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Friday, April 25, 2014

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I am sure happy to find your website. I am sure you hear that a lot. I have had a sesamoid injury since Oct 2012 (19 months). I went through wearing an aircast ankle brace for 2 months which was a waste, then physical therapy for 6 weeks, then a cortisone shot in July 13 which wore off by December. I am a very active person. I do aerobic and pole dance fitness for activities. I went to a foot and ankle specialist in Feb and had to wear a cam boot for a month.

 After it not showing improvement I went to the joint reconstruction center. Each doctor tells me how risky surgery is. He referred me to get a PRP injection. I had it done on the 14th and have been using a knee walker since then. At first I was told I would use the cam boot then was surprised by crutches. Knee walker is the best invention. I feel like I will never get over this. It is sending me into depression. I can't not be active. Have you had any experience with prp injections. Do you see hope for me? I just dont know what to do.

Dr Blake's response:

     Thank you so very much for your email and kind words. I read through your description and here are my questions for you to email me back with and I will attach to this post later. First, PRP is not a standard injection that helps joint problems, and disputed for tendon injuries (like achilles). However, it probably has a place in orthopedics and more and more studies need to be done. It may prove very helpful for you. 

Here is a link to one review on PRP:


http://www.hss.edu/conditions_platelet-rich-plasma-prp.asp


Secondly, non weight bearing with a knee walker always increases pain and swelling in the foot. This is because the weight bearing is our natural compression pump forcing foot swelling back towards the heart with each step. You have to follow your surgeon's advice, but do not expect to feel better until you get back to protected weight bearing (the emphasis is on the word "protected"). 

Here are my questions.



  1. Do you have imaging studies like xray and MRI to review?
  2. With the cam boot, is the sesamoid area being off weighted?
  3. What are you doing daily to work on swelling?
  4. With sesamoid injuries, you are talking bone injuries, so how is your Calcium/Vit D3 and bone density?
  5. Do you have protection for the sesamoid as you begin weight bearing (orthotics, dancer's pads, etc)?
  6. Do you have an understand about going from non-weight bearing to weight bearing (knee walker to cam boot, or shoes and orthotics)?
  7. Are you taking the steps now (if needed) to get your shoes in order?
  8. Besides working on bone strength, are you daily strengthening your feet? There are so many foot, ankle, and core strengthening exercises to do so you do not decondition?
  9. Are you swimming and/or stationary bike for cardio-vascular? You can always put the pedal in the middle of your arch and not push off the wall with your feet, etc. 
  10. Are you elevating your feet alot and using compression socks to fight the swelling in the tissues? Swelling is our biggest enemy.
So, get back to me. Typically without MRIs and CT scans we do not know actually what is going on. X rays may be helpful if there is something very obvious, but most of the time these are subtle injuries. I hope this helps. And good luck. Rich

And here is the patient's response:
Hi Dr. Blake,

Thank you for the response. I am feeling so depressed and hopeless so I greatly, greatly appreciate your info and help!!! You are an angel to many I am sure. Thank you, 

I am going through your questions
  1. Do you have imaging studies like xray and MRI to review? 
    was having troubles downloading the files from our health system. I actually work at the hospital and was trying to get them myself. I would have to have the MRI sent to me though so I couldn't get it. Not sure how to use their application. Here are some of the Xrays and reports though. Dr Blake: Keep trying!!!
  2. With the cam boot, is the sesamoid area being off weighted?The cam boot does off load the sesamoid. I don't know why they wouldn't want me weight bearing honestly. The doctor that referred me for this shot said I would wear the cam boot then the doctor that performed this injection said no weight bearing. Dr Blake: With the new procedure, that doc has say, but make sure you understand how long you have to remain non weight bearing.
  3. What are you doing daily to work on swelling?I actually haven't had much swelling but I was keeping my foot elevated when i was having swelling. They said not to take ibuprofen because it slows healing with this injection. I mostly have been resting to reduce swelling. Dr Blake: Swelling sometimes can not be seen and is felt by joint stiffness only. Once you are through with the PRP part, try to ice pack 2 times daily and do one contrast bath session daily, even if you do not see the swelling. It can be in the bone, called boney edema, and that swelling can slow down healing. 
  4. With sesamoid injuries, you are talking bone injuries, so how is your Calcium/Vit D3 and bone density?
    I have been taking Calcium 600mg and D3 2000IU daily. I have not had any bone density tests. I read about that month ago and wondered why they never mentioned that. A pharmacist at work recommended it. I work in the pharmacy. Dr Blake: It would be great to get a bone density screen and Vit D3 blood level. 
  5. Do you have protection for the sesamoid as you begin weight bearing (orthotics, dancer's pads, etc)? 
    I do have orthotics they prescribed when i was doing the therapy. I also used the dancer pads for a while to try to reduce pain. I didn't feel like they were helping enough so I probably gave up too soon. Dr Blake: This is a crucial time before you begin weight bearing fully to get the orthotic and attached dancer's pads in place.
  6. Do you have an understand about going from non-weight bearing to weight bearing (knee walker to cam boot, or shoes and orthotics)? 
    I do now after reading a lot on your website. Which makes total sense because its weak after not being weight bearing.
  7. Are you taking the steps now (if needed) to get your shoes in order?Not sure what steps I should be taking honestly. But, thinking i should re order dancer pads. Dr Blake: There are so many shoes that can help with this problem. Find a shoe store that has a good selection of stable shoes, shoes with rocker bottom can help, hiking boots, but they all must fit your orthotic device.
  8. Besides working on bone strength, are you daily strengthening your feet? There are so many foot, ankle, and core strengthening exercises to do so you do not decondition?
    I am trying to do some exercises you mentioned and I did in therapy now.
  9. Are you swimming and/or stationary bike for cardio-vascular? You can always put the pedal in the middle of your arch and not push off the wall with your feet, etc. I havent been doing any exercising since I got the injection. Since they said no weight bearing. But, I have been doing weights still with arms and I have been doing core exercises to try to keep some strength. I also have been doing stretching. I thought about biking but wasn't sure. Dr Blake: Stationary biking with the heel on the pedal would be totally fine. Lower the seat and resistance so as not to irritate your knees
  10. Are you elevating your feet a lot and using compression socks to fight the swelling in the tissues? Swelling is our biggest enemy.See I am confused because with this prp injection they told me some swelling is good and it increases healing. They said it is our bodies natural way of healing. I do not feel the doctors at the Sports Complex are informing me enough for sure. None have asked things like you have. I almost feel like this is a losing battle and it will be a fight for the rest of my life. I feel i will not be able to dance anymore and really be active aerobically and I am only 35. Very Sad Dr Blake: You are right, PRP want some swelling for a short period, but the rest of the time we are fighting against that swelling. So, most of my anti-swelling advice is not for the 2-4 weeks around the PRP injection (the length of time that they told you not to use Anti-Inflammatory Meds). See if you can get me the MRI scan to review so I have a better feel. If, in the end, you have to have the sesamoid removed, you will do fine. But, it would be a hard call without seeing repeated MRIs and a CT scan. So, hang in there and take it day by day. 


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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.