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Friday, March 16, 2012

Fractured Fibular Sesamoid: Email Advice Before and After Surgery

Hi Dr. Blake,


I sent you an email with lots of questions about a month or so ago. This is the link if you need:http://www.drblakeshealingsole.com/2011/10/sesamoid-injury-email-advice.html. I have a couple other questions for you. I saw a podiatrist and he suggested removing the fibular sesamoid bone rather than trying the bone graph that the orthopedic doctor suggested. So I am waiting to see him again to schedule surgery. My question is about the surgery to remove the bone, what are the statistics for the surgery as far as positive and negative outcomes?
Dr Blake's comment: I am unsure of the exact statistics, but 50% excellent (no problems), 45% good (some problems, but surgery still successful), and 5% fair to poor (surgery not considered successful) would be a close estimate of my experience.

Also how long does it take to recover from the surgery mostly in order to return to work and of course to the dojo too. I am still working to find a comfortable arrangement of the taping and the off setting the foot with the pads, that is a work in progress.
Dr Blake's comment: Return to work and activities vary immensely because of the demands on our feet. Overall, 2 weeks the stitches come out, then 10 weeks of physical therapy for swelling reduction and scar reduction, running in 6-9 months with the proper shoes and orthotics. Most people take 2 weeks off work even if they have a desk job. 

While looking at new posts you have made I found this link:

http://www.drblakeshealingsole.com/2011/09/sesamoid-fracture-email-advice.html and I have a question about the pictures. On the fourth picture where you are showing the placement of the felt, the boot you are showing is much shorter up the leg than I have been able to find. It looks like it comes up just above the ankle. If this is so, where can I find one? I have just about worn out my second cam walker and I have been looking for one that is this low.
Dr Blake's comment: It is called an Anklizer, and you can google where to find it. Of course, do not forget the EvenUp for the opposite side.

My final question is about orthotics, the doctor suggested purchasing orthotics with a morton's support which is supposed to keep the big toe side of the foot straight. After I have surgery to remove the bone, will that be necessary or will the orthotics need something different?
Dr Blake's comment: Typically for 2 years after the surgery, the big toe is protected with orthotic devices. The ordering practitioner must experiment with amount of arch support ordered, amount of additional metatarsal arch applied, and whether it is appropriate to use a Morton's Extension or a Reverse Morton's Extension. The goal of all of these factors is pain free function.

 If I am going to buy the orthotics which are not covered by my insurance, I would like them to be good for a while until I wear them out. Or is this something that I talk to the person when they fit them?
Dr Blake's comment: The basic design of the orthotic device is to shift weight to the center of the foot. There are soft based orthotics which will probably last 2 years, and more permanent plastic based orthotic devices that may last 20 years with some regular refurbishing. 

I have been using the bone stimulator for about 3 months over night, wearing the cam boot daily with taping and the padding to off set the foot placement. I am not consistent on taking the vitamin D and calcium or the soaking which I am working on since I know it will help. This weekend marks 8 months since the injury and I feel my foot is in the same situation it was 5 or 6 months ago. Reading the information from your blog helps to see what you suggest and how others are dealing with this injury. I appreciate your wisdom and your willingness to share that information with everyone. Thank you again for your help and have a wonderful Thanksgiving!

Tammy

Hi again Dr. Blake,


I hope you are having a great Christmas and New year. I read your latest post and I am sad to hear that someone else is in my situation, but at least she has you to take care of her. When you mentioned that your new patient may move to using a bone growth stimulator, I remembered that I have one that I used for 4 months and now it needs a new home. I have no use for it now and she can have it is she would like.

As I write to you, I am nursing a foot that is now minus one bone. The surgeon removed the fibular sesamoid bone that I broke back in March. He did say that the bone was completely broken in two, I guess that would explain why my foot has been so painful. I go to see the doctor next week to have the stitches removed and to talk to him about orthotics and therapy. I am going to take your suggestions with me when I see him and see if we can get orthotics with those stipulations. Even though I am still a long way away from going back to the dojo, I am on the look out for light weight shoes that I can put the orthotic in so I can keep my foot protected while getting back to the fun of katas and sparring. To begin with though, I need to get back to work. I am a teacher and my students have moderate to severe disabilities so I need my feet ready to stand all day and run when necessary.

