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Friday, November 25, 2016

Sesamoid Injury: Email Advice

This is an email from a patient struggling with pain from a sesamoid fracture. We have had a few correspondences to help some. 

Hello Dr.Blake

I am attaching here the picture of the footwear I'm wearing these days.
Dr Blake's comment: The patient has a post operative stiff soled shoe with an ace wrap and Dr Jills Sesamoid pads. 

1) The post -op shoe which I got last week , I wear with a  sesamoid pad made by
 combining the Dr.Jill's pad and a pad cut out from felt .On top of that I tie a
bandage and then wear the shoe. Is this the right way of wearing these things?
Or the stiff shoe has to be worn on its own?
( I thought it was too hard to be worn without padding)
Dr Blake's comment: This is very good as long as you are achieving the 0-2 pain level consistently, and you are able to increase your weight bearing for mineralization. If not you would have to go to a removable boot, like the anklizer. 


2) I also wear the Crocs Clogs ,with cushioning and sometimes the bandage as
 well ,find this quite comfortable.
Dr Blake's comment: I am so happy you found a shoe/clog that gives good relief, and can rotate with the post op shoe. This will allow the stresses to be variable with each shoe. That is typically very good for overall healing. 


I am quite confused about the PT and the strengthening exercises which are
 recommended . I feel that some exercises which involve flexing of the toes 
forward and backward will not let the bone unite,is it so? What exercises and
 PT is one supposed to do ?
Dr Blake's comment: When you are trying to heal the sesamoid, you want to avoid bending the toe forcefully upwards. Typically, I will have the patient do metatarsal doming, flat footed balancing with a sesamoid protection (a hole of the sesamoid in the middle of 4 books), and posterior tibial and peroneus longus theraband (resistance bands). These strengthening exercises can be found on the blog. 


The calf muscles of my left leg (fracture in left foot)  has really become loose,
can it become firm again or is it permanent atrophy? How does one make
 them firm again ?
Dr Blake's comment: The flat footed balancing will start getting them strong as you build up to 2 minutes. You can do weight bearing squats with the well for the sesamoid, you can do 2 positional theraband calf strengthening (just without having the band push hard on the sesamoids. These can be found on the blog also.


There are days when walking does not cause pain and then there are days the
 pain is too much and even travels upwards to the leg. Why is it so?
Dr Blake's comment: It is always a good sign when there are good days, and hopefully the periods of good days will last longer and longer. However, the area can get inflamed from what you did yesterday, and not bother you until today. Typically, it is limping from you protecting the area that can give you shooting pains which are muscular. But if it feels neurological, it can be that you are picking on the sciatic nerve. Definitely try not to limp, and you should be going gentle calf, quad, and hamstring stretches twice daily. For the calf stretches, try using a towel to pull you foot towards you without pushing on the sesamoids. 


How much should one walk or stand?
Dr Blake's comment: You are trying to both re-strengthen your feet, and return to normal activity. These are two distinct phases of rehabilitation that we are always trying to blend together. Based on your circumstances, you try to increase both activities gradually, sometimes breaking the activity into small sections. So, a runner must do a walk run program first before they can run without stopping. I love 2-3 fifteen minute walks daily, no limping, 0-2 pain level, and gradually weekly bounce it up by 5-10 minutes. It is based on how you feel. The standing is actually sometimes harder, but the dancer's padding helps, or the soft Crocs. When you stand, try to get your weight even from front to back, and right foot to left foot. Get off your foot when you can, ice when you have irritated it. 


Will life ever get back to normal ? If yes ,then how long will it take?( I've been
 like this 10 months)
Dr Blake's comment: No guarantees, but are you making progress. Are you somewhat better than where you were 3 months ago? I find for these situations making benchmarks can be psychologically beneficial. Spend a day making 5 functional levels of what you can do now? This is what we will look at each month. These benchmarks may include: the duration of a walk before pain, the time standing before pain, the number of weekly bad days, etc. The progress may be slow with one of these 5, but significant in another. At least look at this for 3 months, and report back based on those benchmarks. Good luck again, and thank you for the donation to the blog. Rich



Thank you

PS Here is the ordering sites for my new book (and it's ebook version). 




The Patient then replied to my comments.




Thank you so much for helping me! I cannot express how relieved I am to hear that there is still hope for my sesamoids, even after 8 months of pain. It really made my day, as I’ve been rather pessimistic after the visit at the orthopedist.

Attached are some of the MRI images showing the sesamoids in addition to the x-ray of the right foot. It was a bit difficult to pick images showing bone marrow edema, since I’m not sure about what I’m looking at (no doctor has explained it to me, I’ve only been told that the MRI is showing bone marrow edema).
Dr Blake's comment: You sent a beautiful image of the bone marrow edema in the tibial sesamoid. 



