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Thursday, September 16, 2010

Sesamoid Fractures: Advice when not healing well

Subject: question about fibular sesamoid non-union fracture in dancer from Milwaukee, WI
(photo above pointing to the tibial sesamoid, the fibular sesamoid is the closest one to the second metatarsal)

Hello Dr. Blake,

I am writing today because in conducing online research about my injury, I came across your healing sole blog, and you offered your contact information so that folks might contact you with foot-related concerns. Thank you for extending yourself in this way. I could not find anything on your website about my particular injury, and so I thought I would write you. I have seen an orthopedic surgeon and a podiatrist, but I'd like to have another opinion. Also, I find it very difficult to get answers out of these doctors, as they only have a few minutes scheduled to talk to me.

I am a 29 year old female. I started dancing in college (modern and some ballet) about 8 years ago, and have continued on and off since then. I took some time off, but started taking classes about 3 - 4 days per week in July 2009. I am not a professional dancer, but have received scholarships for dancing at my studio, and have been involved in pre-professional training programs for modern dance. It is very important to me.

In about September 2009, I noticed some pain in the left ball of the foot. I stopped dancing for 1 week and it got better, so I resumed. However, the pain returned very gradually. I visited a sports medicine orthopedic doctor in February 2010 for a different concern (right ankle stability), and also mentioned the pain in the left ball of the foot. He diagnosed it as "sesamoiditis," and seemed confident of his diagnosis, so I declined an x-ray. I avoided jumps in dance classes as I had been since the onset of the pain, but I continued dancing. The pain very gradually became worse. At the end of May 2010 I decided to stop dancing and seek physical therapy, as the orthopedic doctor had said this was an option. After three sessions of physical therapy (involving ultrasound, iontophoresis, soft tissue mobilization, taping and home exercises), my foot was much worse - it was swollen and painful to walk. Prior to this, my main pain came from dancing, not walking. At the beginning of June 2010, I went to a different orthopedic surgeon and he took x-rays, diagnosing my injury as a non-union fracture of the fibular sesamoid. (A pre-injury x-ray from 2008 ruled out bipartite sesamoid.) I was in a walking boot for the month of June and non-weight bearing (on crutches) beginning in July. Upon recommendation from a friend and family doctor, I sought a second opinion from a podiatrist. The orthopedic surgeon said that if my bone wasn't healed by the end of August (after 8 weeks non-weight bearing), it would require surgical excision of the fibular sesamoid. The podiatrist has been more conservative in his treatment. On August 18, I began using a bone growth stimulator once a day for 30 minutes. It is the DonJoy Condensed Magnetic Field (CMF) stimulator. After my 4-week check-up on September 8th, the podiatrist added a twice daily contrast bath to my regimen, along with the bone growth stimulator. I will see him in another four weeks. I am still non-weight bearing, and I have been conscious to take calcium supplements, drink milk and eat yogurt this whole time.
Here sesamoids shown in a CT Scan
http://www.youtube.com/user/drblakeshealingsole#p/a/u/2/rRt5hC24Afg for information on contrast bathing.
My concerns/questions are:

1) Is there anything else I should be doing to heal this bone (without surgery)?

2) I am a very patient person and would do anything to save my bone rather than have it surgically removed, as I fear it will compromise my dancing. However, is there a point at which we can be fairly certain that the bone won't heal, and I will have to resort to the surgery?

3) What risks would surgical removal of fibular sesamoid involve? Again, my main concern is with the function of my foot - I am very active and want to be able to dance for the rest of my life! I read on the Internet that removal of the sesamoid affects a persons balance and power, may lead to hallux varus as the tibular sesamoid loses its counterbalance, and may affect the tendons (adductor hallucis). My concern is that the doctors all tell me the surgery has no effect and I will be back to normal. I am a smart woman who has done her research and recognize that this isn't the case. Could you please provide me with an honest, realistic representation of what might happen over the course of my lifetime as a result of sesamoid excision?

4) Is arthroscopic surgery an option?

5) Are bone grafting or pinning options?

6) I have struggled to trust my doctors. What do I look for in a surgeon (if it comes to that)? Should I go with a podiatrist or an orthopedic surgeon?

7) When I get back to dancing, how can I avoid future injury to the fibular and tibular sesamoids? I realize that the impact is greater if both sesamoids are removed, and want to avoid that at all costs!

Dr. Blake, I apologize this is such a long email. I hope you are able to offer me some advice. Thank you for your help.


Sincerely,

Jenni
See how sesamoids are under the first metatarsal

Dear Jenni, I will try to answer your questions in this blog posting. There are 2 sesamoid bones under each first metatarsal which make up the "ball of the foot". These sesamoid bones act like the knee cap in function: they protect the first metatarsal from direct pressure, and they separate the tendons from the joint axis increasing the lever arm of these tendons. Increased lever arm means increased power from these tendons which need, at times, to handle the force generated up to 5+ times body weight. The photo below shows these sesamoids sitting under the first metatarsal with the fibular (closest to the second metatarsal) having a fracture. In this example, you can clearly see how the fibular sesamoid looks irregular. The actual fracture occurred 10 months previous to this fracture.

     At times, the sesamoid bones never completely fuse in adolescence, and so xrays show that they are in 2 (bipartitie) or 3 (tripartite) pieces. The photo below shows a non painful bipartite tibial sesamoid.

 Fractures can be misread on xray as bipartite or tripartite sesamoids (false negatives), and bipartite/tripartite sesamoids can be misread on xray as fractures (false positives). Bone scans or MRIs clearly make the diagnosis of sesamoid fracture when not completely obvious as in the photo above.
On an aside, ultrasound is contra-indicated for stress fractures, probably why physical therapy aggravated the situation. Golden Rule of Foot: If ultrasound irritates the injured area, consider an underlying fracture may be present.

     I will try now to answer your questions.
#1 Is there anything else you can do to heal the bone in an attempt to avoid surgery?
     First of all, anything that you do now to help yourself avoid surgery, even if you need surgery, will help you post surgery immensely. This is a perfect time when the bone is sensitive to design perfect orthotic devices that protect them. These modifications in orthotic devices are a post in themselves, but most sports medicine podiatrists and physical therapists can design deceit orthotics for this problem. You may have a biomechanically challenging foot, with a very prominent first metatarsal and this could actually take the work of a biomechanical expert (hope this is not you). The goal of any othotic device for you, and athletic shoe ones are made first to wean you eventually from the boot, is to shift weight back onto the arch and onto the 2nd and 3rd metatarsals. Without a corrective orthotic device, at some point in each step, 100% of your body weight goes through the big toe joint and sesamoids. In the front of the orthotic device is a "dancer's pad", also called a reverse Morton's pad, and sometimes an additional metatarsal pad.
Here an additional met pad is used to shift more weight off of the sesamoids.

