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Saturday, October 17, 2015

Sesamoid Fracture: Email Advice

i have tibial sesamoid fractured too from running backward at high intensity, had small bump in my new shoes and broke my sesamoid and felt the pain immediately, i got MRI and seen at least 8 specialist... 

after 1year they told me i had fractured my sesamoid, i stilll have pain i went see a orthopedic surgeon and he told me he could remove a part of my non-displaced sesamoid fracture (a very small liquid is between the 2 part shown on MRI a month ago). so his idea is to remove the smaller part(about 45% of the sesamoid..) do you think its a good solution?
Dr Blake's comment: I have only seen one case of this which was unsuccessful, so my limited knowledge won't help. Alot depends on how healthy the joint looks when they go in there, so you have to trust the surgeon to possibly remove it all if appropriate. But, technically it makes sense. 

 he think the pain is coming from that sesamoid not healing completely. But i hesitate so much on getting the surgery im so scared the problem become worse.. 
Dr Blake's comment: The surgery to remove the whole sesamoid is very common, and 85% successful (meaning 85% of the patients say they wound have done it over again). So, since it is a successful surgery, most do not hesitate to do after 6-9 months of conservative care. The downside with this is you have to wear toe spacers between the first and second toes forever, and some form of dancer's padding/orthotic device, to protect the other sesamoid. And you have to get the abductor hallucis very strong. 

and another weird thing, when i walk in the sand its magical for my sesamoid pain, i cant explain why walking in grass and in sand help me and anything involving anyking of shoes or sandals or anything give me pain. I learned to live barefoot because thats truly helping me. when i stand on my sesamoid i dont have pain, but when i touch it i can get about 8/10 in pain also bent it cause pain. 
Dr Blake's comment: The hypersensitivity to the touch of finger or shoe is nerve pain that settles into some chronic problems. You need to work with NeuroEze, prescribed nerve creams, neural flossing, massage for desensitization, etc. 

But if i keep my feet flat i have no problem. One important thing in my case is i learned 1year after the acute injury that i had fracture because they didnt seen it on x-ray. then 1 year later i bought a MRI and they finally seen small crack in the sesamoid that is non-deplaced fracture. Another thing is that my feet now cracking all the time when i walk and it never been like that before the injury.
Dr Blake's comment: The crackling is from fluid retention, either inactivity, chronic swelling, or both. It will disappear as your foot gets normal. The MRI makes me believe that the nerve hypersensitivity may be your biggest problem. Check out some pain management specialists who deal with peripheral pain syndromes, before any thought on surgery. My patient that had the unsuccessful partial sesamoidectomy finally got better with soft Hannaford orthotic devices with dancer's pads and a pain management approach. 

Its impacting a lot my life and tried everything i could, at this point i have 3 solution that i found could work:
1- Live on the beach 24/7 in a hut where i would NEVER walk on hard surface(dont have that $$$ to do that) Dr Blake: Sorry!!
2- Have sesamoid removed partial or completely
3- I never been in the boot, they told me its too late after a year, is it true? do you think if i put my feet in a boot pointing my toes downward for a while could fix my problem?? im thinking about trying this
Dr Blake's comment: When you take a pain management approach, you have to spend 3-6 months in a pain free environment (the boot may help in that regards), use topical and sometimes oral nerve meds, learn biofeedback and other desensitization techniques, and ice three times daily. I hope this helps. Thanks for your kind words. Rich
please come me back dr.blake you ARE the ressource on the sesamoid over the internet!!!!

4 comments:

  1. Hi Dr. Blake,
    From all that I have read here and elsewhere it can be difficult to tell from an Xray if a sesamoid is fractured or bipartite. My daughter had a sore toe one day four months ago, played sport and seemed fine but then awoke the next morning and could not walk on it. The MRI showed a stress response with no fracture line or fragmentation. She wore a boot for 3-4 weeks but then resumed a bit of sport with more rest and ice in between. We determined she had modified her gait and started avoiding push off the first MTJ on her injured foot. Note, she also has a high arch foot type. We had an xray taken more recently that showed two parts to the medial sesamoid (only on that foot). The parts look like they fit together to me but the xray report didn't say anything about a fracture or bipartite and the podiatrist that ordered them wasn't concerned either. Note also that the other foot does not have a bipartite sesamoid.
    Since doing all this research and learning that this diagnosis can be confusing I thought about looking at the MRI to see if I can tell if it was split/ bipartite at the initial time of injury. It looks like both sesamoids are whole to me in the MRI at that initial time but is that a valid image to assess as it was all bright with oedema? She is now able to walk without pain and do a fair bit of activity without pain, however it always hurts to press on it from the side. Could it be a fracture? The only time she had massive swelling and pain was the initial time of injury and the MRI showed no fracture or fragmentation. She did have a few small setbacks in the initial weeks after removing the walkable boot but we iced and seemed to recover well so I am not sure when a fracture / separation would have occurred. If a subsequent fracture / separation occurred would there have been another big pain and swelling or could it have been more subtle?

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    1. Yes, with subsequent fracture/separation there would have been increased swelling with a 4-6 week setback. She sounds like she is doing well. The small stress fractures vs stress reactions are normally healed in 4-6 weeks of immobilization, but very sensitive for another 6 months. Especially in hard arched feet with their increased ball of foot pressure. You can get a stress fracture in a bipartite sesamoid, so the most important thing is the edema in the sesamoid. That edema is our enemy since it makes the bone very sensitive, and can cut off the circulation to the bone. Twice daily you should ice pack the bottom of her foot for 10 minutes, and once daily do the 20 minutes of contrast bathing. This will make sure the fluid is not trapped in the bone. You or she should massage the area twice daily for 5 minutes to desensitize the tissue. It must be pain free massage. It will hurt for the next year to push on, so that is a poor indicator of how she is doing. She should have dancer's pads in all her shoes. You can purchase the 1/8 th inch adhesive felt from www.mooremedical.com. Hope this helps. Also see if spica taping with 1 inch kinesiotape helps. Rich

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  2. I am not sure how to add images to my previous post on sesamoid vs. bipartite questions. Let me know how and I can send these along.
    Thanks.

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    1. Just email with post url to drblakeshealingsole@gmail.com

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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.