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Thursday, May 11, 2017

Sesamoid Fracture: Email Advice

Dear Dr. Blake, 

I hope you are well and thank you for your great book, blog and guidance that have been instrumental during this challenging time.

I have seen a few doctors and have felt that your book and blog were the most informative and caring/humane and that is why I am reaching out to you desperately at this critical point in my life.  It would mean the world if you can let me know your thoughts, insight and valuable advice, and of course this can be shared on your blog to benefit everyone.

Summary:
- Athletic and active 31 year old individual trying to get his life back
- Pain on and off for over a year under big toe
- Sudden sharp pain end of December 2016 while walking
- Increasing pain, saw doctor few months later in 2017, X-Ray Feb 25 (attached): Left medial sesamoid fracture.
No obvious fracture to the sesamoid can be seen on AP view

Plantar Axial View clearly shows the break and sclerosis (over whitening) seen in Avascular Necrosis


March 22 started complete non-weight bearing (NWB) with crutches and had foot in walking boot with barely any foot/toes movement for 6 weeks (believe this probably wasn't the best path to take after reading your book and blog recently)
Dr Blake's comment: After all the walking you did not knowing you had a fracture, the fracture fragments are together, so it is not considered unstable. Some believe in non weight bearing for a time to let fragile bone elements get stronger, a theory, but I also find that the bone demineralization and swelling build up from non weight bearing which may cause 3 months of soreness for 6 weeks off the ground.  Then, after the 6 weeks, it is hard to evaluate the symptoms accurately. 
- Used to wear Dr. Scholl's flat feet soft orthotics in regular shoes, and the person that provided me with the boot attached a rubbery material to harden/lift the arch even more and cut out the part under the sesamoid so that it floats (image attached).

- MRI Taken on April 16 (after ~3.5 weeks in NWB).
- X-Ray taken on May 2 attached (after 6 weeks NWB)
- Saw doctor on May 3 (6 weeks NWB) and MRI report and video with images (file can be opened using Google Chrome) attached
Avascular Necrosis of left medial sesamoid
Plantar Plate Tear



Bone Demineralization from Non Weight Bearing

Arrow pointing to Intact Plantar Plate Ligaments

Arrow pointing to Massive Bone Edema ?Avascular Necrosis of Tibial Sesamoid


History:
Flat feet, overpronation, previous left ankle sprain several years back (no fractures), other than that healthy

Goal:
I would like to bring my sesamoid bone back to life if possible without aggravating the fracture and hopefully healing it at as well and getting back to normal active life.

Based on reading your book/blog, here are my proposed next steps and please let me know if you would prefer any alteration/addition.

Next Steps:
- Ordered Exogen bone stimulator to start asap, 3x day: morning, lunch, evening.
Dr Blake's comment: Twice daily fine!
- Starting Contrast baths
Dr Blake's comment: Start with 1 min hot and 1 min cold alternating each for a total of 20 minutes each evening. As you feel better, see if you can progress to 2 hot 1 cold for 18 minutes without feeling like the joint is getting stiffer. 
- Physio Therapy (PT) in the morning before work, workout with upper body weights and stationary bike in the evening after work
- Setting an alarm for every 30 mins just to move my ankle around (and toes?) a little throughout the day 
Dr Blake's comment: Excellent, definitely can not hurt yourself with moving your toes on your own. Don't forget using oil or gel to massage your foot for 2 minutes three times a day to de-sensitize the nerve over-reaction of protection. 
- 1 week partial weight bearing in boot w/ help of crutches, then get Evenup for other foot and walk in boot.
Dr Blake's comment: Get some 1/4 inch adhesive felt (moore medical) and make a dancer's pad for the foot of one or two layers to float the sesamoid some.

- Continue Calcium, Mg, and Vit. C and D supplementation with healthy diet

Questions please:
- Do I have a good chance?
Dr Blake's comment: For sure. One of my concerns is the plantar plate tear. Did you have a fall, the only way to tear at your age, or is this an other read? It will take 9 months or bone stimulation, contrasts, good bone health, and keeping the pain level between 0-2 in the healing range. You have to be willing to take the sesamoid out if it does not work, and it can take one year or so to figure it out. May need some help from friends to keep you focused. Have a surgeon picked out in your mind, but vow internally that you are going to prove you will not use their help. This is what I would do for myself. 
- Do I take any blood thinners to help blood flow for AVN, ex: aspirin?
Dr Blake's comment: Never heard of that research, so probably not. 
- I do not see swelling or feel pain (unless I press w.finger on sesamoid there is some). Do I need to ice? Not sure what is best given AVN and want to promote blood flow.  If iceing then how long and freq. please?
Dr Blake's comment: Icing gets a bad wrap on stopping blood flow, which is only temporarily. Read about Hunting Phenomenon below. 5-10 minutes is all you need to quiet the inflammatory aspect twice daily. 
http://www.sportsinjuryclinic.net/treatments-therapies/cryotherapy-cold-therapy/effects-cryotherapy-cold-therapy