     The bone stimulator for a nine month period is great, just do not stop it too early. If you are using the bone stimulator, best to be committed to it for 9 months. Remember, pain is going to be a poor guide on healing. As you continue non weight bearing, the area will get stiffer, weaker, more swollen, and with more bone and nerve sensitivity. You are in the easy stage of rehabilitation. It is getting you back on your feet gradually that the work begins. The doctor managing your care will need to balance the pain you have with a gradual increase in function. It can be a trade off to allow more function with some more pain initially. This is the same issues that have to be dealt with post operatively.
     Learn to do spica taping to restrict big toe joint dorsiflexion with kinesiotape. The 3 photos show the placement of 1" kinesiotaping. It should be applied easy, not to pull the toe down, but to restrict the upward motion of the toe. It should not feel like it is tight or jerky on the toe. You can experiment with longer arms of the tape under the arch. The 1" tape is split in 2 for 1" to wrap around the toe. An upcoming post will show a video on this technique.
     Stay strong with all those foot intrinsic muscles, but also you knees, hips, and core. The stronger you stay, the faster you heal, surgery or no surgery. The weaker you become, the more collapse of your arch into the ball of your foot, the more pressure on the sesamoids. You are in the Immobilization Phase, but you need to be blending the Restrengthening Phase into it. You need a smart physical therapist to begin restrengthening your body. Golden Rule of Foot: Begin Restrengthening the Injured Area even before you injure it.

     Get a Vit D 25 level now, and a bone density screen, to make sure everything is perfect in those two areas.
     You should be taking 1500 mg of calcium (normally 5 daily servings of calcium rich food, or you can supplement diet with 500mg sugarfree TUMS at the end of each day to make up the difference.
Papertape is used to secure the arms when they begin to loosen.
   
 Eat a balanced, healthy diet.
     Make sure you stay with a relatively painfree environment (see link to post on Good Pain vs Bad Pain) as they wean you from non-weight bearing to a weightbearing removable cast, then removable cast to athletic shoe and orthotic and tape, to smaller orthotic with dressier shoes and tape, to dance shoes with dancers pads and Hapad archs and tape, to gradually return through the various levels of difficulties in dance.
Spenco is glued to the bottom of a shoe insert as a dancer's pad.

#2 When are you sure that the bone needs surgery?

    
     Sesamoid on CT Scan shows irregularity at the interface with the bottom of the metatarsal head that you know will break down the metatarsal head cartilage over time and cause a worse problem. This is the case of the patient with the xray above when I first met her. I knew at 30+ that she couldn't coexist with this for the next 70 years.
     Surgery is also indicated if the MRI shows damage to the underlying first metatarsal. However, a bone stimulator with serial MRIs may show healing over a 1-2 year period of time.
     I definitely feel surgery for this injury is an individual thing. You are a candidate for surgery 3 months after your injury. No one would blame you for having surgery. Personally, I would try to perfect all of the factors that could delay or eliminate the need for surgery (diet, strengthening, physical therapy, spica, orthotics, padding, etc.) Anything that you learn before surgery, may help you prevent surgery, but definitely help you in the post operative period.

#3 What are the risks, especially in an active person, to remove the bone?
     When you remove the sesamoid, you can be extremely active at a professional level, but you must always try to protect the other sesamoid for the rest of your life with orthotic devices, dancer's pads, etc. Most doctors underplay the actual time it can take a high level athlete to get back. I believe that there is a 2 year total healing time to a strong and powerful big toe joint following surgery. The first year is all about swelling, initial strength, scar tissue, and biomechanics. The second year is re-strengthening at the level of gaining not tone, but power, endurance, and quickness. And yes, surgery can be have it normal array of problems--excessive swelling, incomplete correction requiring re-operation, excessive scarring causing stiffness/pain, tendon balance problems requiring prolonged taping, and many other issues. Hallux varus is rare, although surgeons know what foot types are prone and can tell you if you are a remote candidate.

#4 Is arthroscopic surgery an option?
     No, the joint is too small. Most surgeons approach the fibular sesamoid from the bottom of the foot for easy access.

#5 Are bone grafting and pinning options?
     No

#6 What should I look for in a surgeon, and should it be a podiatrist or orthopedist? Sesamoid surgery, or trying to avoid sesamoid surgery as you are, is all about rehabilitation and biomechanics. It is an ideal perhaps to find a podiatrist or orthopedist who does surgery, and also pays alot of attention to the rehabilitation part and the biomechanics part. They do exist, and most create a team in dealing with this problem. Our top surgeon will use me for the orthotic devices and some of the rehab, and physical therapists and trainors for the rest of the rehab. Unfortunately, you also must see your limits with your insurance carrier, but also have a clear understanding from the surgeon about how you will be rehabed. I am biased toward my profession, but surgeons in general only have time to focus on surgery. Find a surgeon that embraces the TEAM approach for the rehab phase, after the surgeons have pronounced you "cured".

#7 How can I minimize the risks of re-injury when I return to activity?
     This is really answered in how can I prevent surgery?
     To summarize:
  1. Gradually return to dance start with barre work and finishing with grand allegros.
  2. Learn to tape your big toe joint.
  3. Learn to apply hapad longitudinal metatarsal arches and dancers pads in all your shoes.
  4. Make sure your Vit D, Calcium, hormones, bone density, and diet are all great.
  5. Gradually learn the Good Pain vs Bad Pain principles
  6. When not dancing, have supportive orthotics where you feel no pressure in the sesamoids in all your shoes
  7. Learn what shoes are helpful (amount of cushioning, heel height, flexibility or rigidity, etc, can all make a difference) The Golden Rule of Foot with Sesamoids and Shoegear: Follow how you feel, not some general rule--you may be an exception!!
  8. Gradually start strengthening your foot, but not through pain. There are so many ways to strengthen an injured area and the body above it. You should be strengthening daily, and keep pushing the limit. You should be biking and/or swimming if you are non-weight bearing, and  perhaps doing some thera-band and other foot strengthening techniques.
Jenni, I sure hope this helps you. Rich
South of France

51 comments:

  1. Dear Dr. Blake,

    Thank you so much for taking the time to answer my questions so thoroughly. I will read and re-read your answers and make any changes in my treatment accordingly. I can't thank you enough for this selfless extension of your expertise. It has given me some peace of mind to get another professional opinion.

    Enjoy your vacation, I presume in the South of France!

    Thanks again and bon voyage,
    Jenni

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  2. Dear Dr. Blake,

    Thank you so much for your incredibly informative blog, and in particular, for your posts on sesamoid fractures which have been immensely helpful on my healing journey.

