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Sunday, November 20, 2011

More Email Advice on Sesamoids

This email was received 1 month ago, so I am definitely behind, and for that I apologize.

Dr. Blake,


It's Victoria again (http://www.drblakeshealingsole.com/2011/09/sesamoid-fracture-email-advice.html), and just wanted to thank you once again for your very thoughtful response and advice. I have began using the Exogen bone stimulator for 20 minutes a day, twice a day and incorporated contrast baths when possible.
Dr Blake's comment: When a fracture seems to have a chance at healing, consider a bone stimulator to help it along. The Exogen system uses ultrasound I believe and can be effective at 20 minutes twice daily.

I am really hoping for the best and doing all I can to avoid surgery, but I wanted to pick your brain to see what conditions have to exist for you to believe surgery really is the better option?
Dr Blake's comment: For most sesamoid injuries, no one would say you rushed into surgery if after 1 year you still had significant problems with disabilities (inability to do things that surgery may allow). That being said, many of my patients are on a good road to recovery at one year, and can see that they are making process, that it is very realistic they may not need surgery at all.

 Is there a time limit after which the bone likely will not heal?
Dr Blake's comment: Probably 5 years of continually seeing bone edema on the MRIs with associated pain, probably means that the situation is too far gone to avoid surgery. That being said, the pain may be from the fracture, the chronic swelling, scar tissue that develops, arthritic changes within the joint, etc. I know of too many of these injuries that the patient does great but the bone does not look perfect. So why do some patients continue to hurt and others not? This is the dilemma of the patient and doctor. At times in the treatment it makes sense to focus for periods of time at other causes of pain, while still protecting the bone. I remember a striking example of that during my initial years in practice. A patient presented with to me an obvious unhealing sesamoid bone requiring surgery. She had done all the standard treatments but not better. As I scheduled her for surgery, I also started her 3 times a day on contrast baths to make sure there was minimal swelling in the area at the time of surgery. She never had the surgery. The chronic swelling in the area, the actual cause of the pain at that time, was eliminated by the contrast bathing!! Good lesson.

If I opt not to do surgery, will I have the potential for sesamoid flare-ups the rest of my life such that it would be best to remove it and be done with it?
Dr Blake's comment: If you opt not to have surgery, that means you have developed a method to control pain and protect the sesamoid. Every day that passes the area will get less fragile and it will take more abuse to cause a set back. Controlling and watching and attempting to eliminate set backs becomes the main job for the next 2 years. With most of my patients, I am now 2 to 3 years out past the original injuries by now. If they are still having major periods of sesamoid woes that this time, I say enough is enough. This is probably less than 5% of patients (1 in 20) requiring surgery at this time.

 If I remove it, will it place more pressure on my remaining sesamoid bone?
Dr Blake's comment: Yes, so some protection of the other sesamoid for life is necessary. This normally is no big deal (sometimes a dancer's pad in a high heel will do the trick).

If my goal is to return to being able to wear heels, go salsa dancing in them, play tennis, and take up running again, which scenario would you steer toward?
Dr Blake's comment: If you plan on being very active following a sesamoid injury, and wear Lady Gaga-like heels, and play tennis like Serena, think save your sesamoid at all costs if possible. It is the saving of the sesamoid that allows the most normal post injury function, not in removing it to get on with life. Removing the sesamoid causes three problems (hopefully all minor, but you never know). These problems are: scar tissue, weakened joint, abnormal functioning joint, and possibly a surgical complication like infection, etc. Not removing the sesamoid may perserve the joint the way it was originally designed. So, unless the pain and disability can not be improved, but in slow cases taking several years, I always try to perserve.

There are so many variables that I could really use your advice on what the pros and cons are of either living with the hopefully-healed sesamoid versus surgically removing it.



Thank you in advance,
Victoria
Dr Blake's comment: I hope this helps some, but you see it gets very individual. Mild pain to one person is sharp to another, mild disability to one is life changing to another. If you have done your due diligence and tried to save your sesamoid, and after 1 year you and your health care providers can not see a way to improve your disabilities, have it removed. The more I know about problems, because there are actual human beings attached with different sensitivities and goals, surgery or nonsurgical treatments become the way to individualize for each patient. Most medicine based protocols can be too limiting as the health care community learns more and more and more and more. For me, it would be easy to give up my 4 inch heels, but maybe not for you if that was what you were eventually asked to do (to avoid surgery or even after surgery).

1 comment:

  1. Thanks for the great post! After struggling in very similar ways to Victoria it is nice to hear some concrete answers. It is so difficult to get a quality, honest, well informed opinion on this injury.

    ReplyDelete

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.