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Saturday, January 28, 2017

Sesamoid Fracture: Email Advice

Hi Dr Blake,

Thank you very much for writing this http://www.drblakeshealingsole.com/  blog.  Your website is the only one which has wealth of information regarding sesamoid issues. I have been following your blog and taking advise.

I have sesamoid fracture, I have been to 3 podiatrists, the advice so far, I got was, custom insoles and surgery.
The pain I have has gradually begun over many years, 5+, more so in last 3 years. My right tibial sesamoid has a fracture.

It started as little bit tingling and 0-2 pain while driving long distance, slowly the pain grew. I ran with the pain and even experimented with barefoot. The pain eventually got lot worse and even walking in dress shoes became painful.

My first podiatrist made a custom insole (it’s been over a year), which help off-loading my weight. The pain did not go away and he wanted me to go for surgery. As I was researching, I stumbled upon your blog. I changed podiatrist and pushed him to do MRI and prescribe Exogen bone stimulator. I got my MRI done June 2016 and finally got my Exogen Bone Stimulator on 18 Aug 2016. I have been using bone stimulator since then and had 151 (5 months) treatments so far.
Dr Blake's comment: Are you creating a 0-2 pain level? Due to the time from injury until now, it will take another MRI after 9 months of bone stimulation, to compare and see if you are improving/healed. So, in May (3 months or so from now) get a new MRI so we can compare them. 

I took your advice and started icing, contrast bathing and Spica taping. I have to admit that, I have not been regular with icing and contrast bath, last few weeks have been better. The pain and inflammation is down. I walk couple of miles back and forth from work. My pain is between 0-2 for few months now. But if I overdo anything, like brisk walking for couple of miles, I will see some soreness the next day. I have no issues bicycling or doing weight machines in Gym. I can’t do free weights as it puts lots of pressure on sesamoid and I see soreness for the next few days.
Dr Blake's comment: See if you can pad your foot with an off weighting (my four books with a whole in the sesamoid area) so you can do your free weights. The day you walk briskly, only do 2 ten minute ice packs or ice soaks that night and no contrasts bathes. If something particularly irritates it, heat in any form can inflame it more. 

I sometimes wear Salonpas Pain patch (camphor, Menthol, Methyl Salicylate) and it helps. Should I use this on an on-going basis? Will it interfere in anyway with healing?
Dr Blake's comment: No that is a great idea, and I should recommend those more. Just do not use before activity to deaden any pain, you need to feel if you are irritating it. 

Does my MRI point to any other underlying issue like blood supply issues with sesamoid or the biparte causing damage to tendons or first metatarsal? Which may force me into surgery?
Dr Blake's comment: The MRI report did not discuss anything bad like metatarsal damage or avascular necrosis (patient shared some photos with me of her foot, and the orthotics, and MRI report over google drive with drblakeshealingsole@gmail.com). I was confused that the orthotics have no off weighting padding, they need to be full length and have a dancer's pad incorporated. You do not need another orthotic, just have the top-covers redone with the above.

If I can continue to do what I do, will it heal eventually?
Dr. Blake's comment: No guarantee, but no negatives right now. With the new MRI you will get a good idea of the healing. 

I live in NJ and work in NY city. I would like to know, if there is a podiatrist you know in PA/NJ/NY area which shares your view and can help me.
Dr Blake's comment: I recommend these these in no particular order: Dr Karen Langone, Dr Robert Conanello, and Dr David Davidson. They are around NYC, not in, so there will be some driving. One of my patients just saw Dr Joseph D'Amico in NYC and really liked him. He is at the school of podiatry I think.

Here is the MRI report from lab.

--------------------------- Report Start -------------------------------
Final Report
History: Chronic forefoot pain for 6 months. No trauma. Possible sesamoid fracture.

MRI of the right foot

Technique: Routine multiplanar imaging of the right foot was performed on a 1.5T MR scanner according to standard protocol. Field of view is focused on the metatarsophalangeal joints.
There is no prior study available for comparison.

Findings:

A Vitamin E marker has been positioned at the plantar aspect of the first metatarsophalangeal joint.

There is a fracture of the tibial hallux sesamoid, with associated bone marrow edema. Associated high signal of the adjacent first metatarsophalangeal medial plantar plate is also present, suspicious for underlying partial tear. There is strain of the abductor hallucis tendon. Subcutaneous edema is present within the adjacent plantar soft tissues. The fibular hallux sesamoid is unremarkable.

The joint spaces and alignment are maintained. The articular surfaces are intact. There is no aggressive osseous destruction. There is no significant joint effusion. There is no synovitis.

The visualized extensor tendons and ligaments are intact.

There is no Morton's neuroma.

There is no abnormal signal in the musculature to suggest atrophy or denervation. The subcutaneous tissues are unremarkable.

Impression:
Nondisplaced fracture of the medial sesamoid with associated bone marrow edema as described above. Associated grade 1/2 strain of the adjacent insertion of the abductor hallux tendon.
Dr Blake's comment: Keep your focus on the nondisplaced fracture aspect. Great sign. Good luck. Rich

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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.