    I broke my tibial sesamoid 9 months ago. We don't know how it broke, possibly due to leg length discrepancy (actual discrepancy of 3/4 inch, the sesamoid that broke was of the left, longer leg, and this bone was double in size compared to that of the right leg).

    After reading so many horror stories online I chose a very conservative treatment -- 2.5 months on crutches with camwalker, total of 8 months on camwalker with bone stimulator. I've had many ups and downs, and until last month we weren't sure if it was healing, based on x-rays and continued pain. Switching from the boot to shoes was painful, and your suggestion to wear hard-soled shoes and to restrict dorsiflexion of the big toe with kinesiotape worked wonders. I found that Dansko clogs with a metatarsal pad and taping got me to wean off of the boot.

    I have the x-rays on a disk, I'd be happy to email them to you if you're curious.

    Now here's my question:

    After 9 months of conservative treatment, last week I started jogging on a treadmill (just about a mile at a time). I'm offloading the sesamoid with an orthotic insert. I feel some tenderness after jogging, a teeny bit of pain, but overall it feels good. I'm concerned, however, that if the bone isn't fully healed, if I could be causing little stress fractures that would re-brake the bone. Or if it hasn't ossified fully, if this could compromise the ossification process. Short of getting a cat-scan, which I can't afford, is there a general rule of thumb here? How do I know when it's time to run again?

    Thank you so much for your feedback and time!

    Debra

    PS -- see my blog-in-formation at sesamoidchronicles.worpress.com

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  3. Debra, Thank you for the kind words and email. The posts that you must read are:
    Good Pain vs Bad Pain
    Walk/Run Program
    Generalizations of Treadmill Running

    If you can walk 30 minutes, you can start a Walk/Run Program. I would start a Level 1 and gradually increase the levels after surviving each level 5 times. Since you should only run every other day, these 5 times can take you 10 days, and the 10 levels will take you 100 days. Slow but safe. You should run every other workout on the treadmill, and every other workout on a soft outside surface. Never use the incline on the treadmill, and avoid steep hills that forces you onto the ball of the foot. Kinesiotape for running, and ice 15 minutes within 2 hours of stopping the workouts. When you start the next workout, you must be back to where you were pain-wise before the previous workout. Avoid minimalist shoes at this point in your running career. I hope this helps. Rich

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    1. Hi DrRichBlake,

      I also have the good pain vs bad pain problem on my sesamoid bones. How can I find the post 'Good pain vs bad pain'?

      thanks

      angelina ballerina

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    2. I have linked the post on "Good vs Bad Pain". Thanks for the comment. Rich Blake

      http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

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  4. Dr. Blake, I have been diagnosed with a fractured medial sesamoid bone. I wish I had a good excuse, such as training for a marathon or heavy duty salsa dancing, but I think I have to chalk it up to simply being a lover of high heels for most of my 35 years of life.

    I went to 1 podiatrist, who after 1 month of electrotherapy and taping, recommended surgical removal. I sought a 2nd opinion from another podiatrist, and he thought it was simply sesamoiditis. He started by putting me on anti-inflamatories and gave me the short orthodic boot. 1 month later, and not much better, he recommended heavy duty steroids for a week. I went back in and still felt pain. He then recommended the weight-bearing air cast, which I wore for 1 week. I woke up one evening in the most pain I have felt since I started with this problem.

    I called the next day and demanded an order for a bone scan to determine once and for all if it was inflammed or fractured. Results confirmed it was indeed, fractured.

    Questions:
    1) In your experience, could the use of the air cast have actually made it worse? I swear I feel more pressure on my sesamoid using the walking air cast, than simply wearing my Birkenstocks.

    2) All in all, nothing seems to have helped my foot more than wearing Birkenstocks. Besides being a great marketing story for Birkenstock, is there science behind this?

    3) No one has ever suggested taking extra calcium or simply going all out with a plaster, non-weight bearing cast with crutches. Would this be overkill? I am a very patient person, and would rather try every alternative possible before resulting to surgery.

    I would greatly appreciate any insight and recommendations you have. I have read about all the risks of removing the sesamoid bone, and besides being vain and wanting to avoid bunions, I am ready to get back into an active lifestyle to lose some baby weight and get back in to a healthy lifestyle. Thanks much in advance-

    Victoria Garcia

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  5. Dear Victoria,
    I am not a doctor - but I used a cam boot early in my injury and it totally exacerbated the injury - in part because we HAVE to have j-padding - or padding like the doctor has suggested above - the cam boot sole is so hard and rough - so to put weight on the injured foot on that surface with no padding -(thanks to my horrible experience) is pure insanity - I am not saying you are insane - but that the common wisdom of slapping a cam boot onto a foot with a sesamoid injury without other wrapping or padding is completely insane!. Those little bones will just get pushed apart. I am currently cutting and pasting padding as suggested above. You may need to take weight off completely, IMHO, but not if you can jerry rig something that offloads the sesamoids - coz ultimately when we take weight off completely - all the supporting structures around the sesamoid tighten up and pull on it - and no longer support it for those times we must use it (oh like bathroom and changing! I'll never understand how people do these things without weight bearing!!) Not sure what doc says but massaging around the area esp the arch - using tennis ball on arch if not painful will help keep those tendons awake - warm baths (not too warm!) also to limber up morning and end of day - swimming down the road- but careful! perhaps the doctor will have suggestions for that - I have multile taping cofigurations going but havent found the secret to swimming yet! Maybe some taping of the foot with use of water shoes (and someone to help me into the water!) I am gobsmacked with the conventional wisdom floating around that sesamoids are unecessary and that they take 6-8 weeks to heal. The next person that suggests that to me is getting clobbered and then handed a heap of literature! Be sure to get a long healing path onto your agenda and that will ease yours and everyones expectations and enhance our chances for healing properly. Good luck! (lisa)

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  6. Dear Dr. Blake,
    I had wonderful progress with a tibial sesamid fracture by minimal weight bearing for 3 months, 3 month of HBOT and swimming then on to light walking and almost no more padding. Unfortunately I went barefoot too soon and leaned on the foot accidentaly at the wrong angle and 10 months down the drain, start again. I have no money for HBOT now (actually I had RSD as well hence the extreme and expensive measures - I have NO regrets at all) so I am thinking of bone stimulator.
    Questions:
    1) Which is more effective, ultrasound or electromagnetic? I am assuming I should opt for ultrasound since I had/have very quiet RSD symptoms.
    2) when do I know I can start swimming? It is hard to swim without moving that joint! But surprisingly the bone actually became a union even with months of swimming. Gradually everything came nicey together. It broke apart again due to fascia strain (going barefoot) followed by light but damaging pressure at a precarous angle, and all of this just too soon. (my diagnosis, of course)
    You are truly a saint for this blog. Please don't hesitate to test out HBOT (I prefer monochamber - the hood thing just didnt work for me) in patients with RSD who have no contraindications. It saved my sorry arse (foot injury overall - it was lightly crushed in many places; and RSD neuro immune wonkiness reverberated through whole body; no it's pretty minimal but I may need to do some more HBOT once in a while - that RSD thing is a monster) Thank you!! (lisa)

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  7. Hi - I have seen a podiatrist and based on x-rays I have fractured my sesamoid. Currently, I'm in a knee high boot for 6 weeks but am a little confused about how this isn't putting pressure on the ball of my foot and keeping it from healing. I'm sure it takes some pressure off but would it be better to just keep it wrapped in an ACE bandage and using crutches as much as possible?