http://www.sportsinjurybulletin.com/archive/1066-cryotherapy.htm

- Contrast baths, do I end with hot water to promote vasodilation?
Dr Blake's comment: No, always end with 1 minute of ice. Hopefully, the 2 articles above will help you understand icing or cyrotherapy better. 
- Spica taping? Any other foot or toe limiting movements I should apply?
Dr Blake's comments: If I ask 20 patients with this problem what is crucial, there would be 4 distinct camps. 5 would say spica taping is crucial, 5 would say Cluffy Wedges are crucial, 10 would say dancer's padding is crucial, 5 would say custom orthotics are crucial. Just got to try everything to see what is crucial for you. 
 Any while sleeping?
Dr Blake's comment: Typically nothing is needed. 

- Move toes around? Piano and other toe moving exercises? Both plantar flexion and dorsiflexion are good and won't deter healing or just stick to plantar flexion and ankle and 
 leg exercises?
Dr Blake's comment: We have to avoid impact stress, like jumping down hard, or forceful push off, but moving of the toes, ankles, knees, and most exercises can be slightly modified to take pressure off (like dropping your sesamoid into a hole made of four books so you can do balancing or stretches, or putting the weight in the arch with the pedal when stationary biking). Just listen to your body. But we need motion, some weight bearing, strength, cardio, etc. 
- When sleeping do I elevate foot on a pillow or does it press on calf muscle and limit blood supply?
Dr Blake' s comment: It depends how it feels in the morning. Swelling up or down. If down, no need to do anything. If up, try books between the boxstrings and mattress at the foot of your bed, and gradually raise up. Try 1 inch to start. 
- I am wearing a thin dancer's pad as well stuck to foot, do I keep that on?
Dr Blake's comment: Yes, you will be wearing dancer's pads for a long time. Typically, people can figure out how to attach it to the shoe or shoe insert. Here is where you buy a roll of the 1/8th inch adhesive felt to make your own. 
https://www.mooremedical.com/Index.cfm?Ntk=all&No=0&Search=Search&Ns=TotalRevenue%7C1&Ntx=mode+matchpartialmax&Ntt=Adhesive+Felt

- Would I do Exogen before or after the following: icing, contrast bath, PT, exercise?  Any particular order you would recommend for all these to make sure I promote blood flow and healing?
Dr Blake's comment: Icing after you do walking or exercises that you think may irritate things. Contrast baths usually in the evening as a deep flush to daily move out the swelling trapped in there. Exogen twice typically early am and before bed. 
- Massaging foot? just pressing hands (and on sesamoid too?) or shall I get a foot roller (any recommendations?)?
Dr Blake's comment: At this point, I would gradually increase pressure with your 2-3 times daily sesamoid and total foot massage just with your palms. You will have to go lightly around the sesamoid at first, but it is vital to de-sensitize the nerves to be right on the sesamoid area. 
- Cluffy wedge for now or later down the line or not needed?
Dr Blake's comment: Now, and as long as need that protection. Sometimes, it is hard to tell initially, but so many of my sesamoid sufferers swear by it. It may be more important when you are taking more normal steps. 
- How long in boot before transitioning to post-op shoe, then how long after that to hard-soled shoe?  If I insert carbon graphite inserts in my regular shoes, will these be too harsh on sesamoids? If not when can I do that?
Dr Blake's comment: The post op shoe is if you can not take any weight transfer onto the sesamoid, so that can be first or never. The boot, with an built in dancer's pad (sometimes up to 1/2 inch float, is more the starting point. Hard soled shoes can be a long time away, with soft soles (like Hoka One One with a Rocker, or Altra Olympus with just cush and zero heel height (drop)). There is a lot of experimenting that can be done as you begin to get comfortable walking in the boot, and you know on the horizon as shoes. Get familiar with Road Runner Sports and Zappos. These are online places with great policies on shipping and returns. 
- Boot is large, shall I bike in socks and put weight on arch/heel, or bike in post-op shoe at this stage?
Dr Blake's comment: Start with weight on heel initially, and after 5 times, and if you are feeling good with that, try a few times with the weight in the arch. As the weight goes into the arch, there is a little more pull on the tissue that attaches to the sesamoid. You can not hurt it, but the extra pull may be irritative right now. 
- Is Evenup high enough to balance other side of body? Purchasing one right away as already feeling a little hip aching?
Dr Blake's comment: Yes, there are 2 parts to the EvenUp, and one can be removed if the EvenUp is too high initially. Women typically have little problem finding a shoe with the correct heel height. More struggle for men. 
- When would I start acupuncture vs dry needling? which one?
Dr Blake's comment: Technically, they are the same, although many practitioners separate the nerve part and the muscle part. It is up to the skill and purpose of the practitioner. I always feel acupuncture is one of the best ways at increasing blood flow, increasing our body's own immune system, and desensitizing nerves. So, if given a choice, I tend to recommend acupuncture. Dry needling, is really acupuncture, but used for muscles more I think. 
- X-ray followups how often roughly? F/up MRI in 3 months? CT scan?
Dr Blake's comment: I would get a CT scan now to get the bone health. I would get a followup MRI 6 months after the first one to check progress. 

