Sesamoid Injury: Email Advice

Hi Dr. Blake,

I have been reading your book and blog.  Thank you so much for the information!!!  I have been to 3 doctors in the last month (2 orthopedic surgeons and 1 podiatrist).  I have xrays from September 2018 and an MRI from December 2018.  2 of the 3 doctors believe that I have a fractured fibular sesamoid and their recommendation is to have it removed.  The third doctor, an orthopedic surgeon, says that the xrays look like the sesamoid is multipartite and that the MRI just shows inflammation in the bone and surrounding tissue.  I am waiting for approval from insurance to get a CT Fusion.  I am a healthy, active 47 year old female and had some blood work to check Vitamin D, magnesium, calcium, etc.  Everything was normal. 
Dr. Blake's comment: The CT scan is a better test for fracture vs bipartite (2 or more pieces congenital) so I am glad you are having it. The bipartite sesamoids I think are weaker bones since they are not completely united, so they can more easily fracture along the junction. The junction of these multi-piece sesamoids are fibrosis (syndesmosis) like ligaments, cartilaginous or partial bone bridges. The cartilage (synchondrosis) or boney (synostosis) can fracture and should be treated like a fracture. So, at the end of the day, if the MRI is positive for bone inflammation, treating the sesamoid as a stress fracture is the safest way to go. 

I am not sure when I first noticed some pain in the ball of my foot.  I believe it was around November 2017.  I am a pilates instructor and I do recall coming home one evening and noticed the ball of my foot felt sore.  I went from teaching bare foot to wearing my normal minimal shoes (LEMS) and things settled down.   Over time, I would occasionally have a flare up (mild inflammation after doing loaded exercises/stretches in dorsiflexion of the big toe), but it would quickly go away.
Dr. Blake's comment: This is definitely the symptoms of sesamoiditis where you are bruising the bone and not enough passes to let it totally heal. It is not the history of something who has broken the bone.


In June 2018, my husband and I started swing dancing.  I don’t remember it bothering me too much until August when we started a style called “Charleston” swing dance.  It is a lot of bouncing on the ball of the foot and turning on the ball of the foot.  Our fourth week into it, last week of August 2018, I was having a flare up and remember thinking I shouldn’t go to the last class.  I went anyway and after that evening, it was uncomfortable to walk for a few days.  The week after that we were in Santa Barbara and I had a hard time walking there as well.  When I got home, I got xrays because I was concerned.


The radiology report indicated “1. Mild osteophytes first MTPJ. 2. Multipartite or fractured lateral hallux sesamoid.”  By the time I got the xray, it wasn’t really bothering me anymore, so I had a hard time believing that it was fractured.  I changed to Altra running shoes and started building up to wearing correct toes and using a metatarsal pad.  Things calmed down and in December, I did some jumpboard work on the reformer (jumping while lying down with springs attached to the carriage) and I had started pushing it a bit with stretching the big toe/metatarsal area.  I had another mild flare up (no more than a 2 or 3 pain) and my acupuncturist insisted that I go to a specialist to get it checked.

Dr. Blake's comment: The xrays indicate some wear and tear in the big toe joint. The MRI typically tells us how bad. But your symptoms are not bad, mainly very short lived, and not consistent with a stress fracture or full fracture. As of now, I would side with the bone bruise people. You will have to figure out if Dr. Jill's 1/8 th inch or 1/4 inch gel dancer's pads can help when you are barefoot (usually needs some tape to hold in place).  If you have a prominent ball of the foot, you may need 1/4 inch. Has anyone commented on your foot structure? Do you have a high arched foot which definitely will put more pressure on the big toe joint/sesamoid?

In late December, my foot felt ok when I went to the first doctor.  There was no pain upon palpation and ROM was normal.  He suggested surgery based on looking at my xrays.  When I said no, he suggested a carbon fiber insert and sesamoid pad be added to my shoe and wrote a diagnosis of sesamoiditis.  I asked for an MRI and he prescribed it.  I got it a couple of days later (December 21, 2018).  The radiology report is as follows:

“TECHNIQUE: Sagittal T1, sagittal and coronal fat-suppressed T2, axial T1 and T2 fat-suppressed, coronal PD, T2, T2 fat-suppressed.

COMPARISON: Radiographs dated 9/13/2018.

FINDINGS: Linear decreased signal intensity extends across the midportion of the fibular sesamoid on axial image 15. There is diffuse bone marrow edema within the sesamoid. There is also linear decreased signal intensity extending across the medial margin of the tibial sesamoid on axial image 15 and there is mild edema in the tibial sesamoid. 3 mm focus of chondromalacia with underlying subchondral edema at the plantar margin of the first metatarsal head. No effusion at the first MTP joint.