    Another question - what do you know about Exogen treatments to help fractures heal quicker? Anything else such as vitamin/mineral supplements?

    I'm am wholly against surgery so am wanting to be as aggressive as possible in doing everything right to get this to heal quickly.

    I've read the horror stories about how people continue to have problems for months and years and it's scary. I want to make sure the podiatrist I'm seeing is giving me the best advice possible too and he doesn't seem to be concerned about the pressure I feel with the boot on. If there is any recommendation for a speicalist in Denver I'd appreciate it! Thank you so much for your blog!!

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    Replies
    1. Please see my post on 3/7/12. Hope it helps you. Rich Blake

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  8. Dear DR. Blake,
    I read your online article and it helped tremendously.
    This is what I have done to heal my sesamoditis.
    Thank You for sharing your knowledge.

    Sesamoditis WILL go away. This is what you MUST DO:

    I am Physical Therapist and very athletic person. I had sesamoditis for myself and I want to share my knowledge to help you.
    The pain was completely gone within 3 weeks.

    1. REST REST REST. If you are runner, dancer... take some time off and allow healing process.
    2. ICE MASSAGE (not ice pack). Use an ice cube to massage your foot for 10-15 minutes daily (before sleep).
    3. BUY/WEAR flat and stiff bottom shoes. Best are tennis and cross training shoes. ( NB, Nike).
    4. BUY/WEAR metatarsal sleeve to unweighted big toe area. I recommend: FlexaMed-Metatarsal-Sleeve.
    Walking will not be the most comfortable but your foot will adjust to it. Most important : you will walk !
    5. TAPE YOUR BIG TOE to immobilize joint, daily.
    6. Take CALCIUM supplements to allow faster bone healing.
    7. BUY BIOFREEZE pain reliever and massage your foot with it before sleep.
    8. STRETCH: Gatrocenemius muscle 3 x 30 sec daily.
    9. BALANCE exercises ( as soon as you can do it) EX: Stand on one leg for 30 sec x 3.

    Also you can add:
    Hamstring, Quads stretch and Peronals muscle strengthening with thera- bend. (resist foot pointing down).
    Daily Active ROM : toes up and down and circles (do not go beyond pain tolerance).
    Also, you can add inserts with arch support to your shoes. It does help.
    Within 3 weeks you will be able to go back to your activities pain free.
    Remember REST, REST, REST.

    I hope this helps.

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  9. I had my Sesomoid on my left foot removed in April it was a success,my toes are very numb right now and under the foot feels as if iOS a big knot while the toes are black.Any one that had the op just let me know what the feeling was like while healing.

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  10. Hello, Dr Blake
    I am currently dealing with a torn flexor hallucis brevis tendon and bone marrow edema in the fibular sesamoid. My podiatrist calls it "an odd injury." It started with extreme swelling and pain in the ball of my foot after working a night shift (I'm a nurse, but this is a home case and my kid sleeps at night, although I'm up and down a lot.) I saw my podiatrist the same day; he did an X-ray-negative-and blood work to rule out gout. I couldn't bend my big toe, which was also quite swollen below the second joint.

    He diagnosed possible tendonitis, told me to wear offloading pads, RICE, rest as much as possible and wear my orthotics at all times. Improved around 50 percent in the first week. Two weeks later, no further improvement. Ordered an MRI, which showed the tear. Gave me a boot, told me to continue wearing the offloading pads and walk on it as little as possible. He also gave me an injection of Traumeel, which I'm still skeptical about.

    I went to Disney(he told me not to) but used a scooter the entire time and spent very little time on the foot. Came back-still swollen and and sore to touch. Now I'm totally non-weightbearing for 5 weeks, two of which have passed. Ball of foot is still swollen up into the big toe, point tender to touch and slightly numb around the base of the toe. I haven't put my forefoot to the ground once; I walk on my heel a little and use a knee walker in the house.

    I'm looking at the summer fast approaching and thinking-"How long will this really take to heal? Is there anything else I should be doing?" So I figured I'd ask you!

    I'm 61 and overweight, and I know tendons heal slowly--I've torn several in the past,had surgery for a Gamekeeper's thumb tear 2 years ago-(I tore that by getting my thumb caught in the pocket of my pants when changing!) have hypermobile joints which seems to go along with this and am generally a klutz. I don't know how I did this but suspect hopscotch with my granddaughter--I only did one jump!

    Any sage advice or fresh insight? This really is a little scary.

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  11. Hi, It does sound scary right now. I know we can function with a torn FHB tendon, but it could lead to sesamoid issues and chronic scarring. If it is only partially torn, the immediate pain is much worse since part of the tendon is pulling hard still on the damaged part. Same with achilles injuries, complete achilles tears actually hurt less than partial tears. The bone marrow edema in the sesamoid is disturbing. I wonder if this is actually a fractured fibular sesamoid with so much swelling around the tendon that it appears torn. This also happens a lot and much more common than a torn FHB tendon. You need to be in a pain free environment. Stay in a removable boot for 3 months. You can put your orthotics and dancer's pads, etc, into the boot. Get an EvenUp for the other side. Repeat the MRI after the 3 months and see what everything looks like. Learn how to spica tape and maybe purchase one of the carbon fiber plates I mentioned in my May 9th blog post. Avoid shots into the joint with a passion, and ice pack 5 to 10 minutes three to five times a day. Non weight bearing only makes swelling worse, so partial weight bearing to mechanically pump the fluid back to the heart is best. Read the post on Good vs Bad Pain and try to stay on the Good Pain side. Happy to have you send the MRI for a 2nd opinion to Dr Rich Blake 900 Hyde Street, San Francisco, 94109. Hopes this helps some. Happy to have you email me directly also or through this post comments for more info or followup. Rich

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    Replies
    1. I ordered the MRI on disk and will send it out to you on Monday--thanks!

