Recent Sesamoid Fracture with Fear of Osteonecrosis

Dear Dr. Blake,

I'm sure I speak for everyone when I say, "THANK YOU for your informative website and sharing your expertise!!"  I have seen 2 orthopedists and 1 podiatrist and they have only helped me a mere fraction of what I've learned from your website.

My MRI shows "Markedly abnormal tibial sesamoid, suggestive of fragmentation and osteonecrosis."  Based on MRI, the podiatrist predicts 90% surgery for me, but he says that I can try doing conservative tx (8 weeks immobilized, NWB).

On 4/20/2016, my foot injury occured after many months of competitive tennis (no orthotics, pronated foot, high arch)   I had severe pain and could not put any weight on my foot and was in a wheelchair for several days.

Today (3 weeks post-injury), my pain level is 0-2 when walking in flat shoes or tennis shoes!   My 1st Met Joint + Big Toe is swollen; swelling seems to have increased after 1-week of NWB.

I hope you can please help with these questions (which I believe will help many other sesamoid sufferers):

1. Here is the million dollar question:
   For sesamoid fracture recovery, do you advise "NO weight bearing (NWB)" or "LIMITED weight-bearing"?
  (After 1-week of NWB, my GTJ is more swollen!  I see where it is mentioned NWB may increase swelling and also about how NWB can cause mineralization of sesamoid.)
Please clarify:  What is best for sesamoid fracture:  NWB or limited weight bearing and if so, how much?

2.  Will Exogen Bone Stimulator improve healing of a "fragmented" sesamoid?  
    
3.  The doctors said the MRI quality was poor (like low definition!).  Would a repeat MRI be helpful at this point to obtain better views of sesamoid in order to properly diagnose if it's fractured or fragmented and if there truly is osteonecrosis?   

4.  Will Contrast Bath help with my osteonecrosis?

5.  Do you advise wearing the orthotic boot when sesamoid patient is SLEEPING AT NIGHT TIME or RESTING ON COUCH... or is it okay to sleep without orthotic boot?   Is it helpful to Spica Tape(Plantar-Flexion) of Big Toe,... ALL of the time or only when sleeping? 

6. For a fragmented sesamoid, is the conservative treatment (3 months rest) the same as for a fractured sesamoid?

7.  May I please, please send the MRI to you for your expert review?

Thank you again for sharing your time and expertise!!!  

Kind regards,

Dr Blake's response:

Linda, sorry for your predicament. As long as you can accomplish 0-2 pain level, partial weight bearing is preferred for bone mineralization. NWB always causes more swelling and pain, making decision making harder for progress. Exogen helps strength of bone, but no one is sure about the fragmentation. I have patients doing well with fragmentation and others waiting for surgery. It is one strike against you, however, did you say this was less than a month old. Fragmentation from bone death increases surgery, fragmentation from the original surgery may not. You need a CT to really look at the fragmentation. Yes, get the best resolution MRI you can, call around. Also, may be they can do a CT scan at the same time. Contrasts bathing done twice daily is the best thing you can do at home to really eliminate the deep swelling which cuts off the circulation and leads to bone death. You should not need anything at night, unless you are a sleep walker. Right now, you are probably a fractured in multiple pieces than a fragmented patients. Once you have the CD of the new MRI and/or CT scan, you can mail to Dr Rich Blake 900 Hyde Street San Francisco, CA, 94109. I am happy to help. Rich

Hello Dr. Blake!!!

Thank you sooooo much for your reply and concern!!!

Yes, my fragmentation and osteonecrosis is from injury (it is not from surgery).
Yes, the injury occurred on April 20; it is less than one month old.   Does that increase my recovery chances,... and does it change the treatment plan?  
I play competitive tennis (pronated foot with high arch) which resulted in pain in my 1st Met;  this got worse six months ago.   Doctor suspected stress fracture of 1st Met so I was put into an AirCast Cam Walker on April 15, the day before I went on a cruise ship.

On April 16-20, I wore the AirCast Boot on the cruise ship where I was walking about 2-miles per day because it was a big ship with lots of trips to the food buffet!

