Sunday, May 19, 2013
Sesamoid Fracture: Email Advice
I was recently doing some research and came across your orthotic blog. About a year and a half ago I was diagnosed with a stress fracture in my right foot sesamoid bones. I ran cross country in college freshman and sophomore year and was running about 45 miles a week. In the middle of the sophomore season the bottom of my foot began to hurt but it wasn't bad enough to stop running. By the end of the season it was very painful so I went to see a doctor.
An MRI revealed that I had bipartite sesamoids as well as a stress fracture. I was in a walking boot/cast for 8 weeks. After that I did not run for at least a year. I did other activities like spin class, elliptical, and aqua jogging. In December of 2012 I began to run again. I started with 10 minute bouts and that was painful but eventually got better. I slowly began to increase and at first it would be painful but after a few weeks at the same time and speed it began to get better.
I am emailing you now because I seem to have gotten stuck at about 30 minutes. I usually run 3-4 times a week. The pain is mild when I run but afterwards is about a 7/10 on pain scale. I want to increase my mileage but am afraid I will be doing more damage. Is it okay to have pain? Can I make it worse by running?
Dr Blake's comment: You have to listen to your body and honor the pain. The worse pain is when it occurs during the later stages of a run, but the second worse is when it occurs afterwards. You must manipulate the running to have the pain stay at 0-2 afterwards. This can be running more flatfooted, making sure your shoes and inserts adequately take pressure off the sesamoids, running shorter time or every fourth day, avoiding hills, icing for 30 minutes as soon afterwards as possible, etc. If this fails to make a significant change, a repeat MRI to compare with the old will always help.
My physical therapist said that if it was a fracture it should have grown back stronger and that I can't damage the bone anymore.
Dr Blake's comment: I kindly disagree. That general rule does not work with sesamoids since it is a weight bearing bone with poor blood supply.
I forgot to mention that I am seeing a physical therapist. We are working more on mobilizing my mid foot, I have very high arches and a very rigid foot.
Dr Blake's comment: Rigid feet pound more, and high arch feet have more metatarsal and sesamoid problems. This is due to the fact that the metatarsals point downward more in the high arch foot leading to more pressure on each of the metatarsal heads (where the sesamoids are).
Other things that I am doing are: wearing custom orthotics, icing after every run, not wearing heals, and taking NSAIDS when the pain/swelling gets really bad. I've been thinking of switching to altra-zero drop shoes to see if that will help any. I keep looking at sites and seeing that this pain should be gone within 6 months-year after the fracture and yet mine is still hurting.
Dr Blake's comment: You can not use time to judge since everyone is different. You need to create this pain free environment by manipulating each aspect of treatment. I agree you should be running some to help find out what works. Can you make your orthotics better? Do you feel that the arch support puts your weight off the big toe joint when you run? Do you have a dancer's pad within the orthotic device? If so, is it high enough to off weight the sore area? You should be icing 3 times a day for ten minutes minimum, and probably use the evening icing time to actually do a full contrast bath to flush inflammation. I agree to keep the NSAIDs as needed. Look at when you are irritating your foot. Is it only running now? Or how bout barefoot? Dress flats?
I don't want to have surgery because I know that the chances of being able to run again after that are slim-none.
Dr Blake's comment: Not running after sesamoid removal is due to a surgical complication, not in the nature of the surgery itself. I always expect my athletes to run after sesamoid removal, and I presently have a 4:10 miler doing just that. However, surgery has a 20% failure rate for return to running, and even though great odds for surgery, not great if you are the 1/5 that can not run. Goal: Have surgery only if you have done everything else and waited until the MRIs (at 6 month intervals) document no longer any healing. The more sports medicine learns about this problem, the fewer patients have surgery. We get smarter.
I'm not looking to be running 45 miles a week again. I'd love to be able to do 20-25 miles/week. So I guess my main questions are:
1.) Should I keep running? Yes, with modification.
2.) If I keep running can I damage my foot further? If you keep running with level 7 pain, yes.
3.) Is there anything else I can do...should I be going back to see a doctor? If MRI is over 6 months, get another one. If PT can do the rest for you, including orthotic modifications, stay there temporarily. You are in the Return to Activity Phase of your rehab, and you are having problems. This is when we learn the most to individualize the treatment, no cookbooks. Make sure the bone density, calcium, Vit D3 is great. You want a D3 level around 55 or you will break something else when you start running. Hope this points you in the right direction. Rich
Anything else you think might me would be greatly appreciated.
Thank you for your time,
Mari (name changed)