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Tuesday, January 31, 2017

Sesamoid Fracture: Email Advice

Hello Dr Blake,

I hope it's ok to write you an email. I didn't know if it was better to write an email or post a reply on drblakeshealingsole.com
Thank you in advance to read my request here...
  • Feb. 2014; sesamoid fracture
  • Only in July 2014 (5 months after the fact) Doctors told me that it was fractured 
  • Walk boot (camwalker) for 2 months
Dr Blake's comment: Here is where the initial mistake happens. The cast typically should be on  for 3 months creating a 0-2 pain level environment. Then there is a 2-6 week weaning out of the boot all the time maintaining that 0-2 pain level. If you can not maintain it, there is more time in the boot while the shoes and orthotics and taping and physical therapy are modified/started, etc. 
  • Stopping all activities, pain while walking
  • Till end 2015 (2 years without change); many appointments with different specialists all through that time
  • My pain was chronic and I was looking everywhere for answers (tried dancers pads with relief)
  • In December 2015, for the first time, an orthopedic surgeon gives me an answer. He suggests surgery to shave/smooth the bone fragments to alleviate tendon irritation and pain. He told me that my case is very rare, seeing only one in 5 yrs.
  • 1 year passed and I finally got my surgery on November the 4th, 2016 (partial sesamoidectomy); which was anything but standard and required on the fly adjustments and «had to go deeper » (as the doctor said)
Dr Blake's comment: I have no experience, except one patient that it did not work. But, it is too small a sample to come to any conclusions. If it doesn't work, you have to finish it off with a complete sesamoidectomy, or find another conservative solution (thus the email). 
  • 2 months later; still can’t walk, I've got less pain but the inflammation persists and is distributed – sometimes I feel it in my big toe... lots of tension in tendon. 
  • I do daily massaging and stretching within pain threshold (not "assez fréquemment et sérieusement)
  • Still not capable of foot flexing for movement
Conclusion:
Where do I go from here? Was told before the surgery that I would be better in 2 weeks, it’s been nearly 3 months now!
Dr Blake's comment: Any time a modified approach is taken that does not produce results, then a full sesamoidectomy is considered. This is similar to the hundreds of knee meniscectomies I have seen fail, only to have the patient go on to a knee replacement. Any foot surgery can take up to 9-12 monthes to get back to normal activity and still be considered in the normal healing. You were just told the most wished for course. 

But after the surgery, I was told it needed to be adapted and was a little "artistic" procedure.
What would you think in your professional opinion are the next steps to take?
Dr Blake's comment: For all I know, the surgery could be very successful, but it just going to take awhile. Typically start doing the normal things that work on the 3 sources of pain: inflammatory (ice and contrast bathes), neuropathic (massage, neural flossing, avoiding pain over 2, local anesthetic injections), and mechanical (boot, rocker shoes, crutches, orthotics with a good arch and dancer's padding). Create that 0-2 healing pain level environment and hope monthly you can gradually do more and more. 

Scheduled for 2nd post op appointment with not much difference in between.
The surgeon believes in a positive outcome (claimed pain free for a start!) maybe to keep my morale…

Thank you in advance for your opinion!
*If you need my last xrays, let me know!
Dr Blake's comment: I hope this helps you. I tell my patients if the surgeon tells you a month, give it at least 3 (and I love surgeons, we need them, but they can oversell the rehab part). Part of them making you feel good about having the surgery. Why didn't they just remove the whole bone? Was that logical? Ask for Plan B if this surgery does not work after a year. Rich

4 comments:

  1. Hello Dr Blake,

    I can’t thank you enough for what you do on your blog.
    I’m really grateful for your time and implication. I’m sure all the people on the blog want to thank you and are grateful for your honorable gesture.

