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Friday, August 15, 2014

Sesamoid Fracture: Email Advice

Hello,

     I was hoping to get some advice from you. I had a stress fracture in my sesamoid bone almost 3 years ago when I was running 45 miles a week. I was in a boot for 8 weeks, took about 1.5 years off of running. I tried running on and off again with orthotics, but the orthotics actually made it worse and I could never run more than a few miles a week.
Dr Blake's comment: There are so many factors that can be considered in making orthotic devices for a patient suffering with sesamoid pain (under the big toe joint). Unfortunately, there can be a lot of art in the process, which can drive patients and health care providers crazy. But, in the end, if everyone is willing to stick with it, a proper device can be designed. These factors/components are:
  1. Amount of arch to use
  2. Amount of stiffness across the ball of the foot 
  3. Amount of dancer's pad to use to off weight sesamoid
  4. Amount of varus cant at the heel (inversion) to center the weight as you push off 
  5. Amount of softness
  6. Amount of stability needed from the shoes versus orthotic devices

     I finally started running consistent mileage in March of this year. I was only running about 12 miles a week and only running every other day. I ran a 10k race and had no pain. I decided to start training for a half marathon. I only made it a few 6 miles runs and my foot pain is back. I was careful to progress slowly and only went up by 10 % each week. I'm assuming it's sesamoiditis or could it be that my fracture never really healed? (I know the blood supply is poor to the area).
Dr Blake's comment: If you do not have the right orthotic in my mind, you are doomed to re-aggravate the sesamoid again and again. Once injured, it can heal, but the original injury shows that it is a vulnerable spot in your body (weak link in the chain!!). I am hopeful that this setback will get you on the road to finding the right orthotic for you. That is paramount!!

     I'm not sure if I should be considering removal of the sesamoid or if it's normal to have flare ups and I should just accept this and when it happens, rest, ice, strengthen calves, etc? My hip has also started to hurt so I can tell that my gait is altered. 
Dr Blake's comment: Removal of the sesamoid without the proper orthotic post op, which is the same orthotic you would use pre-op to hopefully avoid surgery is not a great option. It is done so so often, but there is a reason why your sesamoids are a weak spot. We do not know why it is vulnerable, but it is. You need to find out from your treating docs why it is vulnerable--plantarflexed, over pronation, hallux limitus, etc. 

I should mention that in the past I tried ice massage, contrast bath, orthotics, dancers pads, minimalist shoes, turf toe taping, and that it actually feels better when I'm barefoot (which is different from most people it seems). 
Dr Blake's comment: You bring up a good point. Our biomechanics are different in every environment--shoes, shoes and orthotics, barefoot, etc.  Many problems are related to motion or shock absorption or stiffness. It is up to you and the treating docs/physical therapists to decide how safe you are in various environments with various activities. Some activities are better barefoot, some with shoes, some with shoes and inserts. I hope this helps. Rich
Any information you could give me would be great.

Thanks,

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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.