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Sunday, May 18, 2014

Fibular Sesamoid Fracture: Email Advice

     I just found your blog trying to research sesamoid treatments and I wish I had found it sooner! I have been in a walking boot for four months to treat a fibial sesamoid fracture and I'm starting to get frustrated. Every visit to the podiatrist shows improvement on my x-rays, but I'm confused by the questions he asks about pain. He says that if it hurts the bone is moving, but how can it be moving when I wake up in the morning and it's been up and elevated all night long- and still hurt.
Dr Blake's comment: There are so many causes of pain after you hurt a body part, that blaming it on one specific thing may not be correct. The pain is most likely due to the swelling that collects in the area, that is a totally normal part of healing, but loves to sit there and interfere with movement and compromise the circulation and nerves. 

    I've been reading some of the posts and concerned about all the information that I haven't seen before, literally the only treatment has been this boot that I was told was to avoid having to do surgery- but not to remove, but to pin?
Dr Blake's comment: Unfortunately I have no experience with treating sesamoid fractures that have been pinned. It has always seem too small a bone to do something like that, but new technology is being introduced almost daily. I have only seen one unsuccessful surgery where the surgeon removed one half of the two bipartite bones. 

 The more I'm reading the worse this is sounding.
Dr Blake's comment: If you have been in the removable boot for 4 months, you have done everything right up to now. But, it is time to move from the Immobilization Phase to the Restrengthening Phase of Injury Healing. The Restrengthening Phase should continue your 3 times per day icing/contrast bathing, your Calcium and Vit D intake considerations, your protected weight bearing with orthotics and/or dancer pads and/or stiff soled shoes, a gradual strengthening program from the core down, and a gradual return to full weight bearing with no barefoot. 

 In the past month I swear it's been getting worse and the boot itself is driving me nuts and starting to hurt the other parts of my leg. Any advice?
Dr Blake's comment: Typically after 3 months in a removable boot, the negative effects of immobilization start to take their toll and pain syndromes develop. How to begin protected weight bearing without the boot is the next goal and many of your new soreness will abate. 

 My next appointment is in the first week of May and I'd like to sound like I know my options. 
Dr Blake's comment: Sorry, I just had some personal family problems that needed me so I am late with this response. 

My podiatrist is a nice guy, but this is getting really frustrating, according to him I should have been healed by now.
Dr Blake's comment: You can ask any athlete if they continued to have pain when their injury was healed and the majority would say affirmative. You need to respect pain levels over 0-2 and increasing as you work out. You need to gradually stress the injured area to prevent flares. Working with a good physical therapist on lower extremity strength and flexibility at this time on a weekly basis will also get their regular feedback on activity levels permissable.

Dr Blake's comment:
     Thanks for the email. When you see him, ask the following questions.

  1. Can an orthotic device be designed to off weight the sore sesamoid?
  2. Can you go to PT to learn joint mobilization, spica taping, dancer's pads, foot strengthening, and anti-inflammatory techniques?
  3. Can you get a baseline MRI to see where you are at, or CT Scan? There are many reasons to get a MRI other than healing of sesamoid for it can show if other structures are involved.
  4. If he thinks you are slow at healing, can you get a bone stimulator?
  5. What shoes, like hiking boots, can you wear to begin to wean off the cam boot?
  6. Has he had cases like this that heal without surgery? This is check if he has a bias. 
  7. Does he feel you can heal without surgery? If not, who should you see for a second opinion?
Typically, the next 3 months should be geared towards gradually getting out of the cast, developing a good orthotic, gradually increasing activity, gradually understanding good vs bad pain, and daily continuing to ice and contrast bath. Good luck. 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.