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Sunday, November 20, 2016

Fractured Tibial Sesamoid: Email Advice

Hi, I'm so pleased to have found your blog and I'm wondering if you might give me some advice. I am looking for a second opinion on treatment for a fractured sesamoid (the one on the outside of my foot).

Here's the story: I trained for a marathon all summer and the week before hit my pinky toe on the leg of the bed and broke it. I stopped running for 2 months to let it heal and then started back up a couple weeks ago. My foot felt good but I did have a little discomfort in the ball of my foot by my big toe and figured maybe I was overcompensating unintentionally and stressing it a little. 

Dr Blake's comment: I have seen patients one or two years later after an injury still limping and not knowing they were doing it. 
Last Monday night I woke in the middle of the night to severe pain in the outside bottom of my foot when I flexed my toe. The next day I was limping a little and everyday the pain got worse and it was harder to walk. On Thursday night the pain was almost unbearable even when lying down. I went to my doctor and they did an x-ray and only saw the fracture in my toe. He prescribed me pain meds and suggested I ice it and rest it. I wasn't satisfied so I made an appt. with a podiatrist and saw him on Wednesday (this is 5 days before answering this on the blog). After telling him my story he thought it could be my slight bunion bothering me, but I insisted the pain was intense when I touched the area though I could walk better by then. He did a physical examination of my sesamoid bones (very painful!!) and looked at the x-ray and said I could have broken it. 

For treatment he said I should use insoles with a hole cut out to reduce pressure and try to rest my foot as much as possible, but he also said if I would have come in the day of or after he would have put me in crutches for 8 weeks. He said I was too far out from the injury for that to help now. 

Dr Blake's comment: I would definitely not agree. You just need to go for 3 months into a removable boot with an accommodation to float the sesamoid and give it some time to heal. You are putting yourself in the Immobilization Phase. This blog will have tons of information for you on this injury.


Sorry it is so blurry, but does show the accommodation


After reading you blog I feel like you advise an aircast or some kind of non-wieght bearing treatment for the first 6-8 weeks. I'm just concerned that I should be doing something more than just using an insole with a cutout circle so this doesn't become a long term issue as I continue to walk on it. And of course I want to run again someday!

What would you suggest? Thanks for listening.


Dr Blake's comment: Here is an excerpt from my book Secrets to Keep Moving. And good luck. You should get an MRI to document that it is broken. Rich

The top 10 initial treatments for sesamoid fractures are:

  1. Exogen bone stimulator for 6 to 9 months
  2. Removable boot for 3 months to create a consistent pain free (0-2 pain level) healing environment.
  3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths twice on non-work days.
  4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.
  5. Learn how to use 1/8th inch adhesive felt from Moore Medical to make dancer’s pads for the boot and for post-boot action.
  6. Learn how to spica tape for post boot action
  7. When you are not wearing the boot, avoid barefoot.
  8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!
  9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.
  10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

2 comments:

  1. Dr Rich,

    I love all of the info. I am a yoga instructor who has a displaced tibial sesamoid fracture in my right foot. Just started 6 weeks of immobilization and although it's killing me not to move as much, I'm committed. Also icing three times a day. Everything I read doesn't sound very hopeful. I teach about 20 yoga classes a week. Will I ever be able to teach barefoot again? This is my livelihood. If I can't teach barefoot, what do you recommend? I can't wear the boot forever. Thanks. Lisa Martinez

    ReplyDelete
    Replies
    1. Lisa, sorry to hear about your problem. Typically the boot is for 3 months, then you wean out into athletic shoes with orthoics and dancer's pads. That can take 2-8 weeks. After wearing the athletic shoes for 2 weeks, and maintaining a 0-2 pain level, you would introduce a dance specific shoe that you could well pad to off weight the sesamoid. You have to be able to bend the toe at this time, but you still need the off weighting. You then spend the next 2 months weaning out of the padding, but still in shoes. All this time on barefoot. Sorry. Then you are ready to slighter supportive dance shoes, with or without the arch or metatarsal padding. And, you gradually get to dance barefoot!!! Good luck, and be patient. Rich

      Delete

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.