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Thursday, August 15, 2013

Sesamoid Fracture: Email Advice

This email was received 8/15/13. 

Hello Dr. Blake, I just contacted you through your website but wasn't sure if it went through. I also forgot to add that I'm 35; thought that might be important to the osteoarthritis diagnosis. Here is my message again, please forgive if you already received it:
 
I've been using your blog as my go-to guide for the last 3 months. I sustained a stress fracture to the sesamoid bone closest to the outside of my left foot while coming down stairs wearing wedge heels.
Dr Blake's comment: This is called the tibial or medial sesamoid.
My first podiatrist diagnosed it as sesamoiditis and ignored my repeated phone calls saying I was in immense pain. Time to switch doctors. My current podiatrist took x-rays, by this time it was 24 days after injury, but found them inconclusive and ordered an MRI. In the meantime I was put on crutches. 10 days later, after insurance finally approved it and the results came in I got the news that it was indeed a stress fracture and was told I needed a plaster cast. I bargained my way into getting walking boot with the promise that I would treat it as a cast, sleeping in it and never walking on it.
Dr Blake's comment: I always try protected weight bearing since the cast holds in so much fluid that you need some weight bearing to drive the swelling out of the injured area. Protected weight bearing is with 1/4 inch layered adhesive felt to protect the area while allowing pain free weight bearing on the non injured parts of the foot. You can purchase a roll of 1/4 inch adhesive felt padding at www.mooremedical.com 
I've been a model patient and recently went back for my six week check up. (During this time I did take calcium, magnesium, vit d, and vit k, but only for one week as it caused stomach upset.) The doctor stressed the fact that this injury is very slow to heal and that if I move my big toe at all it impedes healing. He pressed on the ball of my foot and I yelped in pain. He said it wasn't healed. He said if it was healed I would have no pain at all. I thought this strange since I broke the big toe on that same foot 9 years ago and can remember being in pain for a few months after it healed. Surely this bone would hurt for a while even after healing! (Sure enough, reading your blog confirmed this!) So, he ordered another round of x-rays. I did question this since the fracture was found through MRI and not x-ray, but he said he wanted to order a bone stimulator and insurance would require a new set of xrays. I consented.
Dr Blake's comment: For many injuries, like sesamoid, pain to palpation can be present almost forever, and it a poor indicator of healing. Functional pain, the pain you get from advancing from non weight bearing to weight bearing, and from weight bearing in a cast to weight bearing in a shoe with protected padding is more important. 
For one of the images I had to get down in a runner's stretch, completely pulling my toes back. (I did have to do this with the first round he ordered, but this was before we knew what the injury was.) Since he had just said moving my big toe would impede healing, I was wondering why in the world we were doing this, but I knew I needed the bone stimulator and had to do it. The tech and I had to bend my toes back and forth repeated trying to get mobility back in them so that I could get them back far enough for a good image. This maneuver left me in pain for several days afterwards.
Dr Blake's comment: Sports medicine as a discipline evolved around the concept of protected weight bearing, sensible motion to keep things moving as best as possible, and anti-casting as much as possible. I love to move things, weight things, touch things. The more normal the stimulus, the faster healing back to full function occurs. For every day you completely immobilize an area, it can take up to 4 days to get the area back to function. And, returning to a function state can be painful, but not a sign you are not healing. 
The results of the x-ray was that the sesamoid bone now has osteoarthritis in it. He said it was due to the fact that the bone is receiving no impact through walking in order to build it. He ordered the exogen bone stimulator and said to stay on crutches and come back in 2 weeks.
Dr Blake's comment: Osteoarthritis takes a long time to settle in, but the changes in the bone could be related to the fracture healing and the demineralization from non weight bearing. It is almost impossible to predict what this means in relationship to the final outcome. 
I go back in 5 days and insurance still has not approved the device. Fortunately a friend had one and I've been able to use it twice a day for the past 4 days. I also switched brands and have been back to taking calcium, mag, vit d, and vit k for the past 9 days.
Dr Blake's comment: Remember the goal standard is 1500 mg of Calcium daily (diet and supplement) and 1000 units of Vit D (unless you know your blood levels). 
I called the doctor yesterday and told him I did not want another round of x rays. He said he wasn't planning on ordering any, just performing another physical exam (presumably to see if it still hurts when he presses) and at that time he would consider ordering another MRI.
Dr Blake's comment: The first MRI is the baseline. The second MRI should be minimum 3 months (and up to 6 months if you are doing a bone stimulator). I hope you do not feel pressed into a quick solution!!
He did say removing that sesamoid left me in danger of developing bunions later on and that surgery would be a last resort. In the meantime, I've been on crutches for 8 and 1/2 weeks and have lost so much muscle in my calf and foot. My foot even has muscle spasms now, which from my very scientific research on the internet seems to be coming from loss of muscle integrity.
Dr Blake's comment: Unfortunately you are developing "cast disease" or "cast rot". If you want to calculate your road to healing, take the amount of time it takes to get you to full weight bearing without a cast, and crutches, and times by 4. At that time, you will have recovered from the damage caused by the cast. This is why I always say that a cast is a "necessary evil". When needed, it can allow something to heal, but it sure takes a long time to get your foot back, grossly and subtly also. 
In your opinion, what should be my next move? In reading your blog, it seems like it should be continued use of the bone stimulator, vitamins and supplements, and transitioning to walking in the boot for 3 months. But can I just "start walking" after not touching my foot to the ground for 3 months and losing so much muscle?
Dr Blake's comment: No, inside the boot you will need cast accommodation with 1/4 adhesive felt or an orthotic that off weights the sesamoid. You need to continue daily icing 10 minutes 3 times, learn to spica tape, and perfect the orthotic you will be wearing out of the cast. The rest of what is said is true.

I really appreciate any help and advice you can provide. Thank you for making your blog available, I would have been lost without it!
Dr Blake's comment: Great, I am glad it has been somewhat helpful, and good luck finishing this healing. 

2 comments:

  1. Dr. Blake, my sesamoid PT includes doing toe scrunching with a towel. However, when I get a particularly tight scrunch in, it causes lots of pain in the sesamoid area in the bottom of my foot that I feel even after I stop contracting my toes. Is this consistent with sesamoid injuries or could it be something else? Thank you in advance.

    ReplyDelete
    Replies
    1. Towel scrunching is a completely un-natural motion and can cause cramping and pain as the nerves are irritated under the foot. Metatarsal doming is a little kinder, and more natural, but can also cause pain. I would recommend switching to metatarsal doming. In of themselves, this is not an indication of anything wrong. 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.