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Saturday, January 11, 2014

Recent Fibular Sesamoid Removal: Email Advice

I had a fibular sesamoidectomy 4 weeks ago and I am still having a ton of pain in the big toe joint. It is actually worse than before the surgery. My surgeon never taught me how to properly tape the area and I was wondering what the best way to support the toe was. Also what exercises could I be doing to help the area. I still don't have full range of motion.

Thank you for your help.


Dr Blake's Response:

     You are in the 3 month zone of the surgeon's responsibility before they release their patients back to people like me who will rehabilitate. Everything I discuss has to be discussed and agreed upon by your surgeon who has ultimate responsibility and first hand knowledge. My primary goal here will be to give your some normal guidelines on what happens and can be done. 

     After you leave the hospital or surgical center, you will have bandages and stitches and post op shoes/boots, and crutches. These will all be in part of your life until 2 or 3 weeks when the wound has healed and your stitches can come out. The joint is sore, swollen, very limited range of motion, and basically non functional at this point. The next 10-12 weeks you have to reverse all the swelling accumulation with icing twice daily, NSAIDs, contrast bathing each evening, and 2-3 times per week physical therapy. This is where you are at right now. Your goal the next 8-10 weeks is to reduce swelling, but get strong. 

     So, during this next 8-10 weeks, use crutches, removable boots, post op shoes, big tennis shoes and orthotics, whatever it takes to minimize the day to day irritation that will keep aggravating the swelling. You want 2 months from now to be in a great position to re-strengthen the foot and leg. The Immobilization Phase (now for you) lasts typically 3 months, and the Restrengthening Phase until your 1 year Anniversary. Don't let the inflammation linger into the 4th month by pushing it too much now. 

     The physical therapist goal in seeing you is to reduce inflammation, gradually increase range of motion, gradually teach you how to strengthen your whole lower extremity progressively, sometimes design dancer's pads and/or orthotics, make recommendations to the surgeon on your progress and changes in treatment, etc. 
After the 12th week post operatively, typically the swelling is down, the range of motion is better, and the Restrengthening and Return to Activity Phases are gradually blended. Some activities will take you 1 full year to get back to like cutting hard in basketball, whereas running with off weighting orthotic devices can be started at 3-6 months. Depends on the force needed for the activity. 

     It is important to understand about scar tissue maturation. At 9 months, the scar tissue produced by the surgery will begin to thin, and cause less interference with normal motion. By 12 months, the scar tissue is typically no longer a problem restricting motion and causing pain. Some activities require this normal scar maturation process to occur before they are comfortable. 

     So, in my practice, you would have the stitches removed, you would have little to no pain because you would be using crutches, removable boots, etc, whatever is needed, you would be icing 2 times a day, contrast bathing once daily, you would be going to PT 2-3 times weekly, you would have a healthy diet, you would be getting soft based orthotics (like Hannafords) to protect the joint, using dancer's pads (1/8th adhesive felt from mooremedical.com),  you would use spica taping when you feel you need it, you would be using the Blaine Scar Kit for twice daily massage, and the physical therapist would definitely have you on the stationary bike (arch on the pedal), swimming/running in place in the pool, taking NSAIDs orally or topically, doing Hallux Limitus Self Mob if allowed twice daily, walking progressively more and more, not trying to manually increase normal joint motion, and using intelligent activity modification principles. Memorize my post on Good vs Bad Pain. 

     I sure hope this helps some. Rich 

10 comments:

  1. I am 41 and injured my foot in a car accident. After an MRI (2 months later) my podiatrist said the tibial sesamoid was fractured and had to be removed. When he was in there he also found that the cartlidge was pretty much gone so he cleaned that up. I am 5 weeks post op. I was not given any PT or instructions other than to wiggle my toes and transition into a regular shoe. I have been trying to stay off my foot and keep it up as much as possible. At work I wear the walking boot. If I try to wear a shoe, I am good for maybe 10 minutes and then the pain becomes too much. I also find that without the walking boot I have to walk on the outside of my foot which is giving me hip pain. Should I be massaging the area or doing anything else? I do roll my foot on a frozen water bottle at night and try to move my toes when I sitting. He had told me I should be healed in 6 weeks, but I sure don't feel like another week is going to make a huge difference. I have an active daughter and we are eager to get work to life. Thank you.