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  12. Thanks so much! I saw my podiatrist yesterday because the foot pain intensified- I thought I might have done something to it in the night. He said it was more swollen than it was two weeks ago. He spent a lot of time going over the MRI again and told me absolutely no weight bearing at all. He did spica tape and showed me how to do it. I'm using a knee walker--would this give me enough mechanical pumping action to keep the blood flowing? I'll read the good vs bad pain post and check out the carbon fiber plates. how would I go about having you take a look at the MRI? Thanks again for this forum--it's so hard to find info on the internet, especially when you have something rather odd lol.

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  13. Hi Dr. Blake,

    I desperately need a 2nd opinion, but my insurance won't pay for one. I was hoping you could help! I have been dealing with dysfunctional sesamoids since April 2010. I developed sesamoiditis after running 2 marathons in the span of 8 days. (Probably not the smartest idea, but I was in great shape at the time). I quit running completely, was non-weight bearing in crutches + walking boot for 3 months and returned to normal activity shortly thereafter (but never returned to running). I was never completely pain-free, but it was only sporadic & I have a pretty high pain tolerance, so it was easy for me to ignore. I just (incorrectly) assumed that quitting running would solve my problems & it would eventually heal. Fast-forward to May 2012.. I wear painful 6-inch heels (bridesmaid requirement) for my brothers wedding and am nearly unable to walk the next day. I go back to my doctor and MRI & CT show a fractured sesamoid with complete destruction of the cartilage around metatarsal and resultant cyst formation in the metatarsal. My doctor (PM&R) prescribed 3 months non-weight bearing in a cast & crutches. I got the cast off yesterday and am currently in more pain than ever before. He now wants to fit me with a graphite shoe insert for 6 weeks before even considering referring me to a surgeon. Is he on the right track? I don't really have any options to see another doctor (this guy is supposedly the best person to see for my injury under my insurance), but I would really appreciate another opinion. Thanks for your time!!

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  14. Dear Sara and Erik, I am going to leave a response on my post for today. I sure hope it helps you. Dr Rich Blake

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  15. Hi
    I was diagnosed with a fractured fibular sesamoid about 10 weeks ago and advised to treat it wearing insoles and recently with a cortisone injection. I am keen to get back to running as I have already missed several races. How long do these sort of injuries take to heal as I am still getting pain. Will it be case of just getting on with it and stop moaning or should I continue to seek the treatment and advice from my podiatrist? I also suffer numbess between my 3rd and 4th toe ( the other foot, not related to this injury) what could be causing this and is it something I should mention? Your previous comments are very interesting which is why I decided to seek your advice. Thank you

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  16. Hi, I will answer fully on my blog post tonight 9/8/12. I hope it helps you. Dr Blake

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  17. Hi Dr. Blake,

    I have been dealing with a fractured seisamoid for several years now. I have seen orthopedic surgeons and a podiatrist that works with an Ortho group. I have had x-rays and an MRI confirming that it is fractured. I wore a walking boot for 5 very long months. I have taken anti-inflammatory medications, I have had an annual cortisone injection (which last about 6-8 months and then I tough it out). I have tried to have custom orthotics made, and every time they make me a new pair, it causes another area of the foot so much pain that it's worse because two areas hurt. I have heard a metatarsal sleeve is helpful.

    I used to be a recreational runner, but have not had that pleasure for about three years now. I do live near the mountains in Colorado, and I love to hike. I have found that shoes with stiff and rigid soles help, and I have stopped wearing heels except for an occasional special occasion like a Christmas party. I have a VERY high arch.

    My doctor is at the point of surgery, but I am terrified that all I will be doing is trading one pain issue for a host of pain issues, and that I won't even be able to hike. I have NEVER read anything good about that surgery or it's success.

    Is it possible to get a shoe insert made that is very hard & stiff to make even softer soled shoes more rigid?

    I am desperate!

    Sheila

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    1. Sheila, please see my reply on the blog 11/5/12. I hope it helps you. Rich

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  18. Think very carefully before having surgery and find a doctor you really trust and who will take the time to go through all the possible outcomes with you

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  19. I would like to know how Jenni (the person with the original post) is doing now. Jenni are you out there??? I'd love to here how things went for you.

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  20. I had fractured my sesmoids in my right foot. 1st metatrasol. By a overstep ,coming down from a platform desk at work... Upon going to a workmans comp clinic they stated nothing found. 2wks later , it felt like I was walking on broken glass, sharpness when walking, going up/down steps.. severe bruising & blisters on the bottom of my foot.. calius' began to appear on the ball & edge of my outter foot...from adjusting the difference in walking. Upon being referred to a Podiatrist the found the fractured and also stated it had a second fracture . after seeing it in a MRI... 7mths later the pain remained the same. the fracture did not heal... 2 Podiatrist recommended the sesmoids come out! Immediately following my surgery. It felt like someone had relieved all the tension/stress from my foot. allowing me to wiggle my toes & relax without any pain.. Now 3wks after surgery . I'm just adjusting to flexing my big toe. It is very stiff at times. but the sharp pains are gone and I can walk on it.. Just have to learn to make the foot flex and move again as it use to!

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  21. I am so happy that worked out for you. Continue to protect the big toe joint with orthotics designed to off weight the area some. Work on foot strengthening like metatarsal doming in my blog. Ice daily for 15 minutes until you are back to full activity. Dr Rich Blake

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  22. Hi Dr Blake
    I am 67 and I had Bunion surgery Jan 2012) on my rt foot a big and painful and callused on Metatarsal pad. I finally got the courage to have had the surgery.
    Didn't use the orthotics prescribed last summer and went walking every other day, slowly developed a painful joint with each step on left toe , a quick forming bunion developed.
    On March 5th 2013 , I got a shot of cortisone that didn't really help much. On April 2nd I had a fall ,over a cement block in a dim lit parking area and on the way way up I hyperextended my toe on the left foot, and the big toe that had the shot in it popped so loud that by the time I got home I had to take my shoe off to walk to my door (the one I was considering bunion/hammertoe surgery for next month) My surgeon suggested taking the seismoid bones out as the tendon has torn . When I went for my Xray, it showed, the tendon ruptured and the bones were not in their place. My surgeon has made a J shaped insert pad for my left foot which brings some relief , otherwise it is painful to walk without it, although I do walk ok in my home without shoes.
    Is correcting the Bunion, Hammertoe and now removal of Sesamoid all at the same time too much trauma and will it be more painful then the right foot that I have screw and a rope connecting the big toe to the 2nd and 3rd bone in rt foot surgery. Although that surgery was uncomfortable, I was healed up pretty good by a month to five weeks and walking again.
    Is it possible that the Bunion is causing the pain, as the cortisone shot lost it's effectivesness, as I only have pain on the side where the shot was given , the same type pain I had from the bunion. I do get some relief from the J pad my Dr taped to my foot, but have to be careful to not bend it too fast. I have stopped exercising now for 2 weeks and have slowed down to a crawl. Does 3 surgerys in one day seem a too much at my age

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    1. Will answer this on my blog during the week of May 28th, 2013. Rich

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  23. Hello Dr. Blake,
    in one of your post you mentioned that bone graft is not a good option for a fractured sesamoid. Is there a reason why? are there not other options to saving the sesamoid other than completely taking it out? I read somewhere that there is a doctor(limbs and preservation(if I'm saying this right)who does not take out the sesamoid, but does a technique for fixation and repair, which I can only assume is grafting, not sure. I found this online doing a search.

