Sesamoid Fracture: Need Help in Los Angeles, California

This is an email sent by a young lady several days ago. I have already sent her to a good friend of mine Dr Daniel Altchuler in Santa Monica. I know Dan personally to have similiar philosophies as I do. When you need help, a good place to start looking is go to the website of the American Academy of Podiatric Sports Medicine at www.aapsm.org  and look in their membership. Most of the podiatrists in this academy are serious about treating athletes and that normally means they are pretty conservative in their treatments (normally!!).  

Hi Dr. Blake,

First of all thank you so much for having an email address where people can reach out to you.  I was diagnosed with a sesamoid fracture in my right foot yesterday.  I went to the Podiatrist two weeks ago with severe foot pain and swelling.  She was treating me for sesamoditis.  Two weeks later, I went back still in pain.  She xrayed me again and this time the fracture showed up.

Dr Blake's comment: Fractures in many areas of the body can take 2 weeks to never to show up in an x ray. Sesamoids, little bones under the first metatarsal at the ball of the foot, are particularly difficult to diagnosis by x ray. The patient and treating doctor when the injury seems to be sesamoid related should initially attempt to create a pain free environment. It will almost make the diagnosis because it will be harder to create this pain free environment with a true fracture vs an inflamed sesamoid (called sesamoiditis). You have to treat the worse possible cause of pain, unless you go right to a bone scan or MRI. If you create this pain free environment, sesamoiditis will need less time overall to resolve where a stress fracture of the sesamoid normally 3 months to 2 years. And some do have to be removed, so we want to calm that sucker down quickly.

  She put me in a cam walker and within an hour or so I was feeling pain at the fracture sight.  She recommended that I go back into UNO boot & surgical boot which is what she had me in when she thought she was treating sesamoiditis.  You mentioned in your blog that all podiatrists know to how to make a walking boot pain free, yet she didn't mention this as a solution.  She also didn't offer me an MRI.  Should I be seeing a "better" doctor? She takes conservative measures so I felt she was capable of treating my fracture.  Can you give me a referral to a Podiatrist in Los Angeles?  

Dr Blake's Comments: Wow, there is a lot to comment there. It sounds like she is trying to rest the area, but is missing some subtle aspect, like accommodative padding to take pressure off. Normally docs do not recommend MRIs initially if they can get the area calmed down in the first followup visit or two. In general, the first month is reserved for making the proper diagnosis, and creating a pain free environment so you and her are half way there. Does not sound like she is lacking in effort, and this is what you want out of the health care provider who has agreed to help you. Those cam walker, also called removable boots, need to be modified alot, but can be very helpful and can even become your friend the next 3 months. For right now, go with what makes you comfortable in all activities, instead of one item that makes you hurt. Common sense and listening to your body is key. Do you need a second opinion? The jury is still out.

While I am emailing you I have another question.  Two weeks ago I upped my speed/time on the treadmill and I also began running for a few minutes at a time.  The day after this I started feeling foot pain and within 1 or 2 days I couldn't walk.  With this increase in my activity it's pretty obvious what caused my fracture.

Dr Blake's comment: Fracture pain comes on suddenly like this, sort of one day you do not have it, the next day you do, whereas sesamoiditis tends to come on gradually. 

  SO about one week into the doctor wrapping my foot in an UNO boot/Surgical boot I started feeling dull aches in the sesamoid in my other foot.  By the way I had surgery 15 years ago to remove a fractured sesamoid from my left foot so I only have one in there.  Fast forward a week or so and the dull ache is still about the same.  I feel it here and there usually when I put more pressure on that foot.  I can still flex/scrunch/point/push that foot without any pain.  I am REALLY praying that I didn't fracture this one as well.  Is it possible that it is just irritated from extra pressure?

Dr Blake's comment: What makes sense here? A fracture or just soreness in an old injured area from compensating. Everyone raise your hand who thinks it is a fracture. 

From what I have learned, sesamoids are very difficult to heal.  I have a 2 year old and 6 month old so this has been a huge burden and I am having a pretty rough time emotionally.  Also I am experiencing shooting pains in my lower back in only one day from being in the cam walker.

Dr Blake's comment: You definitely need to get an EvenUp for the other shoe and may need some time with crutches (but of course that would depend on how successful you and your health care provider were at achieving this pain free environment). Sure hope this helps you. 

Any advice, insight, info along with a referral would SO appreciated.

Best