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Please consider a donation if you feel the blog has helped you. A $5 donation will help me pay for the blog artwork, guest writers, etc. $90 has been donated in August 2017. I am very honored and grateful. Dr Rich Blake

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Tuesday, March 19, 2013

Sesamoid Fracture: Email Advice

Hi Dr. Blake, 

Just a quick update on my LEFT foot tibial sesamoid fracture.  So I got my recent flare-up in January and after your advice, I put myself back the boot to create a pain-free environment and all went well and I was back to 1-2 level pain (good pain hopefully) within 10 days.  Thank you!  Hopefully no more of those!  The bone has healed with part bone and part fibrous union, so it still appears mostly partially union with a slight bridge of bone on an x-ray.  But pain is manageable (0-2) at this stage in a stiff soled shoe.   

Though I was hoping you could help me out with one more thing.... my RIGHT foot.  Clearly my right foot has taken the brunt of the weight during my recovery of the left foot.  During my 3 months in the boot, I did experience slight sesamoid pain here and there in the right foot (which I had never felt before.... no foot problems whole life).  That clearly concerned me during at that time (6 weeks into the left foot sesamoid injury).  My podiatrist concluded that there was no fracture on the right foot given her examination (palpitation) and x-rays.  When I got out of the boot (on the left) after 3 months, the pain on the right subsided and I felt zero pain on the right. 

Anyway, 5 weeks ago, I started getting the pain back in my RIGHT foot and it was a little more prominent than it had been before but not even close to what my fractured sesamoid on the left felt like in the beginning of that injury.  It has not gotten worse or better in the last 5 weeks and the pain is probably at a 3-4. 
Dr Blake's comment: Definitely we need to do something with the pain level above 2. Normally, I would just have you starting 10 minute ice pack on the area 3 times daily to see how that goes for 2 weeks. 

 When putting weight on it, it tingles more so than hurts, which is totally different from when the left was initially injured which was straight 8-9 pain.  Still, I was worried and got x-rays with my podiatrist again with negative results for a fracture.
Dr Blake's comment: Tingling is nerve pain. Removable casts, even with EvenUps, can torque the back and cause referred pain to the foot. L4/5 nerve compression at the back can cause referred pain right to the sesamoid area. Lucky us!!! The nerve pain can also come from swelling near/around the sesamoid pressing on the nerves internally (not from the back). The icing should help that. 

  I went for a 2nd opinion to the foot orthopedic surgeon I had seen off and on with my left foot.  He saw nothing on the x-ray and ordered an MRI.  Last week, I got the MRI and the radiologist concluded that I had sesamoiditis in the right foot, though "no fracture".  My foot orthopedic surgeon does not agree with the findings and thinks I have a fracture.  He is basing this on a to some discoloration (darkness) in the tibial sesamoid on the MRI and also a possible line on another MRI image.
Dr Blake's comment: A fracture of the right sesamoid would be rare if you do not have a bone density issue (how is your Vit D and Calcium intakes?) However, a stress reaction to the sesamoid, without a break, is possible from favoring, and would cause swelling in the sesamoid bone. This is worse than sesamoiditis, but not as bad as a sesamoid fracture. Treatment is to ice, contrasts, protect the bone, and perhaps PT or accupuncture to flush the swollen bone. But, PT is the trickiest, and you would want to be very certain of that diagnosis. 

  He said it might even be AVN (which I know is probably the worst thing ever). 
Dr Blake's comment: AVN means avascular necrosis or dead bone. What are the odds, since we are always playing with reasonable odds, or educated guesses, that you have a dead bone from limping? Not high odds. In the MRI world, sesamoid AVN and peroneal tears are the 2 big calls that normally are not there. So, for right now I would take those odds. 

 My podiatrist says that based on the fact that I have very little pain from palpitation, and given the radiologist conclusions, that I do not have a fracture.  Clearly I like that conclusion better, but she admits that she is not an expert in reading MRI's.  She also scared me a little with saying that if there is indeed no fracture, that she could do a cortizone shot to help the sesamoiditis inflammation.  After everything you have written, I know that's not the best thing to do given the uncertainty of the bone right now. 
Dr Blake's comment: Definitely long acting cortisone would potentially be bad, but short acting cortisone, like 8 days of oral cortisone in a tapering dose, may be very very helpful. The long acting just masks pain for too long and you can really hurt yourself without knowing over the next 9 months. Find out what type of cortisone, and also discuss oral cortisone. 

 I do have a lot of trust in this well-respected orthopedic surgeon, though it's hard to emotionally face his prognosis (especially as I'm still recovering on the left foot sesamoid injury 5 months out with a stiff soled shoe).  Given his fracture diagnosis, he said he recommend getting into the boot for 2 months and if it still hurts after that, doing surgery to shave down the sesamoid (he believes it is fractured).
Dr Blake's comment: Well meaning, but too aggressive for me. 