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    1. Hey, thanks for the email. I only know of one patient that had a partial sesamoidectomy where the doctor left in one half of the sesamoid, removing the most damaged half. That patient was no better off after surgery, but it is too small a number to draw any conclusions. The pain from sesamoid fractures come from the irregularities between the sesamoid and first metatarsal. A bone graft may heal the fracture, but may cause abnormal bone where there should not be any. I do not know how they would control the bone multiplication, but again I have not seen this, so it may work out great. Sorry for being unsure for you. Rich

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  24. Dr. Blake,

    I have been dealing with left foot pain for over five months. I was placed in a boot for five weeks for stress reactions in the 1st, and 2nd, and 3rd metatarsals, followed by six weeks of physical therapy. During the physical therapy, the pain on top of the second metatarsal and bottom of the 1st metatarsal got progressively worse and the physical therapist ended up cancelling half of my sessions because of the pain. I also ended up wearing the boot again for two weeks and then a surgical shoe for two weeks during the last four weeks of the physical therapy. In the last two months, I have worn athletic shoes full time, minimized the amount of time on my feet, and started experiencing constant swelling over a two inch area down the entire length of the top of my foot. If I spend more than a few minutes on my feet, the pain on the bottom of the 1st metatarsal gets worse and worse. I have also periodically had shooting pain over the 2nd metatarsal when walking. I recently had an MRI, which showed marrow edema in the plantar and lateral margins of the 1st metatarsal head and nonspecific marrow edema in the hallux sesamoids. When my doctor initially reviewed the MRI images, he said it looked like I had an extra outer sesamoid. After reviewing other images, however, he decided that this was not the case as he did not see it in those images. There is a black jagged horizontal line through the outer sesamoid in three of the MRI images. Other images of the same sesamoid show no line. Is it possible that this is a partial sesamoid stress fracture? The doctor determined that I have sesamoiditis and told me to wear a metatarsal pad in my shoe for the next six weeks to off-weight the sesamoids. I tried the metatarsal pad, but it has made the pain significantly worse. What do you suggest?
    Thank you!

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    1. Hey, thank you so very much for the email. Typically, you have one source of all this pain (say a fractured sesamoid or first metatarsal head) and when treated improperly, the pain and swelling magnifies to involve a larger area. Swelling alone is no big deal since it is a reflection of a healing response of your body. Pain and swelling means you have not stabilized things well enough and healing is being somewhat compromised. Remember stress fractures are tiny cracks in the bone, hurt as much and as long as true fractures, and normally may not be seen other than the bone edema (swelling) noted on the MRI. Thus, the confusion of whether a black line is seen or not probably means stress fracture vs true fracture. Stress fractures on the bottom of your foot take a long time to feel better since first the fracture and then just the resultant bone edema hurt. The things you need to do in the next 2 months are: make sure the inserts have maximal off weight bearing padding (called dancer's pads), make sure you have high and tolerable arch support, ice minimum 3 times a day for 10 minutes to keep cooling down the area, do a full 20 minute contrast bath daily and twice on weekends, learn to spica tape to stabilize the big toe joint, keep your legs strong with biking (you can rest the arch area on the pedal), weight bear to tolerance (all immobilization and non weight bearing can increase the swelling in a foot/weight bearing great for moving swelling, make sure your Vit D and Calcium are normal, eat healthy, use crutches, get a new MRI 3 months after the first, and hang in there for some of these injuries to completely heal can take several years and your job is to create a pain free environment to allow healing. Another 3 tests that could give alot more information are CT scan, bone scan, and CT fusion (which is a combination of the above). If insurance allows, and the way you are struggling, I would try to get more information also with one of these tests. I sure hope this helps. The information on all of this (like contrasts) is all within the blog. Rich

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  25. Hi Dr. Blake,

    I have had quite a journey that I never expected to deal with in my life time. I would like some advice about physical activity based on the surgical procedures I have had. When I was 20 yrs old, I had a routine bunion surgery on my right foot. Due to an ineffective surgery, the bunion returned and even had a bump on the top of my foot causing pain at the site of the bunion. I decided at the age of 30 to fix the problem so I ended up having another surgery where it was determined I had hypermobility and had the head of the metatarsal joint shaved down to fix the bunion. The surgeon also had two screws placed on the top of my foot to help with the hypermobility. Well, that didn't last long even though I was on non-weight bearing cast for 4 months as the problems returned 10 fold. I was running about 33 miles a week and general cross training. At the age of 40, I went to a Podiatrist and he could see several problems going on with my right foot. He determined that I do have hypermobility, hallux valgus and my sesamoid bones were completely destroyed. He had to go in and replace the greater toe joint with a Hemi toe implant, fuse the second toe joint, remove the sesamoid bones and remove the screws as they were causing extensive pain as they rubbed against my shoes. Ultimately after 3 surgeries, my left foot ended up having a collapsed arch and I had to have surgery to fix that with pins and a cast for 2 months. I have a bunion surgery for the left foot next summer (As a result my left foot is now 3/4" longer than my right foot!). So, I have had some problems with my feet you could say. =) I am a really active person, I use orthotics, hapad metatarsal pads, and I did receive physical therapy. So far, my right foot has been feeling good, however, I did have extensive discomfort while it was healing. My right big toe is stiff with limited mobility and it's difficult to move and PT helped in a limited amount. Due to my biomechanics in my feet have changed how my weight is distributed I do see some calluses on the outer edge of both feet, but is very minimal. I have curtailed my running and now use an elliptical trainer, I do engage in weight training and watch my diet.
    What kind of activities do you recommend with all of the surgeries I have had? What other kinds of foot strengthening exercises can I do to continue my healing process and any recommendations do you have for me at this time? I have tried to find your blog on metatarsal doming, but with no luck. My podiatrist is excellent but I would like other opinions as well. I appreciate your time in reading about my extensive surgeries and you providing advice on my case. Thank you!