-       Dancer’s pad/other orthotics: I’ve been using a dancer’s pad (home-made of felt) for only a a couple of weeks because I discovered your blog only recently. Before that, I used the blue sole into the post-operative shoe I’ve got (images of both attached in the first mail), but this sole only seems to provide some arch support, it doesn’t protect the sesamoid specifically. Right now I’m trying to wear the blue soles combined with a dancers pad in Hoka (One One) shoes because this feels most comfortable. Before I’ve been thinking that the Hoka shoes haven’t got soles stiff enough, but perhaps they are acceptable? Especially since you recommended rocker bottom shoes. I can also mention that I will have somewhat more customized soles made soon.
Dr Blake's comment: You are creating a good healing environment to spend the next 3 months in while you increase your weight bearing. There are no surprises in the MRI suggesting difficulty in healing, and that makes sense based on the history of where you are at right now. There is nothing all-important except creating that 0-2 pain level, and increasing your weight bearing. Everyone will be different in the stiffness needed, rocker needed, cushion needed, off weight bearing needed, and arch support needed. And what combo works well in one shoe, may not do the trick in another shoe. Experimentation to create that 0-2 pain level is crucial. 
-       About the pain: As I mentioned, I find it quite difficult to find an acceptable pain range. Still, I think I am in the 0-2 pain range most of the time and have been for about 1,5 month (after getting that post-operative shoe). However, I feel very constrained by how little I can do when staying in the 0-2 range. Luckily, I can still work because I have a sedentary job, but that’s about it. To be honest, I don’t really have a plan for staying in the 0-2 range other than not walking too much on the foot (which is perhaps a bad plan in the long run).
Dr Blake's comment: Make sure you read the post on good versus bad pain. It is almost a new month and December should be 10% more active than November, with the same for January, and so on. Each month you need to do a little bit more, and ice after you walk, try short walks twice daily, experiment with arch massage, get an anklizer boot that rolls more for increasing your walks,etc. 
-       I began doing contrast baths about two days ago
Dr Blake's comment: I love the daily contrast bathing, with twice daily (especially after exercise) icing for 10-15 minutes. 
-       I will have my vitamin D level checked the next time I have an appointment with my doctor (which is in about a week).
Dr Blake's comment: Great, it will be good to know how if your overall bone health needs some work. 

I have also scheduled an appointment with a physical therapist next week, because this was what the orthopedist recommended. But I’m still not sure how that can help me right now, considering that I feel quite immobilized for the time being.
Dr Blake's comment: You are in the Re-Strengthening Phase of your rehabilitation. You should be learning safe lower extremity exercises without putting too much pressure on the sesamoid. Remember, if they ask you to do something that hurts, do not do it as politely as you can. Get the calf tension stretched and massaged out would also be great, along with arch massage to make your foot more pliable. Alot to do!!

This also leads me to what you said about the different aspects of treatment – e.g. dancer’s padding and orthotics, but also activity modification and foot strengthening. I guess I’ve been doing quite a lot of activity modification for the last months – namely going from being active to being inactive. However, since I get very restless from not being able to do much physical activity, I’ve done a lot of exercises at home (e.g. push-ups on the knees), focusing on not doing anything that puts weight on the left foot. Maybe the physical therapist can help me find even more appropriate alternative exercises?
Dr Blake's comment: Perfect!!

I’m not entirely sure about what you mean with foot strenghtening, although I can understand why it might be needed. After I began the contrast baths, I’ve tried to wriggle my great toe in a non-painful manner when in the warm water – and I’m quite shocked to see how stiff and difficult to move it has become! Therefore, I would really appreciate more advice on the different aspects of treatment – especially foot strengthening. If you have the time to do that in separate posts, as you mentioned, that would be really great.
Dr Blake's comment: Since you are seeing a PT, ask them to make sure you know how to do metatarsal doming, posterior tibial and peroneus longus resistance bands, flat foot balancing with the sesamoid in a well between 4 books, same for the 2 positional calf stretches, and self mobilization for a stiff big toe joint. I have made posts on all of these. 

Finally, having read about sesamoid fractures in medical journals, it worries me a bit that avascular necrosis is said to be a potential complication of sesamoid fractures. When having a sesamoid fracture for months (and potentially 1-2 years, in my case), do I run a risk of avascular necrosis? Is the risk higher the longer one has a sesamoid fracture?
Dr Blake's comment: Yes, and yes. You need to focus now on the opposite of avascular necrosis which is re-vascularization with contrast bathing daily, bone stimulation daily, creating that 0-2 pain level so the inflammation stays in control. 

Again, thank you so much for helping me! I’m looking forward to your next post. If you need other MRI images than the ones I sent, just let me know and I will try to pick some better images.

Best,

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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.