First off, your blog is amazing! I learned more here about treating my tibial sesamoid fracture than I have any other sources combined together. My question is primarily regarding getting the proper treatment and when it's time to seek a 2nd opinion. I fractured my tibial sesamoid back in January of this year. I'm not one to rush to the doctor, so I waited 5 weeks from when the pain started to get treatment. The DPM I went to took X-rays that clearly showed an acute fracture of the tibial sesamoid resulting in a bipartite sesamoid. He said that the bones may never unify, however most cases heal with a fibrous union between the fractured pieces. He put me in a cam boot and sent me on my way with instructions to come back in 6 weeks. He also said to ice 3 times daily and take ibuprofen for pain. I’m on week 5. At week 3 I had really bad heel pain due to the boot and added a gel insole. That greatly helped the heel pain. Once that calmed down, I realized that I still had light pressure on my sesamoids. I did a sesamoid accommodation myself and that’s help alleviate the pressure on the sesamoids while wearing the boot.
Since the boot is almost impossible to sleep in, I was sleeping barefoot and was waking up in a lot of pain. I had a muscle spasm that jerked my big toe one night and was in a lot of pain after that. I dug more into your blog and learned to spica tape. That’s allowed me to sleep and shower much better. I only walk outside the boot for just a few steps on the side of my foot to get to the bathroom that’s right outside my bedroom. I can do that pain free for the most part. Do toe jerks and things like that re-break the bone if fibrous tissue is trying to grow?
My 6 week appointment is next week. I don’t know if he’ll want to keep me in the boot another 6 weeks for a total of 3 months in the boot, or if he’ll try to wean me out of the boot. I’ll need help getting a good insert for my shoes with a sesamoid cutout for that to be the case. Should he be doing this with me in the office?
- Not rely on x-rays at all, they are visually way behind the healing, and usually cloud the judgement rushing patients into surgery. But, not a reason to give up on a doc if this is what they are used to relying on.
- Ask the patient to self pay for an Forefoot MRI without contrast at some imaging center (typically $500 or so). It may be a crucial baseline in 3-6 months down the line.
- Keep the patient in the cam walker for 3 total months (initial plan), and actively design inserts with dancer's pads and some arch support to off weight the sesamoid. It can be that by 8 weeks with the right off weighting insert, the weaning process can begin early.
- Request 2 times daily ice pack 10-15 minutes, and evening contrast bathing to control inflammation and flush out bone swelling.
- Make sure diet, calcium, Vit D3 are good. Consider Vit D3 blood test.
- Make sure patient is getting core, cardio, and lower extremity strength and flexibility work close to daily.
- See if you can self pay for Exogen. If not, it is a judgement for the patient to wait and get another x ray 3 months from the first x ray documenting the delay healing for the insurance company.
- Have the patient learn how to spica tape (takes a few times to get good at it)
- Look at their shoes and perhaps replace (how is the padding, flexibility, heel height, etc). It is at least good for the patients to look at Hoka One One, New Balance 928, carbon graphite plates from Otto Beck, etc.
Thanks for your time, I sincerely hope you can help guide me with an opinion of how to proceed.