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    1. Hey, Thank you so very much for the email. You are right to think about focusing more on non impact sports like elliptical, cycling, swimming, and moderate running. Sounds like your orthotics or changes in biomechanics have gotten you to the outside of your foot. Continue to work with the orthotic maker to try to keep you centered. The better your core, the less collapse into your arch you will have. The better your foot strength, the less stress on your bones and ligaments. You could easily improve your foot strength by a magnitude of 2 or 3 by daily going through 3 exercises each evening. I will place in my labels all the foot strengthening posts in a minute. I will also place under this email that I will officially post within the hour. I hope this helps. Rich

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  26. I was diagnosed by xray with tibial sesamoid fracture May 30,2013. I am 36 y/o and healthy, female. Not sure how I injury occurred. I am seeing podiatrist, he put me in walking boot for 3 weeks. Repeated xrays showed fracture was worse and no signs of healing. Then he recommended continue with boot, but non weight bearing for 3 more weeks. On July 11th, diagnosed with Non union fracture, still no sign of any healing or improvement. Podiatrist said to allow another 2-3 weeks, but may walk in boot and see how pain tolerance is. If still no improvement then begin cortisone injections. I notice burning pain and discomfort after about 5 hours of working, up and down on my foot. He stated that he has seen good success with injections, I just am not sure that is the route I am comfortable with. Do you recommend cortisone injections or are there long term side effects from them? I have read about surgery, but podiatrist only recommends that as a last resort or failed attempts with cortisone. I am a nurse for a busy Family Practice physician and I need (or my boss) needs me to be back at work asap. She is very understanding but this is very frustrating. Its only been 8 weeks! Any suggestions? I have not been told of pads to use, can you get them at medical supply store and at my age do you still recommend bone density testing? Thank you for your opinion, any suggestions or help is greatly appreciated.

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  27. I will reply to this on my blog tonight and I sure hope it helps. Rich

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  28. I am a dancer too and, as many dancers, I suffer from a sesamoid fracture. Thank you so much Dr. Blake, this post was really helpful, it gave me some hope!

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  29. Dear Dr. Blake,

    I suffered an avulsion injury. The fracture in zone 1 of my fifth metatarsal is not displaced and the ends of the fractures are within 1 mm of each other. I have been given conflicting advice: 1) no weight bearing (for at least 4 weeks) in a knee high air cast with a follow up x-ray at about 4 weeks to monitor union and 2) ace bandage wrap and stiff shoe boot with weight bearing as tolerated. I live alone and have a job that requires me to be hands free and so complete "no weight bearing" is not an option for me and so I have been basically following the advice of "weight bearing as tolerated" My two week x-ray showed no change (no worse no better). I was also been given and ultrasonic bone stimulator about two weeks post fracture as an aid to speed healing. What are your thoughts? PS There is no pain with the fracture and no pain with weight bearing (I usually use one crutch so as not to place full weight on the bad foot.
    Thanks,
    CAthy

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    1. Hey Cathy, These fractures tend to heal well, with a little help. The bone stimulator may be overkill but go for it. You need to create a pain free environment for healing, which is what it sounds like. Make sure that you are getting good Vit D and Calcium. Hopefully you have good bone density. X rays are a poor way at following healing, so I would wait another 6 to 8 weeks for any more. You only need some compression to get keep the swelling down. You can hurt the injury with another twist with the next 4 weeks, so be careful. Ice for 10 minutes twice daily, and do a 20 minute contrast bath once daily. Gradually increase your walking. Based on where you are at at 8 weeks will dictate if further protection with taping, orthotics, etc is necessary. Hope this helps.Rich

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  30. Thank you so much Dr. Blake. Your reply was very helpful to me.

    Best,
    Cathy

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  31. Dr. Blake,
    My 16 year old son injured his toe in football and was diagnosed with turf toe. Despite following all the recommendations (RICE, orthotics), it has not healed so we got a 2nd opionion and were told he has a sesamoid fracture and requires surgery to remove it. We are really hoping that he can finish his football season first. Would you recommend cortisone in this situation to help control the pain? What is the prognosis in a young very active boy who wants to continue football? We are very concerned about his running abilities following a sesamoidectomy. Any advice you can offer would be much appreciated!

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    1. Thank you so very much for the comment. Since most sesamoid fractures heal without surgery, I would have to say avoid cortisone to mask pain at all costs. Have orthotics made that off weight the area, learn to spica tape, ice 10-15 minutes 4-5 times per day, make sure his diet has 1500 mg of calcium and 1000 units of VitD, and wear a cam walker/removable boot when he is not playing (except sleeping). See if you can create a pain free environment where controlling the inflammation. Have him understand that there is no limping and sharp pain while playing, which could restrict playing time this year. Get a baseline MRI now and then in 6 months to check the healing. The healing on MRI should be consistent with the relief he is feeling. If he can not create a pain free environment, get several opinions and see what direction they point you in. I hope this helps and good luck. Rich

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    2. Thank you so much Dr. Blake. So you think that this can heal without surgery? We are being told that it should have been immobilized immediately and because we are now about 8 weeks out from the injury, that the bones cannot heal. We are very concerned about surgery and the long-term effects this might have on his foot. We did get an MRI, so now just trying to figure out the next steps-- surgery or try to let him play on it, but not sure if this could possibly risk further damage? Thank you again.

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    3. Definitely most sesamoid injuries can heal without surgery, but it takes alot of work and patience and the right treatments at the right time. I would suspect professional athletes getting big salaries have these removed all the time, accompanied with daily rehab, to avoid/minimize missed playing time. When dealing with children, it is so hard. The parents are in an impossible position. The child does not want any restrictions, and sometimes surgery is the quickest way to that solution. Avoiding surgery now has no guarantees, and then if surgery is truly needed, looking back with regret is tough. I can only tell you that surgery is also unpredictable. I have seen failures with even the best foot surgeons--podiatric and ortho.
      I would definitely go the conservative route and allow a chance for non operative success. You need to create a pain free environment for 3 straight months and then see where you are. I hope this makes sense. I do not envy this tough decision. Dr Rich Blake

