, or at least a thank you!!

Because there was so much going on and pain and swelling everywhere, I didn't realize the pain under my foot was any different than the pain everywhere else, in the first couple months.  Through the entire year, except for wearing a boot for two weeks, around the clock, my instructions remained that I walk on it at home, with no boot (which, for me, meant barefoot, since I can't tolerate slippers or even a sock - nerve stuff) and only wearing the boot when I leave home.  

During this time, I have gradually turned into a shut-in.  Life as I knew it, stopped.  My job, gone.  As the months passed and pain, swelling, and inflammation persisted, I began asking about an MRI.  For months, my podiatrist kicked the can down the road, citing the expense for the insurance company.  Six months after the injury, he finally conceded.  The MRI showed that I also fractured both sesamoid bones.  And my resulting treatment?  IT REMAINS THE SAME!  Just keep on walking on it (booted only when I leave home, which is pretty much never)!  99% of my life is now lived banished to my recliner - but bootless, as instructed!!
Dr Blake's comment: One of the hardest things for docs in the short office visits we have is to fully understand the disability someone has! It is sad, and the patient gets into this predicament. Rehabilitation is a balance between pain and function. Sometimes we actually have to ignore some pain to increase function. It is also the role of cross training. Many patients can not walk but can build up to 2 hours a day on a stationary bike, and this can be emotionally and physically so healing. With a stationary bike, none of the weight has to go through those joints. 

A month and a half ago, I re-injured it while wearing the boot - toes being violently propelled over the top of the bootstrap, resulting in a fulcrum effect, at the base of the toes.  I fractured a new place in my low, big toe joint and the new MRI shows both sesamoid bones, still fractured.  

The doctor says he cannot tell if they are new fractures or old ones, that never healed.  My vote is the old ones never healed.  The pain and swelling never went away!  

And now...  I have de-mineralization (rated as moderate to severe) throughout my entire foot!!  I just saw a sports medicine podiatrist for a second opinion.  After seeing the two MRIs, he ordered a CAT scan, which I had done today.  He said, depending on the results, he may recommend removal of one or both sesamoids.  (He said recovery will only involve non-weight bearing on the front of my foot for 4 - 6 weeks, then I'll be good to go!  I suspected that wouldn't be enough, which I have learned from your site, is true.  Common sense!  But none of this last year falls under the category of common sense, for me.  Why not treat my fractures like fractures, instead of having me walking on them for a year??)
Dr Blake's comment: Please send the CT scan disc to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. It will be good to have a clear view of the injuries since my mental picture is getting foggy. I am from San Francisco known for our fog. 

At this point, I am at home, unbooted, with crutches - why not just use the boot, right?  I CANNOT walk bare-foot on the front of my foot, as instructed by the original doctor.  It seems like I will never be given the chance to let the bones heal through immobilization, because of the bone de-mineralization (that was NOT on the first x-rays/MRI, last March).  I would think that immobilizing, the way it should have been done, now, would make the state of my de-mineralized bones even worse.  If he recommends surgery, I will never know if my sesamoid bones COULD have healed, if given the chance.  This is so not right!
Dr Blake's comment: Docs are given mere thumbnail prints of your last year in one visit. This can make the correct decision clouded by the need for pain reduction and mobility so I can see why anyone with a heart would at least entertain the thought of surgery. 

Am I seeing this correctly?    

Then...  I followed a few sesamoidectomy video diaries on Youtube and the experiences of these poor people were awful!  Do I even want to do this to myself??  ONE AND TWO YEARS LATER, they were still giving updates about their continued pain and limitations!!  Is that my future if I have surgery?  Then, of course, comes the next question.  After a year of this, already, is THIS my future if I do not have surgery???  It all looks so hopeless.  I feel trapped, with no way out!
Dr Blake's comment: Surgery has complications, but sesamoidectomy is a very successful surgery overall. When I struggle with my patients, some do eventually need surgery, and I am sorry, but they do well. I tell my patients that all the skills you learn trying to avoid surgery, help you if you eventually need surgery. You have an unusual case that needs a lot of thought. You have not walked for far too long, and you had a second injury. Also, total healing comes from too many factors that I have time for, but you work through them. But, do not focus on the 1-2% of patients that have major problems post surgery. That will serve no purpose in your attempt to heal. 

(One woman had the surgery, her big toe crossed the others, corrective surgery did not work, they fused her big toe joints, there were complications with that, then the last post was that she had the advice of two doctors to amputate!!!  Scary stuff!!!)  

