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Friday, April 8, 2011

When Is Swelling Bad? Answer to an Email

Email sent from Jeff in New Jersey today.

Dear Dr. Blake,

A year ago I fractured the right medial sesamoid bone. I just recently

had an MRI and it says it is completely healed.


Problem is it is still pretty much swollen as when it first was


injured. The orthopedic surgeon referred me to another surgeon

because he is at a loss why swelling is still present. I have been

walking around for a year in home made orthotics and I had to open the

shoes on top to acommodate 2 inserts and a dancer pad. Quite a sight!

Do you have any idea why the forefoot is still swollen even though the


sesamoid is healed ?

Thank you very much.

Jeff

 Plantar Axial xray showing the broken lateral fibular sesamoid, not the one Jeff hurt.
 MRI image of the 2 sesamoids under the big toe. Jeff hurt the one towards the outside, not the one more internal.
Typical Dancer's Pad to float the big toe as mentioned in Jeff's email.

Dear Jeff, Thanks for the question. The biggest question concerns whether the swelling is just excessive, or does it mean something still is wrong? Swelling is a normal part of healing, and healing can continue for months and months after a bone injury is completely healed. The body first heals an injury and then heals it further to make it stronger than it was originally. This can produce normal swelling for 2 to 3 times longer than the time it took to heal the bone in the first place. Ankle sprains are probably the most studied injury. The average ankle sprain takes 6 to 8 weeks to heal, yet the average patient has swelling to deal with for 4 and 1/2 months.

     You, of course, want to assume the swelling is normal, and just hanging around too long for your liking. I am assuming by your description is that you have no pain, just swelling. Pain from swelling alone rarely gets above 2 in a pain scale of 0 to 10.  Please comment on this post and I will respond if any of my assumptions are incorrect. If you have swelling and level 4 or more pain, the MRI is not telling the whole picture. You may want to consider a CT Scan which isolates the bone aspect.

     Before you get too excited, I would follow the KISS rule. What is the most obvious? The most common problem with foot injuries on any type is that they swell too much. Our feet are down all day, you have probably been less active which means the swelling has less ability to move out of your foot, and you have worn tight shoes longer than normal (plus it has been the winter). All this can make our feet collect fluid in general, and we will collect more fluid in an injured area over any other spot.

    So, what would I recommend? As long as the MRI results seem to match up with your pain level, please be aggressive with treating the swelling for one month. Everyday do 5 things to reduce swelling, and after 30 days you have done 150 treatments for the swelling. The common treatments for swelling are:

    1. Contrast Bathing 1-2 times per day
http://www.drblakeshealingsole.com/2010/09/swelling-reduction-video-on-contrast.html

    2.  Ice Packs 10 minutes 3-4 times per day

http://www.drblakeshealingsole.com/2010/04/ice-or-cold-therapy-helps-in-injury.html

    3. Physical Therapy with topical cortisone called iontophoresis (5 times in a 2 week period)
    4. Elevation of the body part 2 hours per day (even if it is only several inches off the floor)
    5. 24/7 Compression with Tubigrip or Coban like wraps (physical therapists usually can guide you and perhaps even 1 PT visit to make sure you are wrapping correctly would be wise)

Here Coban is being used around a toe, but you will need to wrap it around the ball of the foot (all the way around the front of your foot).

   6.  Medicines like Zyflamend and topical anti-inflammatories (start with generic and see what the pharmacist recommends). Just stay away from the prescription anti-inflammatories like Advil and Aleve since they may slow down bone healing (and we are not 100% sure the bone is completely healed).

   7.  Of course, activity modification to avoid pain producing activities (over a level 2 or 3 pain) will reduce swelling by limiting aggravation. Read and understand the post on Good vs Bad Pain.

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

  8.  5 minutes of painfree massage to the swollen area

  9.  5 minutes of gentle motion of the toe with moving the toe up and down (active range of motion).

      Your doctor can also drain the joint (then they send the fluid to the laboratory for analysis). I have had a few patients develop a huge ganglion cyst after a sesamoid injury that needed to be drained like the one in the photo below.  The first photo is off the patient injured right foot. The second photo shows the difference in the non-involved side. The third photo shows the MRI of the swollen ganglion cyst that I have drained. Jeff, if you can take a similiar photo of the MRI image which shows the swelling the best, email it to me (even 2 or 3 images).


So, dedicate the next month at reducing the swelling. If the MRI shows the swelling this well organized, then you may need it drained. Let me know if this is helping you. Rich Blake

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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.