Recurring Sesamoid Fractures: Email Advice

Dr Blake,
I have had 3 different sesamoid fractures in 1 1/2 years.  One on left foot, one on right foot, then this morning my podiatrist told me my left was fractured again in the same place.  I was given clearance the first time so this is a new break.  I'm thinking this is due to a very high arch putting excessive pressure through my sesamoids. 

Dr Blake's comment: Definitely high arches can place more pressure on the sesamoids due to the downward positioning of the first metatarsal (more downward than in a flat foot). Designing orthotics for sesamoid injuries is difficult at times due to this situation. Sometimes the best orthotic is more on the line of the full length Hannaford style which evens the playing field better. 

 There was not any act in which would have caused this.  It slowly began to hurt and swell.  It got worse and by the second week I was at my podiatrist receiving the news that it was fractured again. 

Dr Blake's comment: It can be very difficult to make this call. The original injury probably caused some irregularity in the appearence of the sesamoid. This irregularity can look like a separation of fragments, even though there is solid internally healing. Also, Golden Rule of Foot: It is hard to break a bone in the same place a second time. This is due to the fact that bones typically "double heal" or get twice as strong as they were originally. So, a word of caution about rushing ahead on any surgery. 

 My dr suggested removing one of the pieces as he does not feel it will heal completely or if it does that the fracture is likely to happen again given the way this one happened.  They are putting me on the schedule to have a partial sesamoidectomy.  I'm fine with this as I do not want to fight this breaking for no apparent reason for the rest of my life. 

Dr Blake's comment: I have only seen only partial sesamoidectomy in my life, so I am not a judge. It did not help the problem, but my comment is not anyway scientific. I would be thinking complete removal of the involved sesamoid, or no surgery until the biomechanics of your high arches were addressed. Without the biomechanics being adequately with inserts so that you feel you have no to minimal pressure on the sesamoids, you will have one surgery, then another, and then perhaps more. 

 I have a few questions given my story.
Is it normal to break a sesamoid in TWO DIFFERENT FEET?

Dr Blake's comment: Yes, and it points to a biomechanical predisposition that you want/need to correct. And yes, there are also surgical treatments for this predisposition, if the predisposition can be eliminated. Typically, non surgical avenues can be explored with complete success. 

Is it normal to break the same sesamoid twice?

Dr Blake's comment: No, but it may have never healed completely in the first place, or the underlying predisposition never corrected. That could be foot biomechanics, shoes, diet, Vit D deficiencies, running style, etc. We look at all causes of bone injury, attempt to reverse/correct all these factors, and this is why it is hard to break the same bone twice. That being said I do have my failures also when I did not recognize a problem, say Vit D deficiency, or the patient did not say on track at correcting the problem, or I forgot to tell the patient their need for the corrective orthotics was a life long committment, or the correction of the problem was difficult to do and we hoped the bone would not break again. 

Would you suggest a different option?

Dr Blake's comment: See above, definitely do three things:

1. Treat this sesamoid fracture conservatively like you treated the first one
2. Have the biomechanics of your high arch feet, and all causes of bone weakness addressed.
3. Get a bone stimulator to use for the next 6 months (I love Exogen since it is 20 minutes per day)

How long can I expect to be back to a normal gait, and pain level?

Dr Blake's comment: Of course this depends on surgery or no surgery.

It is extremely swollen and painful now.  How can I relieve some of the pressure?  I am in a walking boot and ice twice a day and take naproxen to help inflammation.

Dr Blake's comment: Definitely add crutches or in boot accommodations to float the sesamoid to achieve a 0-2 pain level with your protected weight bearing. You should add the Exogen bone stimulator, and do daily contrast baths for deep flushing. You should have you internist look for Vit D deficiency and perhaps a bone density test should be ordered. 

Should I get a second opinion?  I am very comfortable in the surgical route given my dr has been working with me for a year and a half.

Dr Blake's comment: Yes, I love our foot surgeon, Dr Remy Ardizzone, but I always think patients should get a 2nd opinion, and not from someone in the same group. I would look at the member list of the AAPSM (American Academy of Podiatric Sports Medicine) for a referral near you. This does not mean you have to switch. You just want another smart person to give you an opinion. I tell my patients never to tell the 2nd opinion doc what the first doc says. Make it a true 2nd opinion. Just tell them your scenario, and that you wnat there advice on what to do from here. 

I have read about pt after these surgeries on your site but should it be the same for me with a partial instead of a full? 

Dr Blake's comment: Again, I claim lack of valuable knowledge.

Could I have a deficiency causing weak bones?

Dr Blake's comment: Yes!!!!

I'm a very active 31 yr old male with a 4 year old who loves to play sports.  I just want to be back to functioning without extreme pain.

Dr Blake's comment: As a father of 2 boys, I feel your pain and understand. I hope this helps you. 
Regards,
Lawrence (Name changed due to witness protection)