Thank you again for your help and suggestions and please let me know if your patient can use the equipment.

Happy New Year!

Tammy

Dr Blake's comment: After I never responded to this email, I did write Tammy a note one week ago asking for a progress report and apologizing for my laziness of sorts.
  
Hi Dr. Blake,


Yes, a lot has happened since this last email. Right now I am one week away from the anniversary of when I hurt my foot to begin this whole mess. I had surgery on Dec. 16th to remove the sesamoid bone and the dr said that it was completely broken in two pieces. So I guess it is no wonder why it has been hurting. I was out of work for 7 weeks since I am a middle school special ed teacher and my students have severe to profound disabilities. I am on my feet all day pushing and pulling wheelchairs, lifting students etc. I continued to use the shoe padding to off load the area of tenderness in the boot as well as in shoes, but I still haven't mastered the use of the happads or the dancers pads, they just seem to hurt the arch of my foot.
Dr Blake's comment: Tammy is 3 and 1/2 months into a year journey to get the majority of her healing done. Sounds like everything is still quite aggravated. Make sure Tammy that the dancer's pads are just under the metatarsals. No need to get them near the arch. And ice for 10 minutes 3 times daily. If the foot is swollen, the try contrast bathing listed in one of my YouTube videos for one of those sessions. Since you have to walk on the operated foot, cool it down on a regular basis. 

When I went back to work the doctor wanted me to be in regular shoes all the time, but I couldn't make it the entire time. I am currently wearing the cam boot and the regular shoe during the day. I have been walking on the outside of my foot still, even though I can walk gently on the entire foot, but it is almost like I have to concentrate on walking heel to toe. I presume it is a bad habit I have taken up in the last year.
Dr Blake's comment: Tammy I see patients limping unconsciously 5 years after surgery. When some other body part begins to hurt due to the limping, chances are that the limping is not blamed and treatment is based on the wrong premise. It is important at this stage to walk slow, and walk correctly. I allow occasional limping to avoid pain. And walking normal with pain is not right. If you can not walk normal without pain, go back in the cam walker. I have my patients use the cam walker for some purposes for even 6-9 months after surgery. It is okay. There are too many protocols for these things that do not address the individual patient. Just to say you are at 3 months, and you should be full time in regular shoes, is based on averages. Averages are based on Bell Shaped Curves. If you know anything about Bell Shaped Curves, 1/2 of the patients are in front of the average and 1/2 of the patients are behind the average. General rules are just generalizations. Should I get to the Point? You are doing great Listening to Your Body. Have the Physical Therapist gradually remove all limping. They can be objective. 

 I started physical therapy last week, it consisted of some stationary bike riding and then the PT stretched the foot and massaged the scar. It was uncomfortable since it is still sensitive, but manageable.
Dr Blake's comment: Please check into buying Blaine scar treatment. It is a silicone gel pad to use for self massage, and another to wear that gradually gives off moisturizing oils to soften the wound. See my YouTube video on Self Mobilization of Scar Tissue using cross frictional or circular massage techniques.

 (He gave me some exercises to do at home too) The next evening and following day I was in the worst pain I had been in a long time. So I reverted back to trying to get it into a pain free state. It took a lot of drugs, ice and the blumjk topical stuff that you listed on your blog, this went on for two days.
Dr Blake's comment: This is my love hate affair with physical therapy. It takes a physical therapist 3 or 4 visits to know how sensitive tissue is to gradually produce positive change over the normal 10 week post operative period. You did the right thing reverted to what makes you pain free. Never ever go to a physical therapy place that has you see different therapists every time. You need consistently with the same physical therapist every time you go in for treatment. I normally like my patients to even cancel when they find out the physical therapist they have been seeing is off that day, and another PT will sub in. Physical Therapy is crucial for the healing of these injuries, but sometimes the physical therapists forget that.