Does this surgery benefit anybody???  I haven't found that story, yet.  Is it possible to have a life without permanent pain and dysfunction after this??
Dr Blake's comment: Yes, but you have to find a good surgeon if it gets to that. 

Maybe the biggest question is, "How many doctors do I go through before I find one that listens and knows what they are doing?"  THAT is the greatest futility of it all.  (The two ER docs, from each injury, missed it, which is incredible to me.  The very first podiatrist recommended two surgeries based on x-rays that were not mine!  He is known for unnecessary surgery, apparently.  I ran from that place and into the care of an orthopaedic surgeon who said it was no big deal.  He literally said I was not to modify my life, in any way, and to walk on it until I saw him, six weeks later.  At that point, he re-x-rayed one of four fractures, missing the other three, then announced it hadn't healed and I needed six more weeks of un-modified walking.  "Call if you have any problems."  No follow-up appointment.  The next doctor is the one I spent the rest of the year with, until the second opinion, I just got.)
Dr Blake's comment: I am sorry. Let me know what cities you are around, and I will send you a recommendation or two. You will at least need another opinion at some point. 

Another question.  The in-office x-rays (second opinion doc) shows the toe fractures have healed, but I still have pain that shoots out of the joint at the base of the toe (where the fractures were) when I walk.  Is there any correlation to the sesamoid fractures?
Dr Blake's comment: Of course, they are in the same area basically. Occasional sharp pain which quickly disappears is not considered damaging.  The real job now is to create that 0-2 pain level as you begin to walk more. This typically needs some form of off weight-bearing padding and an arch support. Sometimes you need crutches to help. 

And, I am getting this weird internal/external swelling that both doctors don't have an answer for.  When I rest my foot on the floor, my big toe is elevated/suspended more than half an inch off the floor.  The toe next to it (which is also still having joint pain, swelling, redness) is lifted off the floor a little less than the big toe, then the third toe is almost on the ground, while the fourth and fifth toes are on the floor, as they should be.  It has been like this since the first injury, but improving, as time went on.  The second injury brought it right back and it is not improving, at all.
Dr Blake's comment: Anytime that there are positional changes you think of tendon or ligament tears (common in Turf Toe), and these may eventually necessitate surgery. Swelling in the big toe joint typically does not cause these toe positional changes. I would find out what ligaments are torn from the MRI, the bottom or plantar ones causing the toe to go up, and the top or dorsal ones causing the toe to go down. If you lose a ligament, you have to ask the tendon in the area to try to get stronger and compensate. You can initially tape the joint so it stays in the right position. 

It also feels like I did something to the tendon at the center of my toe, travelling over the top of my foot and into the ankle.  It hurts just to touch it.  If it is the tendon, it has been very painful (with swelling).  No one responds to my concerns, at all.  I talk to the wind and the wind doesn't speak.  I wonder if that tendon could be pulling things upward, except the other two toes are involved, so probably not. 
Dr Blake's comment: No, the tendon could be in spasm, being partially damaged. Or there could be nerve issues causing the tendon to contract. Think of seeing a neurologist or physiatrist to evaluate the nerves. Send me the MRIs if you want another look, or I can give you the name of someone in your area, if I can find someone. 

From the moment of the second injury, I instantly became unable to move my big toe, at all (physical therapy had freed it up into an almost full range of motion, before the second incident).  I can get it to flutter a little, but nothing more than that, in either direction.  No one seems to think that means anything or that it needs any kind of intervention.  The MRI apparently says nothing about it, either, which is confusing to me.  (The previous doctor suspended physical therapy, to date.)

Doesn't it seem like doctors should diagnose/treat everything that is going on, rather than choosing the obvious spots to focus on, while ignoring the rest?  That's how I got here, to begin with. 
Dr Blake's comment: I agree. You probably need someone working on the exact injury, someone working on the pain, and perhaps someone overseeing it all to make sure each month you are moving ahead with progress. 

I guess I am sending a message in a bottle, so to speak.  If you have read this far, I deeply thank you for your time.  God bless you for bringing information to patients that wouldn't be able to find it, otherwise, because I am one of those.

Sincerely,

Addition:

If I walk in a boot, is that enough weight -bearing to help the increase of de-mineralization from occurring?
Dr Blake's comment: For sure. Take some photos of your feet and put some xs on where they hurt. Unfortunately, thru this conversation, I still only have a small idea of what is going on. Thanks Rich

 It's got to be better than not walking, at all, or so I would think.  Maybe if I get mobile, in a boot, at least I am walking.  I really do not know who to trust or how to proceed.  (This so sucks.)

Thanks, again...