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Monday, July 25, 2016

Sesamoid Fracture: Email Advice

Hi dr Blake 

I am a physician in early 50s with dx of medial sesamoid fracture since April 2016 after initial misdiagnosis of gout. Been reading your blog on sesamoid injuries and I am impressed with your advice to so many fellow sufferers. 

Here is my story with my main question now at the end

1.  April 15 X-ray showed R medial sesamoid fracture. Likely from hard sprinting and then 3 days later stepping off a curb with sharp pain in ball of foot. DPM saw me on April 15 with x ray and made dx. Tx was low dose cortisone injection and J pad w sesamoid cutout and activity modification. 

2. Only mild improve 2 weeks later so start. cam walker with metatarsal padding.  Then signif slow improvement for about 3 weeks but then signif relapse with swelling of MTP joint and pain similar to initial presentation of April when I drove in stop and go traffic While in cam walker  
Dr Blake's comment: Definitely against the law in California to drive with one of those boots, even on the left foot. 

3.  End of May- now in relapse I get a second low dose cortisone injection and MRI scan. Go to crutches and non weight bearing. MRI shows medial sesamoid fracture with AVN, stress reaction in big toe and maybe some signal in fibular sesamoid.  DPM recommends more time non weight bearing and orthofix EMF stim. If no improvement by end of July. Then consider medial sesamoidectomy. I used EMF stim 3 hrs daily for 2 weeks and it seemed to cause more swelling and pain so I discontinue it at end of June. 
Dr Blake's comment: These bone stimulators do increase circulation, so the 20 minute daily of Exogen is preferable. Non weight bearing I hate, because it always causes more swelling, which causes more pain. The MRI results suggesting AVN really forces the docs hand, since the AVN protocol is non weight bearing. 

4.  I get second opinion from orthopedist foot specialist in notable academic center early July who reviews history and exams and radiology. Says stay with cam walker and non weight bearing for another 8 weeks, start PT to help with reconditioning and strengthening foot muscles, and exogen stim which he feels is more effective than EMF. Wants to avoid surgery because of risk to the fibular sesamoid. While waiting for insurance approval of stim, I get 2 acupuncture treatments with low electrical stim which seems to help.  I just started exogen 20 min treatment for 3 days and now notice possible increase in swelling and pain. Call exogen and they say swelling not common but possible. Tell me to stop 1 to 2 days and restart 5 min a day and build up to 20 again. Thoughts?  Does bone stim cause more swelling again? Maybe this is sign of increasing vascularity and bone healing?  Just ice and do your contrast bath technique?
Dr Blake's comment: Yes, bone stims increase circulation. Stay with the 20 minutes daily since the bone strength is crucial. Twice daily ice pack, and once daily contrast bathes with one minute heat one minute cold reps for 20 minutes for deep bone flush. 

Also crutching around is breaking down my body. Now possible big toe tendonitis in my other foot and R elbow tendinitis. So using I walk 2.0 no hands crutch to give arms a break although I am worried about developing sesamoiditis in my other foot.  More padding now in my other shoe to avoid further strain on my good foot. 
Dr Blake's comment: I love the concept of the iWalk but have no experience. I am happy to review your images. Just take a photo of the T2 images for 3 planes of the sesamoids to start, and several xray views you have. Have they done a plantar axial view. Rich

Thanks so much

2 comments:

  1. Hi I'm also dealing with a sesamoid fracture. I purchased a walker with a seat and it's much easier to get around on then crutches for non weight bearing. I neal on it and use my good foot to scooter around my house. I'm also worried about my good foot so I will be purchasing crocs and committing to wearing them in the house!

    ReplyDelete
  2. Same condition ,wearing crocs and always add padding,helps a lot.

    ReplyDelete

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.