Any other advice or your usual inspirational words would help a lot and I really appreciate your valuable insight and support during this difficult time.

You're a life-saver, sorry for the long email and thank you from the bottom of my heart.

Sincerely, 

Dr Blake's comment: I looked at the MRI he sent by Google Drive, pretty cool that it can be done that way, and saw massive joint swelling which can wash out the visualization of the ligaments (so I emailed him to get a feel if there was any chance he could have torn his plantar plate). You could definitely see the sesamoid fracture with healing edema. 


Thank you very much for looking into it Dr. Blake. No high impact activities or falls. First time I had ever felt some minor pain in this area was a few years ago after walking around for a few hours in the city wearing very thin shoes.  Following that long walk, I had on and off pain every now and then in both feet, more prominent in the left.  I also think I might have not be walking correctly since I had sprained my left ankle several years back and was advised by a physiotherapy student/friend to put my weight on the area under the big toe while walking.  I have very flat feet and overpronation naturally though and have been wearing the Dr.Scholl's OTC orthotics pictured in my original email.  I used to play a lot of soccer but haven't been playing for over a year.  Before NWB I was going regularly to the gym to workout (5x per week): lift weights and bike, eliptical and run on the treadmill (~10 minutes each at high speed).  The night before the day I got the sharp sudden pain (fracture I believe) I was squatting a little heavier than I usually do at the gym, not very heavy weights though around a total of 160 pounds.  I was healthy and eating well with a daily Centrum multivitamin and at least a glass of milk a day. It was winter and I would probably go weeks with no sunlight at all though (work indoors most of the day and cold and cloudy weekends usually).  It was around Christmas and I had received winter boots as a gift and they were actually pretty tight on my toes, and the sudden sharp pain (fracture) hit me while wearing these after wearing them for about a week.

Thanks again for asking and that's all I can think of.  

Kindest regards,

5 comments:

  1. I have a fractured sesamoid, the inside one, on my left foot. I have been in a boot and NWB for 2.5 weeks. I have a trip to Rome for school planned to leave in 9 days. I am a 19 year old womens lacrosse player and have been active and fit all my life. Do you think that the fracture will heal enough before my departure date to just be in a boot and walking? or will I still have to be NWB. I go for an updated X-ray the day before I leave for my trip.

    ReplyDelete
    Replies
    1. In general do you think that 3.5 weeks is enough time for a sesamoid to heal enough to be weight bearing?

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    2. The healing will take awhile and needs to be followed. I do not recommend NWB because of the demineralization, but you also have to create a 0-2 pain level environment. It is hard to advise you because the doctor may have seen something crucial that he/she wants or needs you to be NWB. Follow their advice to be safe. Rich
      See some of the info on making a big dancer's pad in the boot with 1/4 inch adhesive felt (it was in one of my most recent May 2017 posts).

      Delete
  2. This comment has been removed by the author.

    ReplyDelete

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.