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Sunday, September 16, 2012

Sesamoid Fracture: Email Advice

Hello Dr. Blake

Around 5 months ago, I increased my level of activity significantly (too much too soon) and I got tendonitis in my right foot on the peroneal tendon.  I was limping around for about 3-4 weeks and was shifting the majority of my weight onto my left foot.
Dr Blake's comment: Golden Rule of Foot: Avoid limping with a passion!! Limping causes abnormal forces throughout your body, and something else may be injured and it is usually worse than the original injury.

  On May 11th 2012 my left foot started hurting around the 1st,2nd and 3rd metatarsals (throbbing pain).  I rested for a couple of days and it went away, then I walked again and the pain came back even more intense.  By the end of May I was limping really badly and my big toe was tingly and painful.  Palpating the sesamoid bones induced a lot of pain.  At this point even sitting in a chair and letting the big toe touch the floor caused me a lot of pain.

I decided to non-weight bear for 3 weeks. 
Dr Blake's comment: Great, this is much better than limping and attempts to create a pain free environment for ultimate healing.
 The pain reduced dramatically but I still felt some tingly sensations and I had lost the capability of flexing my toes down.  When I tried walking it was extremely stiff and I had a lot of discomfort at the 'toe-off' phase of gait.  I am a 3rd year Kinesiology Student (21 years old) so I knew that there would be a lot of stiffness at first.
Dr Blake's comment: If the sesamoids are involved, you must avoid pushing off for several months or you keep irritating. 
I walked for about 1 minute, and the intense pain came back again.  I was extremely discouraged, and was starting to suspect a stress fracture.  I got an x-ray around July 20th and my doctor said everything looked fine, but from what I have read online, sometimes x-rays don't show a stress fracture unless there is a clear break and a gap between the pieces.
Dr Blake's comment: Definitely right, sesamoid injuries that cause intense pain need an MRI.!!! 

On July 27th, I received a used exogen 4000+ system off eBay and began using it.  Around august 28th my left foot didn't hurt when I palpated the sesamoid bones and I could walk around (with limited dorsiflexion) with no pain, but some stiffness still. I decided to go back to my Doctor and ask for an MRI.  He immediately told me no, because family doctors in Canada aren't really allowed to give MRI's especially for something non-life threatening.  So I convinced him to get a bone scan.
Dr Blake's comment: In San Francisco, there is an MRI facility almost on every block, and you can self pay for around $575 for a foot one. See if you can self pay, and pay in small installments monthly. 
My bone scan was scheduled for September 5th.  I decided I could walk around in the hospital because my foot wasn't as bad.  I should have asked for a wheel chair, because the day after my sesamoids were throbbing and my foot was a bit swollen.

On September 10th, I got the results back from the bone scan, which said there was increased bone activity at the first MPJ and Sesamoids.  I saw two different doctors.  Doctor 1 told me that based on pain upon palpation of sesamoids and the bone scan results, it is indicating a stress fracture.  Doctor 2 said the results were essentially normal, and I should just do physio and use orthotics.  I was a bit offended by what Doctor 2 said, because I have tried physio, non-weight bearing, orthotics, everything essentially for 5 months and I still can't walk.
Dr Blake's comment: Basically both doctors are right, but they are in 2 different phases of rehabilitation. Because of your length of time since onset of pain, you should be where Dr 2 has you--The Restrengthening Phase. But you are not, you are in Phase 1: Immobilization/Anti-inflammatory Phase. You need to be in a removable boot for 3 months, evaluated every month, and doing ice and/or contrast bathing 3 times daily. Avoid NSAIDS since they can slow bone healing. Keep up the Bone Stim for the next 6 months, it is great to get those bone forming cells working. 
Doctor 1 happens to be a fill-in doctor at my family physicians clinic and Doctor 2 is my family physician.  Doctor 1 wanted to send me to a sports medicine specialist, but Doctor 2 (since he is my family physician) cancelled the referral to the sports medicine specialist.  I feel like I am getting no help from my Doctors here in Canada, I have no options left because my family physician is making it his goal to make sure we never know whats going on with my foot.  My last option seems to be going to rheuamtologist that I was referred to several months ago and asking him to refer me to a private MRI clinic which I will pay for myself.
Dr Blake's comment: Wow!! And yes, you need to see someone to get your baseline MRI, put you in a removable boot (around $75 from www.mooremedical.com), and have some compassion. Remember you are getting the MRI to document what is going on, but also most patients have a second one 6 months later. So, the first MRI is a crucial baseline to document the changes seen in the second MRI (if needed). 
I am going to buy some kinesio tape so I can do the Spica taping for hallux limitus.  I will also be buying some Dancers pad to use in conjunction with my orthotics (did I mention that I over-pronate?).  Maybe a rocker bottom shoe or a shoe with a wide toe box will also help?
Dr Blake's comment: You will heal this because of you are thinking through everything. The only rocker shoe I am suggesting patients try right now is HOKA running shoes. The others seem too unstable, especially for pronators. But if you feel unstable in them, return them instantly. I have only seen the HOKA Mumble (sp?), but I do not see that one advertised. 
     I would be remiss not to talk diet. Developing a stress fracture from limping is still not common. Probably more common in pronators, but how is your diet. Do you eat red meat? Are you getting 1500mg Calcium and 1000units Vit D daily? Are you too over caffeinated? Do you eat too much sugar? When looking at bone healing, you need to use orthopedic principles but they may not work if your diet is off.  Something to think about. 
I appreciate any help, I know your very busy running your own clinic and answering questions on your spare time, so I am very thankful for your advice.
Dr Blake's comment: I hope this helps. Rich



Thank you for your very quick reply Dr. Blake,

I am very slightly anemic, but I have increased my red meat and vitamin B consumption.

I lived a very sedentary life style for most of my teenage years (addicted to video games) and didn't eat correctly.  Maybe this made my bones particularly fragile, muscle imbalances and other problems I don't even know about.  I tried breaking out of this life style too quick and injured myself as a result.  This is just my view on it.

I am taking 1500 mg calcium through supplements and 2000 IU vitamin D daily for about 2 months now.  I also drink milk, and eat yogurt regularly my entire life.

I have especially tight calves, which I know increases pressure on the ball of the foot, I am currently stretching it 30 seconds daily.

I wish I could fly out to San Fransisco and get an MRI (you don't need physician referral?), but how can I travel when I am in the immobilization stage of recovery.  In Canada I need a physician referral and I think also I need to leave Ontario and go to Alberta to get a private MRI.

Once again, Thank you for answering my email

Dr Blake's comment: 
     Please show your doctor our correspondence, or the rheumatologist, and see if they will agree with at least our direction as they must treat you not I. Watch out on taking too much calcium. 1500mg of calcium is the combination of dietary and supplements. If you take too much, it could give you kidney stones, and then you have a worse problem. The people in your area will help you. Are the Canadian podiatrists in your area my referral only?? Keep me in the loop. Rich


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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.