Dr Blake's comment: Definitely, mechanics and possibly bone density are problems. Have a nutritionist and a bone density doc review this with you.Hello!
I’m so glad to have come across your blog. The world of sesamoid injuries is quite daunting and your blog and insight offer wonderful information. I wrote to you in August, but I’m writing again in hopes that I will reach you. Many thanks in advance.I am a 21-year-old female with a history of pain and injuries in my right leg. For 5+ years I’ve experienced pain in various parts of my right leg, and have never gotten to the bottom of it. While my primary pain is currently in my right foot, and I have been diagnosed with a stress fracture of the lateral hallux sesamoid (see MRI report summary from 06/27/2016), I find it pertinent to mention my history, as I believe it is at the root of my sesamoid and foot problems. In May 2014, after severe foot pain that prevented me from walking, I was diagnosed with a stress fracture in the 2nd metatarsal bone in my foot. From May-August of 2014 I spent in a boot and refrained from weight-bearing physical activity. In Sept 2014 I attempted to begin to run again, trying change my running form, shifting from heel strike to toe strike, and after experiencing pain, I was then diagnosed with a stress fracture in my 3rd metatarsal.
At this point, I gave up on returning to running. I embraced all forms of non-weight-bearing exercise, such as Pilates, yoga, core strength workouts, and swimming. I did not run at all from late 2014-to the present. I even limited long walks (although, as a college student, my daily routine includes a moderate amount of walking--2-3 miles a day or so). In March of 2016, even with limited weight- bearing exercise I was experiencing significant pain in the ball of my foot. By May, the pain was too much to even walk comfortably. (I believe it may have been this way for a while and I was altering my gait so as to not put pressure on the ball of my foot/sesamoids.) In June, I had an MRI, which revealed edema. Here is the radiology report (I would be happy to get the images to you if that would be helpful.):Dr Blake's comment: Yes, I am happy to look at them and the bone density test you mentioned below. Please send to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109.
Dr Blake's comment: Thanks for getting the bone density test. I lectured at the U of V in Charlottesvile in 2007. What a beautiful and historic place!Impression:1. Imaging findings likely representative of stress change within the lateral hallux sesamoid with suggestion of cortical disruption. Osteonecrosis could have a similar imaging appearance. Correlation with plain radiograph to evaluate degree of sclerosis and/or fracture line may be helpful.
2. Additional edema like signal within the medial aspect of the first metatarsal head is nonspecific but may also be related to stress change. No discrete fracture line is identified.
My orthopedic doctor (in Charlottesville, VA) believes I have a sesamoid stress fracture. He prescribed a pneumatic walking aircast boot (weight bearing) with crutches for 8 weeks. I got a dexa bone density scan as well, with normal results.
Dr Blake's comment: The avascular necrosis of the sesamoid should be first treated with an Exogen Bone Stimulator, dancer's padding, and 0-2 pain levels with appropriate boots and restrictions for the next 9 months. There are stages to the AVN progression, so we want to stop it in its tracks. And, if it does progress, and there is boney fragmentation then possibly surgery is needed. I say possible because we just do not know. I have seen many patients with bone fragmentation, the classic end stage of AVN, just follow along the rehab program and do fine. I personally think it takes 2 years to know you need surgery, but no one would blame you if you had it now. This is for so many problems I deal with.After 8 weeks on crutches and the boot with a significant amount of pain, I went to see a foot and ankle specialist in at University of Virginia. He looked at my MRI, and said that AVN was occurring and I needed to have the bone excised.
Dr Blake's comment: That does not make any sense. Get the D to 55 or higher, and get a full workup, but that should not influence surgery at this point.Knowing the risks of surgery, I sought out a second opinion in Baltimore, MD. After 10 weeks on boot and crutches, he said I did not need crutches. He immediately requested that I get my Vitamin D, calcium, and thyroid tested as well as a general physical. Everything was normal, but my vitamin D levels came back as 40, which he said was on the low range of normal. He has me on Vitamin D supplements for 2-3 weeks, and says if I don’t see some improvement then I should consider surgery. He also has me schedule to have a full endocrine workup just to be safe.
Dr Blake's comment: That does not make sense also. How is the pain walking in the boot? It should be 0-2 after the first 4 weeks. Does anyone know about your other fractures? Have you ever had a Vit D below 30? How is your diet? Your periods? Family history of osteoporosis?Again, I am very hesitant to go through with excision, for many reasons including my age, the fact that there could be pain in both sesamoids, and the dangers of the surgery with the nerve in that area, toe drifting after surgery. etc.At this point, I was on crutches/boot for 10 weeks, and boot only for another 2 weeks (3 months total of immobilization). I am still in the same level of pain as when I first started immobilizing. The pain is intense and debilitating.
Dr Blake's comment: Based on your answers above, we need some weight bearing for bone mineralization, while we keep the pain between 0-2. This could be Hokas with their rocker bottoms and cushion. You need orthotics with dancer's padding. You need an MRI 6 months after the first.Is the boot the best healing device for me right now? Are there any alternatives?
Dr Blake's comment: There are 3 types of pain: mechanical (which should be addressed with shoe, orthotics and dancer's padding), inflammatory (which is helped with icing twice daily and contrasts bathing each evening), and neurological (treated with topical nerve meds, oral nerve meds like Lyrica, keeping it warm, gentle pain free massage, neural gliding, etc--since this is unusual, probably see a pain specialist for a consult.What can I do to alleviate the pain? You say on your blog a level of 0-2 is necessary to begin healing. I am wondering how to reach this level.
Dr Blake's comment: With AVN threat, you are probably looking at at least one year.Is it worth using an Exogen bone stimulator since it has been 3 months?
Dr Blake's comment: You need to use all you can to fight this. Spica Taping and/or cluffy wedges may be important to you.Should I be spica taping?
Dr Blake's comment: Eat healthy, including some red meat weekly (two 7 ounce servings). We need to know if you need anti-inflammation, or anti-nerve meds or diet. I do not know.Should I continue taking Vitamin D? And calcium? Any other supplements?
Dr Blake's comment: Another MRI in November or December for comparison. You could get a CT scan now to see if you really have AVN.Should I get any more imaging done to see what is going on? I have not had imaging since an MRI in late June.
Dr Blake's comment: Since you have not gotten to the 0-2 pain level, you have to do bike with the sesamoid off the pedal, swimming okay but no pushing off, tons of gym activities just avoid impact and pushoff.What exercises and stretches do you recommend to keep up strength and flexibility while I am in the boot?
Dr Blake's comment: For sure, the high arch means that they probably will have to be full length. That is typical for the dancer's pad application.Should I be getting fit for an orthotic? I have very high arches.
Dr Blake's comment: Here is the link to the AAPSM members in Virginia. I personally know Furman and Rubenstein. They can at least tell you where to go. Good luck. I hope this was helpful somewhat. I am happy to look at your images.I live in Central Virginia (Charlottesville) but I am wondering if it is worth it to try to travel to see you. I am very desperate to get my life back!
And the patient responded: