Sesamoid Fracture: Email Advice

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.

   Dr Blake's comment: Definitely, mechanics and possibly bone density are problems. Have a nutritionist and a bone density doc review this with you. 

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. 

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: Thanks for getting the bone density test. I lectured at the U of V in Charlottesvile in 2007. What a beautiful and historic place! 

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: 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. 

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 any sense. Get the D to 55 or higher, and get a full workup, but that should not influence surgery at this point.  

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: 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? 

A few specific questions:

Is the boot the best healing device for me right now? Are there any alternatives?

   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.  

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: 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.  

Is it worth using an Exogen bone stimulator since it has been 3 months? 

Dr Blake's comment: With AVN threat, you are probably looking at at least one year. 

Should I be spica taping?

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 continue taking Vitamin D? And calcium? Any other supplements?

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 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: Another MRI in November or December for comparison. You could get a CT scan now to see if you really have AVN. 

What exercises and stretches do you recommend to keep up strength and flexibility while I am in the boot?

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.  

Should I be getting fit for an orthotic? I have very high arches.

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. 

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!

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. 

http://www.aapsm.org/members-south.html#va

And the patient responded:

Dear Dr. Blake,

I cannot thank you enough for all of this valuable information. Truly, I’ve been feeling very lost with what my next step should be and I appreciate your response immensely.

I will absolutely send my MRI and bone density and blood work to you. To answer your questions, pain walking the boot I am currently in is 0-2. I have been in this boot for 2-3 weeks. While on crutches and in my other boot for 8 weeks, around 4 weeks I began experiencing a fair amount of pain (pain level of 4 or so) while in the boot. So while I have been in the boot/immobilized for 3 months, the total duration of that has not been completely pain free. All the doctors I’ve seen know about my other fractures. It was concerning to the doctor in Baltimore, and that was why he recommended Vit D/other testing to see if something was going on with bone healing abilities. No one has really linked how these three stress fractures are related though. I have never had Vit D below 30 (two years ago it was 42, so it has stayed fairly constant). My diet is very good, mostly vegetarian in the past month but I eat appropriate servings of vegetables, fruit, and protein. Regular periods, and no family history of osteoporosis.

I have a few follow up questions if you wouldn’t mind taking a look!

-Do I need a prescription for an exogen bone stimulator? I am completely on board with being patient to solve this injury, but I am a bit concerned about the cost. From what I can find on their website, it seems like they are around $3,000. Is this how much they cost? Is it generally covered by insurance?

Dr Blake's comment: Exogen does have a self pay program much much cheaper, but I would always try the insurance via RX. Have the doc treating you now, or your primary, start by contacting the Exogen rep. It is relatively easy from the doc's side.

-I appreciate your information about the 3 types of pain. You say that we need to know if I need anti-inflammation or anti-nerve meds or diet. How might I figure this out? At this point, would you recommend seeing a pain specialist for information about what might possibly be nerve pain? Related question: do you recommend Quell for me? I’ve read about it on your blog and am curious to know whether it may help my pain, not in my foot but in my leg as I have general aches and pains in my right leg for 5+ years.

Dr Blake's comment: I am just beginning to experiment with Quell, but one of many patients wore it for a month and when it did not help, got a full refund. So, nothing to lose. I am glad you are now consistently at 0-2 pain. So, you can hold off on the pain specialist, and wear the boot for 10 more weeks. It should be a weight bearing boot, and you should slowly and surely increase your walking. Get an EvenUp for the other side.

-You mention meeting with a nutritionist. After reading my whole case, would you recommend that I meet with someone? A related question, how much Vitamin D should I be taking to get to 55?

Dr Blake's comment: That area also sounds good. Typically you take 1000 units per day and retest in 2 months.

-I’m wondering what my plan for now should be. Would you recommend: 

*Staying in the boot or trying to transition into a shoe such as the Hoka? Mainly, it is crucial to already have orthotics for the Hokas? (in which case I would stay in the boot until the orthotics were made and then transition into a Hoka?) 

Dr Blake's comment: Boot for now, and once orthotics with dancer's pads made and adjusted let me know how you are feeling. I figure that is a month or 6 weeks for now.

*Regardless of what boot/shoe I am in, should I start learning to spica tape now?

Dr Blake's comment: Yes, it takes about 10 times to be good spica taping. Also, see if Cluffy wedges help. Do you have some accommodation in the boot to off weight the sesamoid? You can experiment with that at this time. The problem with Hoka One One brand is the narrowest at the front. You may want to get an extra wide (for you) New Balance 928 also at the time orthotics are being made.

*Should I be doing the daily foot and ankle strengthening exercises on your website?

Dr Blake's comment: Yes, some will have to be modified for the sesamoid pressure with a float made of books with the sesamoid in the middle.

*Should I ice 2x daily and contrast bath in the evening?

Dr Blake's comment: Yes, you want to continually control the swelling in the bone.

*Is there anything else I should start doing, today? (other than keeping up physical fitness through swimming, biking off the sesamoid, core/upper body strength)

Dr Blake's comment: Not that I can think. You are welcome and good luck.

Again, I cannot thank you enough for your help. I will send you my images this week. I am so grateful!

Best,