Flexor tendons and extensor tendons are normal in signal intensity and caliber. Musculature is normal in appearance.
Dr. Blake's comment: The linear decreased signal intensity is typically normal from the ligaments and tendons wrapping around the sesamoid and distorting the image. The chondromalacia part is wear and tear on the first metatarsal or mild arthritis. This may be the only reason you hurt and means that the joint has been beat up for a long time, even much before you started having symptoms. The symptoms you are having is of mechanical bruising and then inflammation that collects. Work real hard at protecting with dancer's padding and orthotics and changes in some routines that really pick on the big toe joints (like some Pilates routines with the weight on your arch and not the ball of the foot). These restrictions hopefully will be temporary, but I am talking about the next year.

IMPRESSION:

1. The fibular sesamoid does not appear fragmented as it did on the radiographs dated 9/13/2018. There appears to be a transversely oriented band of decreased signal intensity with surrounding bone marrow edema at the fibular

sesamoid worrisome for a nondisplaced fracture. There is also mild edema in the tibial sesamoid compatible with sesamoid stress reaction or sesamoiditis. 2. Chondromalacia with subchondral edema at the plantar articular surface of the first metatarsal head.”
Dr. Blake's comment: When there is chondromalacia, basically softening of the underlying cartilage, I think it is imperative to try to reverse with an Exogen bone stimulator for 9 months, and it will also help if you do have a stress fracture.

Approximately 3 weeks ago, I started wearing the carbon fiber insert and sesamoid pad.  I also started following the advice in your book/blog and have been doing contrast baths 2x/day (4 hot/1 cold for 20 minutes), icing 1-2x per day, and spica taping.  I am also getting acupuncture 1x/week.  Before all of this, my pain levels were typically 0-2.  I feel like where I messed up is that I didn’t keep that 0-2 pain level long enough.  The icing and contrast baths feel great.  The carbon fiber insert made things feel worse.
Dr. Blake's comment: Yes, the carbon fiber inserts are the opposite of off weighting that dancer's padding does.


I tried the Hoka shoes with the sesamoid pad and metatarsal pad, but could feel sensation in the sesamoid when I walk.
Dr. Blake's comment: Hoka shoes are wonderful, but each shoe has a slightly different place for the rocker. If the rocker is in the wrong place, it may put too much weight on the sesamoid. Try on 3 different types of Hoka and see if there is any difference to how you feel before giving up on this shoe.


Now, after 3 weeks of this, my foot feels worse.  Now things are stiff and I start to feel more discomfort later in the day.  At night when I wake up, I feel a warm sensation in my foot and mild discomfort (around a 2 level pain).  It does not hurt at all to press on the sesamoids. Dr. Blake's comment: You need to use a removable boot with the same off weighting inside to rest the foot. Hopefully it will only be for a few weeks, but we have to put you in the Immobilization Phase to calm things back to 0-2 pain levels. I know you can get there.

The second doctor does not believe that it is fractured based on his review of the imaging, his exam, and my story.  Again, palpation did not cause any pain and ROM was normal.  He said to “let pain be my guide”, to use the sesamoid pad/metatarsal pad, and stiff shoes, icing, contrast baths, and to remember that I need to be patient for a long time (he said 3-6 months and then slowly start to introduce activities that have previously irritated it).
Dr. Blake's comment: He sounds smart and wise.

Today I went to a third doctor and he said that it is broken and that it needs to be removed because lack of blood flow to bone, fracture, etc.  He did his exam and again no pain.  He didn’t have me immobilize my foot.  He said to wait until we get the CT done. 

I am feeling very frustrated and scared.  If you have the time, would you be willing to review the imaging.
Dr. Blake's comment: I would be happy to. Please mail to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109.


 For now, I have the following questions:

1. My pain has always felt more like inflammation (hot and a dull ache) and the pain (other than the one week after swing dancing) has generally never been above a 2.  The week after swing dancing was about a 3 or 4 and calmed down within a the week.  Is it possible to have a fracture and have minimal to no pain? Dr. Blake's comment: Very unlikely
2. Should I be immobilizing in a boot (until I get the CT and results) just in case even though my pain levels stay in the 0-2 range with my current setup? Dr. Blake's comment: You should have in your possession a removable boot to put on and minimize the days of your flare ups.
3. Any other advice/input based on my email? Dr. Blake's comment: Just to continue to learn about what is it about your foot that caused this. Is there any biomechanical explanation that inserts can help. My wife takes Pilates twice a week for 15 years and plenty of times the injured teachers have to change what they are doing for awhile to let something heal. Good luck. Rich

Thank you so much for reviewing!!!