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    1. Jill, thanks for the comment. Even though the sesamoid was removed, it can take months and months for the cartilage surgery to attempt to heal. Make sure you get a new MRI in 3-6 months to check on bone edema. You need to stay between pain levels 0-2 and that could require 3 months in the boot. You need to get an insert like the Red Sole orthotic and see if it can allow transition from cast to shoe. I like this insert because it can be modified. The transition can take 2-6 weeks, so listen to your body and go slow. You should be icing twice daily and contrast baths each evening. See if rocker shoes like Hoka One One or New Balance 928 and 1069 help. Hope this helps some. Rich

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  2. Thank you for your reply. I am now 4 1/2 months post op. I had gone to physical therapy but my therapist and I decided to stop since it was not helping my pain. In addition to the bone and cartlidge removal that I am trying to heal from, my PT said I had a neuroma affecting the 2nd and 3rd toes. I have not been using a boot and I have been trying desperately to get orthotics but my podiatrist is being difficult because the insurance is taking their time in getting payment to the doctor. And I have not had another MRI, I can't even get in to see my podiatrist, that is how difficult he is being. The foot now feels like it is getting worse and I am back to driving having to use my left foot to brake. I don't know what else to do and would appreciate any advice. Thank you so much.

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    1. Wow Jill, I will try. The best you can do is have a visit with the PT. Ask he/she to fax me their observations and concerns at 415-353-6401. On the fax, identify that you are a patient from my blog. I would need to know about joint limitations of motion, strength of the flexor tendons, amount of inflammation, amount of nerve hypersensitivity, findings in gait. They should also send there treatment proposals for each of the findings that is abnormal. It is a good starting point for us. Rich

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  3. Thank you for your time. I did finally get in to see the podiatrist today for the orthotics he had recommended. i explain the pain and he says that it is a bunion. I told him that he said I did not have one in the foot so he responds that he doesn't know why he would have said that. he said the orthotics won't help bunion pain. I explain that none of this pain started until my accident, not I can hardly drive. I also explained how my PT said that my other issue between the 2nd and 3rd toe is a neuroma. He says the orthotics may not help that either. So I am confused. I forgot to ask him about the possibility of the bone edema that you had suggested. He ends up giving me 2 cortisone shots on the top of that 1st knuckle. The second one he had trouble with because it seemed there was a lot of scar tissue. I ask if that could be the cause of the pain and he said yes. He is ordering the orthotics and I hope the cortisone does something. But I must say I left the appt very frustrated.
    As for my range of motion, that is doing well. I notice some hyerpsensitivity and I think that the PT would say that I don't have full strength yet in the flexor tendons.
    Thank you again!

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    1. Okay Jill, It is so good about the range of motion. That is a good indicator of health in the joint. I hope the cortisone and orthotics help. Continue icing twice daily to reduce any daily irritation. Keep me in the loop. Rich

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  4. The pain in the big toe joint still bothers me but not as consistently, but when it hurts it is a sharp pain, usually on the underside of the joint. The neuroma is still a huge problem for me. I received a cortisone shot between the second and third toe in January. It helped some of the burning sensation go away but if I stand for more than 20 minutes on the concrete floors as work, it feels like my foot becomes the size of a basketball. My podiatrist at first thought it was from the bunion but then when he finally took some time to actually look at my xrays, he said that he did not think that was the case. I do now have my orthotics, which I wear all the time in my good athletic shoes and they do not really seem to help a whole lot. I did go and get a second opinion and he suggested I get more cortisone shots. Would you generally recommend that? Or do you have any suggestions? Thank you

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    1. I would suggest emailing me with the whole history so I can get a better feel of what is going on. If you have a written history, just email to me and I will respond. Rich

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  5. I went back to podiatrist yesterday. He pressed around on the foot and said that if it was just a neuroma it should only hurt on the bottom of my foot but I was also having pain on the top of the 2nd and 3rd toe joints. He now thinks that maybe there is inflammation in those joints which is causing the nerve to be inflamed and he said that can be very difficult to heal. He put another pad in my shoe and taped my 2nd toe downward, but the way he did it just about cut off my circulation and caused it's own pain. He prescribed an anti-inflammatory and told me to ice it every day, which I have been doing frequently anyway. Does this sound right?

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    1. Once you have had pain for awhile in any area, surrounding areas begin to hurt as a form of protection. Since a cortisone shot helped into the nerve, I would still go with neuroma and consider more shots of cortisone or alcohol. Of course, metatarsal pads to off weight, and sometimes splinting (need to start wearing loose and gradually tighten up). Icing and contrast bathing in some form twice daily is crucial to try to keep the symptoms between 0-2 as you increase activity. 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.