***Stupid me,... when walking in the AirCast, I modified my gait in an attempt to keep weight off of my 1st Met...  so my gait was very supinated AND I flexed my Big Toe upwards for 2 miles/day on the cruiseship!   I have since read that supination and big toe dorsi-flexion can expose the sesamoid and moves the protective fat pad away from it's normal location.   I believe my modified-gait resulted in exposure of my Tibial Sesamoid to the hard insole of the Aircast Cam and this resulted in my crushing the sesamoid!!!  

It was cruise day#4 when suddenly after a lot of walking in Aircast, my R foot was suddenly in so much pain (felt like broken bone)  that I could not bear any weight on it and ended up on crutches!    The date was April 20 and my R foot had swelling, severe pain in 1st Met especially planter side, with intense pain upon dorsi-flexion!  
OMG, is it possible that I crushed my own Tibial Sesamoid in the AirCast Cam by walking 2-3 miles with an exaggerated-supinated gait and with keeping my big toe dorsi-flexed upwards?!   Do other patients complain about sesamoid pain in the AirCast Cam?
After my MRI, the doctor put me back in to the AirCast (despite my suspicion that it caused my injury).   The AirCast hurt my sesamoid so after a few days, I took it off and my foot was more swollen.   I now wear a DARCO Ortho Wedge instead of the AirCast.  Is the Darco Wedge okay to use for 4-8 weeks of immobilization and limited weight bearing?  
If the tibial sesamoid dies, then is there an option to leave the dead sesamoid in my foot or is sesamoidectomy required?

Thank you again for your invaluable advice and I will follow all of your advice.   I will also try to pursue another MRI and/or CT scan and I will mail it for your expert review.   Thank you so much again.  

With sincere gratitude,
~ "Squashed Sesamoid"  

Dr Blake's response:
Increase chances greatly, it is not in a chronic state.

Cam Walkers hold the weight down for long periods on the heel and forefoot. Many times you have to modify Cam Walkers to alleviate pressure either in the heel or ball of the foot. So it is possible the Cam Walker caused the problem, but it is important that you are wearing it now with some insert that takes pressure off the sesamoid. The Darco Wedge is okay, but causes an altered gait (not good), and no weight on the sesamoid (some increase in swelling retention and bone demineralization). Okay to wear until the Cam Walker with partial weight bearing has some accommodation to protect the sesamoid and reduces the pain consistently to 0-2. 

No studies about leaving dead sesamoids in there. 

Hope this all helps. Rich

Hello Dr. Blake!!!
Thank you again and your expertise and info are very helpful, and much appreciated!!!

I have one question and I hope this will help others to avoid what happened to me!
 
     At the risk of sounding really dumb,... I think I caused the osteonecrosis (AVN) sesamoid!
  
While on the cruise, the pain from my sesamoid fracture was intense and I had NO pain killers, not even Tylenol.   To relieve the pain,  I put ice in a surgical glove and then applied it directly to my foot and tied it on to my foot,... and I left the ice on my foot for one HOUR!   After an hour of icing, my GTJ was numb and skin was red/swollen.    To alleviate the intense pain, I repeated this direct icing 4-5x/day, such that my GTJ was over-iced for 4-5 hours/each day for about one week!  

Is it possible that my excessive-icing applied directly to GTJ caused AVN of sesamoid?!?
Dr Blake's comment: I guess it is possible to cut off enough circulation to kill the bone, but again, I am not sure if you have osteonecrosis yet. It is good to point out that icing more than 20 minutes can cause nerve damage, so you more likely have nerve problems now. The nerve hypersensitivity will improve likely with massage and perhaps nerve creams like OTC Neuro-Eze. 
I read that the sesamoid has very limited blood supply and this raised my concern and regret that by OVER-ICING, I inadvertently froze that limited blood supply, resulting in AVN!   I also read that AVN sesamoid is uncommon/rare.  
 
Thank you for helping with my question about excessive-icing and AVN sesamoid! 
Hopefully others can learn from my mistake.

I am working on getting the MRI repeated and plan to share the new MRI results/CD soon.

There is scant literature about sesamoid and very few doctors who know how to DX and treat it.
You are a RARE exception and you truly are a doctor sent from Heaven to help me and others.
Dr Blake's comment: We are all our own worse critics, so I appreciate the reference to Heaven. I hope to make it there someday (after a millenium or two of purgatory of course). 

Thank you again and with sincere gratitude,