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  32. Hi, Dr. Blake,
    Your blog has been a WEALTH of knowledge for me this past year... I had a chronic foot injury that went undiagnosed (properly, at least) until March 2013. At that time, my expert ortho surgeon and I decided that my medial sesamoid would be removed, as it was fractured/fragmented. I also needed my bunion repaired and hammertoe (second toe) fused to allow a plantar plate tear to heal. The surgery took place on April 24th. I have had MANY ups and downs since then. I've done everything I can to heal the right away--PT, acupuncture, swimming, orthotics, TENS machine, etc. I just had a follow-up visit last week, and I'm just disappointed with my progress... I seem to have "decent" and "bad" cycles of pain, and have been in a fairly bad one for the past few weeks. Prior to that, I thought I was turning a corner and started doing some more "challenging" activities like some light hikes in the woods and testing out some jumping activities, but always with orthotics on and atop thick Pilates mats! I was doing great, I thought, but as of a couple of weeks ago, the remaining sesamoid region in the left foot started to bother me a bit. My ortho is quite positive it is NOT fractured--everything has healed VERY well on X-rays (screw in big toe is still in place and looks normal), but he said I could get a CT scan just to set my mind at ease... I'm not having a ton of swelling--I actually have not since surgery, but I DO have pain... Part of my pain is related to my tendency to produce EXCESSIVE internal scar tissue when I've had a traumatic injury or surgery. When I fractured my right tibial plateau back in 1998, it took years to feel "normal" again, and I've had flare-ups. THIS is worse, though, as it's my forefoot and taking more pressure than even my knee! ;) At any rate, my ortho is very knowledgable about folks who are prone to excessive scarring (it's definitely genetic for me, though my scars LOOK fine externally!), but there's not much more he can do. My main fears right now are: 1) that I HAVE fractured the other sesamoid and 2) that I'll never feel less pain due to this excessive scarring... I really cannot bear it if I have to wear a CAM boot AGAIN for most of a year to see if yet another fracture will heal. I am praying it's just scarring/bruising/sesamoiditis, b/c at least I can "manage" that somehow... It's hard to know at this point what is "new" and what is just related to my body continuing to "rehab" from the surgery! I know I had rather extensive procedures done, but I guess I had hoped to be in a better place by nearly 8 months out. My doc said it could take my foot up to 2 years to calm down. Any suggestions at this point? Hoping to hear from him today re: ordering me a CT scan! I really don't want to have a totally sesamoid-less foot, but I can't really fathom going through my entire life worrying I've damaged the remaining little bone! ;) Help! Thanks in advance!

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  33. I want to to thank you for this great read!!
    I definitely enjoyed every little bit of it. I have you saved as a favorite to check out new stuff you post…
    Regards - Powiększanie penisa ()

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  34. Dr. Blake,

    I am a 50-year-old woman and I work out 5 times a week. I run on the tredmill for 20 minutes each day and then end my workout lifting weights. I used to be a gymnast and 24 years ago broke a sesamoid bone in my left foot. After several trials of everything, I ended up having surgery removing the broken bone. Following my surgery I developed RSD. To remedy this I had daily injections as an epidural for a week. I haven't had any trouble with that foot since.

    In October I noticed my right foot started hurting in a similar way as my left foot did. I have a high tolerance for pain and continued running on it, not to mention, wearing pumps and boots with a higher heel. It got to the point where I just couldn't take it anymore, so I went to a local podiatrist in Factoria, WA. He briefly looked at my foot, took a xray, and told me my sesamoid bone was broke into two pieces and was splintered pretty good. He put me in an air cast and scheduled a follow up to evaluate whether surgery would be required.

    After that appointment, I just didn't feel confident in the diagnosis, so I decided to go to a top rated podiatrist in Bellevue, WA. Before I went I requested a copy of my xray from the previous doctor, but when I got to my second opinion appointment, no one in the office could open the xray on the CD. Having said that, the doctor had to take another xray. He gave me pads to wear and discussed surgery and available dates. I put my aircast back on and left. On the way home, the second opinion doctor called me and said he looked at my xray as well as his partner and did not see any break whatsoever or any splintering like the first doctor claimed. I have been back for a follow up with the second opinion doctor and have another appointment on Jan. 6th 2013 for a possible cortisone shot. The second opinion doctor doesn't have a clue what it could be causing my pain.

    My foot still hurts off and on...more on than off. I have also noticed than when I cross my right leg over my left, the bad foot tingles terribly. I had a pedicure before Christmas and the girl working on me massaged my feet and pulled on my toes. It did feel quite a bit better after that, but a couple days ago the pain flared up again.

    Today I downloaded a program (OmniVue) that allowed me to open the first doctor's xray. I now have a copy of both doctor's xrays. I compared the two and really don't know what I am looking at. I was able to export the first doctor's xray and save it as an image. Would you be willing to allow me to email the image to you so I can get your opinion on all of this? If so, I would certainly appreciate it.

    We are meeting with the first doctor on Jan. 3rd to give him an opportunity to explain himself. I don't want any trouble. I just want to know if my foot is broke or not. My biggest concern is nerve damage and the possibility of developing RSD once again.

    Thanks in advance.

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    1. Thank you so very much for the comment. I understand your concerns. You could get photos of each image as blown up as possible and send them to me at drblakeshealingsole@gmail.com. X rays normally are not conclusive, so requesting an MRI would be best. You can send the CD of the MRI to me to review. RSD can develop from many reasons, and I would not have a shot unless you are 100% certain it is not broke. Dr Rich Blake

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    2. Thank you so very much for the comment. You can take photos of the xray images (as big as possible) and email to me at drblakeshealingsole@gmail.com. You should however not get a shot unless you have an MRI which is the best definitive test. You can send me the CD of the MRI and I will be happy to look at. If you can not get an MRI, and the xrays not are that definite, I would follow the protocol for a fractured sesamoid which includes 3 months in a removable boot, and a bone stimulator. Make sure you are doing well with Calcium and Vit D3 and icing twice daily with contrast bathing once daily. Hope this helps for now. Rich

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  35. Dr. Blake,

    Thank you for all the valuable insight I have been reading. I was having on and off ball of foot pain for 2 months before I saw a podiatrist. Since that particular day was a "good" day pain wise, he did not think I had a sesamoid fracture but leaned toward either sesamoiditis or a bipartite sesamoid causing some inflammation. Took an x-ray just in case, and turns out I have bipartite tibial sesamoid and a longitudinal fracture in my fibular sesamoid. Podiatrist was extremely surprised, especially since the fracture is longitudinal, which in 20+ years he says he has only seen about 20. All he told me was to wear a dancer's pad and gave me some inserts for my athletic shoes. I exclusively wear Birkenstocks because they give me the most relief versus athletic shoes and inserts but I'm wondering if I should get another opinion? From what I've read nearly every single person with this fracture is put in a boot or is non-weight bearing for several weeks to start the healing process in addition to special bone growth treatments, physical therapy, etc. My podiatrist seemed too unconcerned and casual about this fracture. He didn't even suggest a follow up x-ray/MRI in a few months to see how the fracture is healing. Thoughts?

    Thanks for any help.

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    1. Definitely get into a removable cast and ask about Exogen Bone Stimulator. The sesamoid is too important, and you need to treat aggressively. Rich
      Give him another chance if you think that overall he is smart, kind, and willing to experiment.

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.

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