Fractured Fibular Sesamoid Email Advice

Hello Dr. Blake:

Thank you for your awesome blog. I have found some very useful information with regards to my own problems. However, I do have a few questions for you. I have a fractured fibular sesamoid. I believe I am in the healing stages, but I have some concerns on what is normal/average in healing.

This is an image of the broken fibular sesamoid on the left side. See how round the normal sesamoid looks.

Here is a case where the fibular sesamoid to the left has small dark cracks that are healing, and the obvious bipartite (2 pieces) tibial sesamoid to the right also shows signs of bone healing (irregularities within the bone). 

My background is that I am a 26 year old male and I am moderately active. In mid-September of 2011, I was on a hiking trip/ get away with several friends. We went on an intensive half day hike and spent some time playing some ridiculous dancing game, which I participated in without shoes and on hard wood floors. While on the hike, I wore an old pair of athletic shoes. The following day my foot hurt significantly in an aching sort of away. This continued off and on for a few months as my chiropractor cited their own suspicions for the pain and tried different practices on my foot. However, none of it worked so I went to an orthopedic doctor in January 2012. I had my foot x-rayed and he immediately diagnosed my fibular sesamoid as having a visible stress fracture.
Dr Blake's comment: When diagnosis goes 3 plus months from occurring, thus delaying proper treatment, the treating physician should be more conservative/more cautious in the treatment. Stress fractures of the sesamoids without fracture displacement take normally 3 months in a removable cast to heal, then a 6 week weaning process out of the cast. During this entire time a painfree environment should be established. This is especially true with delayed diagnosis.

I spent four weeks in a cam-walker/boot and returned to have more x-rays. He said that is still showed a fracture, but it was healing. In physically examining my foot he found spot that was still tender.
Dr Blake's comment: The tenderness to palpation can exist for months and months after full healing occurs. So it is of only slight importance at this stage, since the bone swells during the healing process as it brings in the nutrients for healing. The cam walker, like below, should be used with an EvenUp on the opposite foot, and if orthotics are successfully made that take off the weight and produce pain free ambulation during the second month of casting, gradual weaning of the cast can begin. Two months is the fastest to begin weaning out of the cast. X-rays can show the fracture line many months after the bone has completely healed. Part of the reason is that the fracture area will have the most fluid, making the calcium content diluted. X-rays only pick up relative calcium concentrations, so more water in an area will make the bone look less healed. Also, healing of the fracture occurs internally first with strong but immature bone, and the fracture healing on X-ray can be 2 months the actual intrinsic healing. Which is really all we care about. So, X-rays are also a relatively poor indicator of overall healing, although can show the fracture is getting worse, etc, so still used.

 That is when he discussed with me that sometimes the sesamoids don't always heal and that they sometimes have to be removed. (Not something that I wanted to hear.)  I was told to wear the boot another two weeks with an additional two week transition out of it. He stated that if I was still having some pain issues to schedule another visit with him.
Dr Blake's comment: If I took this approach, I would recommend surgery to 90% of my patients unnecessarily. Stay in the boot for 3 months total since you are too young to screw this up. Get some Sole Arch Supports or Superfeet (may have to see what naturally feels better on the sesamoid). The third month in the cast is the time to get the insoles that you will use out of the cast in order with some version of a dancer's pad, learn to spica tape, have your Vit D3 levels analyzed, ice twice daily to reduce the remaining inflammation, and pick up the most comfortable shoe of the sesamoids (normally running shoe or cross trainer). It is not the right time to start figuring that stuff out the day you are ready to wean out of the cast. 

Two weeks later, I am at the present time. I still have aching underneath the ball of my foot. Though it is not constant or necessarily as strong, I am concerned that it may not be healing as it should be. I have not scheduled another appointment as of yet. As a side note, I have been taking a calcium supplement that equates to about 1200 mg a day and 800 units of Vitamin D3.
Dr. Blake's comment: I like 1500 mg Calcium and 1000 units of Vit D3 for athletes in general, and this is a great time to take these levels. 

Here are my questions:

1.     Is it normal to encounter some soreness/ aching while healing?
Dr Blake's comment: Yes, and keep the pain level between 0-2 on the pain scale. Read my post on good vs bad pain and commit to memory. 

I have been visiting the gym and using only the elliptical and bikes for cardio. I attempted a treadmill for about 10 minutes, but it made my foot really ache.
Dr Blake's comment: I hate the treadmill at this stage of most foot injuries. The biomechanics of stress free treadmill walking or running is based on you hitting the treadmill at the exact speed that you set the treadmill at. If your speed is slower than the set speed, the belt jerks your foot to speed you up. If your speed is faster than the set speed, the belt puts tremendous stress on your foot to apply the brakes. I try to keep my walking and then running rehabilitation on the streets. 

2.     Are the machines I’m using likely to aggravate the foot or are they safe to use? Should I be using other machines instead? At what point is it safe to return to the treadmill?
Dr Blake's comment: Do not know enough about you in specific, but I would definitely stay away from the treadmill at this time. Biking is normally fine, and a stationary bike perfect since you can control where you foot is on the pedal. Swimming great. Elliptical without arms is okay if you have the right orthotic/dancer's pad protection. I try to have my patients go with no arms, since that arm motion forces your heel to fit off the supporting surface. Even with that, the elliptical can still put unnatural force against the ball of the foot since it is a solid metal platform pushing back on the sesamoids with great force. But, listen to your body. It tends to tell you as an individual what you can and can not do. 

3.     I asked my doctor at my last appointment if there were special inserts or shoes he would recommend and all he stated was a stiff soled shoe. What would you recommend?

Dr Blake's comment: Stiff soled shoes are wonderful unless you actually try to push off against the stiffness. Patients really vary in the shoe gear. Some patients need more cushion in the forefoot, others need it stiff, others actually need it to be very flexible. We use generalizations for everything in medicine. This is one of them that has a lot of truth, but there are many exceptions to that rule.

4.     Lastly, should I schedule another appointment with my doctor or is this all part of the normal healing process?
Dr Blake's comment: Yes, unless you decide to get some other opinions, which I love when patients are not improving or elective surgery is being recommended. Go in with your cast on, read all the posts on the tips for conservative treatments on sesamoid injuries, but also Hallux Limitus/Rigidus. The same rules and exceptions can apply. Ask a lot of questions. Never stupid questions at this stage since your life long foot health is at stake.  Hope all this helps. Rich

Thank you Dr. Blake. I look forward to hearing your expert advice.

Sincerely,

Brian (name changed to witness protection)