    When you live something difficult and prolonged such as the sesamoid problem, you feel that no one can understand or has any clue about your condition.
    For the first time in 3 years, I felt that someone can relate and even better yet, give me some advice. Thank you!! I greatly appreciate your concern. I’ll take time to digest and comprehend all you wrote in response to my questions…

    Regarding the last part of your comments, you asked why they only removed a part of the bone… It was because the surgeon thought that it was just a matter of sanding/grinding the sharp part of the bone fragment as being a positive approach. I asked him to do as much as he could to avoid removing the bone entirely. I had read a lot about the total sesamoidectomy and I should say I’m still afraid to consider it as a possible solution.
    Thank you very much!
    Again I highly appreciate the time you take in responding.
    It’s hard to find a medical professional who hasn’t lost his humanity!
    Warm regards, Chloe

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    Replies
    1. Chloe, Thank you for your kind words, and I am glad I could help some. As I have my own health issues, and have gotten poor opinions, I know what you mean. I am glad to be the + side of things. There are many burnout doctors, some forced by the organization they belong, that render uninspired care. I personally find my own practice over-whelming much of the time, but a place I try to be at peace with spreading love one patient at a time. Your words inspire me, keep me going, and I am grateful. Rich

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  2. Hi Dr. Blake,

    Thank you for all the hard work you put into your blog. I injured my sesamoid bone three months ago and your blog is the only thing I've come across with any good information. With that said, I have some questions if you have the time and can help me out.

    I am a runner, but take very good care of my feet. I have never had any pain or problems anywhere but my right knee (once, after a half marathon last May). In November, I was on a walking break during an easy run and felt a "crunch" in the ball of my right foot. It was followed by immediate pain and I knew I must've broke something. Went in to have it x-rayed that afternoon, nothing looked off. The doctor said this is normal with fractures and to return in 4 weeks if the pain was still present (didn't mention anything about a boot at this time, just told me to try and keep weight off of it). The tricky thing about the timing of this, though, was that this happened the Thursday before I was set to perform in a musical for the weekend. I worked for 3 months rehearsing and wasn't about to quit right before opening night. So, I danced on it for three days (icing it when I could), and started some serious time off right after the weekend was over. My doctor wasn't thrilled that I chose this, but said I should be fine just for a weekend. 4 weeks later, the pain was still there. I went back and they re-did the x ray, this time there was a fracture visible in the sesamoid bone towards the inside of my foot (I believe you call this the medial sesamoid). He put me in a walking boot and scheduled a follow-up for 6 weeks later. He asked me to limit weight bearing activities, but told me I could swim, stationary bike, or do other things that didn't require my body weight. This appointment was mid-December.

    I got along okay for 6 weeks, but I really miss running. I swim 3 days a week and do Pilates once or twice a week, too. When I went in for my 6-week follow up last Monday, the x ray didn't show any improvement at all. I'm feeling very discouraged. He mentioned that I'm a candidate for surgery now that it's almost been 3 months since the initial injury, but I'm wary of that option. My questions for you are:

    1.) To me, this seems like a very acute injury rather than a chronic stress fracture. My doctor keeps using the words "stress fracture," but should I be treating it differently if it was a sudden, trauma-induced injury?

    2.) What can I be doing to help this darn stubborn little guy heal? I read some of your advice in the sesamoid post "advice when not healing well" and I bought some hapad metatarsal pads and dancers pads for my shoes, but I'm wondering if I need further immobilization?

    3.) Have you seen runners be able to return to the sport after healing their injury? I'm not finding anything encouraging online and I'm supposed to run my first marathon this November. My training doesn't start until June, but I'm starting to think it's really unrealistic and it's getting me down.

    4.) Is it a bad sign to not see any healing in an x ray after 6 weeks? I've been so careful and the only time I haven't been in the boot is when I'm in the pool or the stationary bike at the gym, at home relaxing, or using my Birkenstocks to take my dog for a walk (I don't feel pain when wearing those shoes).

    Again, thank you so much for doing what you do. And if you make it this far, thanks for reading!

    -Elizabeth

    ReplyDelete
    Replies
    1. Elizabeth, I copied and pasted this to my blog today for the answer. I hope it helps you. 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.