 I went back into the boot all day too. Right now I am on the next day and it feels a little better, but I have taken it easy all weekend. I started using the blumjk the week I went back to work, so 4 weeks ago, and it made my foot feel so much better it was amazing. I have used that product a lot and shared with everyone I know. I think if their profits have recently increased I should be getting a kick back. :)
Dr Blake's comment: Tammy is doing all the right things to create this pain free environment for optimal healing. After you go through surgery, you want and demand every thing to go right. It is not a time to hope that things will get better, the patient must step up to the plate as you can see Tammy doing. It is her future, not the doctors or the therapists. I am not sure what medication she is talking about exactly.

 The PT also suggested that I wear a lace up ankle brace to give my ankle some support and hopefully help to get back into shoes, but the brace along the bottom of the foot cuts off right where the painful part is. He was going to try to come up with something else next time I see him. When I wear the ankle brace it is tight in the shoes so I don't use the padding to off set the weight. So I am kind of at a loss of what I should be doing.
Dr Blake's comment: Not sure why an ankle brace is at all necessary for big toe joint surgery!!!

 I went to talk to the man who makes the orthotics, the surgeon said they would be helpful and that I wouldn't need to have mortons extension, and he said to come back to see him when I am wearing shoes all the time. I haven't gotten there yet, earlier last week I was making it about half the day in regular shoes and then the rest of the day in the boot. It seems like I am taking one step forward and then five steps back and it is frustrating and painful. I haven't been at the dojo, other than standing and pointing, but have tried to increase my exercise carefully by riding the stationary bike. Definitely not as fun as sparring and working on katas and self defense.
Dr Blake's comment: Morton's Extension or no morton's extension, you need your orthotics to off weight the big toe joint right now. You wear the orthotics in your shoes, you wear the orthotics in your cam walker. The only role of the orthotic guy/gal is to make you a comfortable orthotic for the big toe joint that works in shoes and cam walker, and someone who understands how to think outside the box if things are difficult. Morton's extensions are a possible addition to the orthotic that may help your situation, it is not the main event. Get one now from someone who knows what they are doing. 

I know you had mentioned before that it will take a long time to heal and get back to normal and I am probably getting impatient. It just seems like I am going from one pain to another and maybe I am just being a baby and whining about pain from the Thursday and Friday. I am generally a tough cookie and can deal with pain, but those days I thought I was going to die and cry myself a river at the same time.
Dr Blake's comment: These are totally normal emotions, and I know you are tough by what you are saying, I hope others find strength in your words. Post surgery you have to throw out the clock and just accomplish one goal at a time. You goal right now is to gradually get out of the cam walker. Then you will set another goal. I did not say that your goal is to get out of the cam walker in 2 weeks, 5 weeks, or any weeks. Just use pain as your guide.

 I have been trying to not take the Norco medication the dr gave me for pain and had gotten down to one per day, but the last few days I have been taking it regularly. I had hoped that after the surgery there would be more improvement, however I also understand that I am only three months out after surgery.
Dr Blake's comment: Why are you taking this medication now? If it is to spend more time out of the boot, then stay in the boot more. If it is so that you can ice less due to time, try to ice more. If it is to sleep better, okay, but try to figure out with the doc or therapist how to cut this down. If the therapist wants to massage so hard to break scar tissue down, may be okay to take the medications the next two days. Goal: no pain medications after 2 weeks after surgery. Yet, again, just a goal. 

 I am at a loss of what else to do or even if I am close to doing the right thing. I am icing daily, attempting to off load the weight, taking the vitamins, doing the exercises from PT, and using the spica taping. I have some improved range of motion but my foot is still red and angry so I am trying to ice as much as possible. Thank you for checking on my progress and for any additional suggestions you can make.

Tammy


Dear Tammy, I am sure you are doing well. Make sure the physical therapist measures your joint range of motion at every visit to document improvement, or lack of. Look into the Blaine Scar Treatment, and get those orthotics. Spend more time in the cam walker if you need to. Do not look at any time table this year. That being said you should be better each month in function and pain. Are you better than one month ago? Always think about that with your doc visits and your therapy visits. I hope this gives you some perspective, and I am happy to help as the months go. Rich Hang in there.

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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.