I have worn the boot for one week, though it is putting further pressure on my not fully healed left foot sesamoid.  Also, I am having lower back pain despite using an Even Up; as I think I'm still very much trying to protect the left foot still.  At this point, I am switching between boot and stiff soled shoe.  Icing 2 times daily, and using the Exogen bone stimulator on both the left, and now the right side. 

Anyway, it's been quite the ride and I'm sort of at a loss of what to do (two broken sesamoids!) and was wondering if you could PLEASE offer your opinion to me again.  I know this would a lot easier if you had the disk (which I can send), but I have attached the three MRI images the summary from the MRI.  Any of your opinions would be great.  If not could you recommend anyone for a 4th opinion in Chicago? 

Thanks again, 
Peter (name changed)


Scanning technique: High-field 1.5 open magnet.  Sagittal T1, safittal T2 IR, coronal T2 IR, coronal PD and T2, axial T2 IR, axial PD and T2 

Findings: 
Inflammation surrounding the medial sesamoid.  Fluid surrounding the medial sesamoid best identified on the coronal T2 IR image #20 series 5 and axial T2 IR image 5. Series 7.  Minimal reactive edema within the medial sesamoid without fracture. Degenerative changes at the medial articulating surface of the first metatarsal with marginal osteophytes.  Lateral sesamoid and articulation with the first metatarsal head unremarkable.  Marginal osteophytes also present at the first metatarsal head dorsally laterally.  Minimal Hallux valgus with 10% first metatarsal head joint exposure. 
Dr Blake's comment: This suggests no sesamoid fracture, but plenty of wear and tear on the big toe joint in general that can get stirred but with limping, but should respond to conservative management. I also looked at the MRI images you sent, and I agree with these findings of no fracture, just wear and tear changes of mild osteoarthritis (my back is riddled with the stuff!!!). The images all have your name and I wanted to keep your identity private so did not include in this post. Rich

Minimal edema within the plantar fat pad beneath the medial sesamoid identified on sagittal IR are image 4 series 3.  No other significant findings. 

Impression: 
1. Inflammation at the medial sesamoid without evidence of fracture.  Edema surrounds the medial sesamoid and extends into the plantar fat pad. 
2. Maginal osteophytes at the first metatarsal head including at the articulation of the medial sesamoid.  Largest marginal osteophytes and laterally. 

Dr Blake's comment: Now this makes sense. What is the easiest explanation for this problem? The easiest explanation is that the right big toe joint has some arthritis (wear and tear) that got all stressed out and inflamed with the overload due to the months of favoring the left sesamoid injury. The treatment for the right big toe joint can be spica taping, icing, contrasts, dancer's padding, arch support, stiff shoes, removable boot in some reasonable order to calm down. Physical therapy and acupuncture can also help. Short acting cortisone shot or oral cortisone burst can help also. Perhaps a low back evaluation with treatment ideas and see if they think some of the foot pain is coming from the back. It is called "double crush" syndrome where the nerve is irritated at both the foot and back and this causes the pain/abnormal sensations to be worse. 

3 comments:

  1. Hi Dr. Blake,
    I have a fractured left tibial sesamoid. It probably started as a stress fracture from running in a new pair of shoes last September. I didn't get an x-ray until January, at which point it was shattered into 3 pieces. My first doc (sports med) told me it would never heal and that I'd need to learn to manage the pain. I pushed back against that a little, and he suggested no running for 8 weeks and a follow up x-ray. The follow-up showed it still fractured, so he sent me to a podiatrist for orthotics for pain management.

    The podiatrist put me in an air cast and prescribed an exogen bone stim machine. Unfortunately, insurance made me wait until the 90 day point to get the bone stim machine. So, I wore the cast, partially non-weight bearing (anything outside the house I did on crutches) for 6 weeks, and waited for the bone stim machine. Got the the 90 day x-ray and it showed, "further deterioration." I've now been using the bone stim machine for 30 days and got the follow up x-ray to see if it's working. The bone is still further deteriorating and my doctor suspects avascular necrosis.

    I'm scheduled for an MRI on Monday to get a better look at what's happening. But, he's saying that the chances of healing are minimal at this point and that the best case scenario is that my body absorbs the dead bone and I can avoid surgery.

    Thoughts on that?

    I don't have direct access to my x-rays, but I have seen them and there is a clear progression of the sesamoid becoming fainter and fainter on x-ray, to the point that this week's x-ray it's hard to see the contours of the bone.

    Thanks for any feedback.

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    Replies
    1. Will put response on my blog today. Thank you for the comment. Rich

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  2. Hi Dr. Blake - apologies if this is a duplicate comment. I tried to add a comment a couple of weeks back to this entry, but I am not sure that it went through. I was hoping you could share what your preferred treatment is for seamoid stress REACTIONS (as opposed to fractures). I have one but I am having trouble finding information online about just the reaction part. Thanks in advance!

    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.