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