Sesamoid Fractures General Rules

Sesamoid Fractures:

 

By Richard L Blake, DPM

 

The top 10 initial treatments for sesamoid fractures are:

 

1. Exogen (ultrasound based) bone stimulator for 6 to 9 months
2. Removable boot for 3 months to create a consistent pain free (0-2 pain level) healing environment with EvenUp over other shoe for balancing. This can be substituted by a bike shoe with embedded cleats for both feet.
3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths daily and twice on non-work days.
4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.
5. Learn how to use 1/8th inch adhesive felt to make dancer’s pads for the boot and for post-boot action (patients also love the Dr. Jill's Gel Dancer's Pads that stick to the foot or shoe)
6. Learn how to spica tape for post boot action
7. When you are not wearing the boot, avoid barefoot (house slippers like Oofos protect and cushion well).
8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!
9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.
10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot/bike shoe period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

 In my Book Secrets to Keep Moving, I review the 20 top general rules for sesamoids.

https://store.bookbaby.com/book/secrets-to-keep-moving-a-guide-from-a-podiatrist

1. They rarely do not heal.
2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
5. Follow up MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI. Always look at the first MRI as probably just your initial baseline MRI.

6.            The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis 

7.            Since we are dealing with bone, we must look at diet, Vitamin D3 levels, calcium/zinc/magnesium, and bone density.

8.            Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Re-strengthening, and Return to Activity.

9.            When the patient is in the Immobilization phase, the treatment visits should be thinking about (and acting on) the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, and cardio.

10.         Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase).

11.         One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.

12.         As treatment starts, the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc.) that maintains 0-2 pain level.

13.         The initial goal is to create this pain free environment for 3 months by whatever means it takes.

14.         Non weight bearing (via crutches or Roll aBouts) always increases swelling (which can be a big source of pain), so some protected weight bearing is crucial. Every step pushes fluid out of your foot.

15.         The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed.

16.         If you are basing treatment on x-rays alone, you may be way off base.

17.         Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques. Go to YouTube and type drblakeshealingsole Self Mobilization.

18.         Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist. Keep the joint/foot flexible and strong. No exercise should hurt however.

19.         Patients with sesamoid injuries are prone for setbacks so do not get discouraged.

20.         If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months wait to document delayed healing, some not. Self pay for Exogen Bone Stimulator is an option

 

Sesamoid Fracture: When One is Already Missing

Dr. Blake,

I'm a very fit and aggressive 65-year-old hiker and backpacker who left the Bay Area eleven years ago for a remote small town in New Mexico.

I have high arches and I pronate, and my left fibular sesamoid was diagnosed with a displaced stress fracture 27 years ago, and was excised dorsally. I was given no further recommendations or precautions at the time.

Pain in that area began recurring 15 years later. Since then, I've seen three different podiatrists, none of whom ordered radiology and none of whom diagnosed a sesamoid problem. No one has ever analyzed my gait. They all simply prescribed new orthotics, and now I have four sets of expensive prescription orthotics, only one of which provides reasonably good arch support.

The latest pain began three months ago. Our (only) local podiatrist likewise just recommended yet another set of orthotics, but it took over a month to get them, so I continued hiking with stiffer boots, adding a metatarsal pad to my best existing pair of orthotics, on my own initiative.

Within three weeks, the pain became acute and I had to stop hiking. I rested it for a couple weeks, but it got no better and began aching at night in bed. Then I iced it three times a day for another two weeks. The ache went away, and the pain (on loading) decreased, but only to a point, so I returned to the podiatrist and requested an x-ray. After reviewing it, he said the tibial sesamoid appears deformed and may be fractured. He said if it is, he will need to remove it and fuse the joint, likely resulting in permanent disability. He ordered a CT scan and left on a three-week vacation before the results arrived.

Dr Blake's comment: No, you first try like...to save it with all the things in this blog, or out in the universe. 

As in the past, he didn't suggest any further precautions or limitations, but on my own initiative, I conscientiously keep the load off that joint. What little walking I need to do around the house, I use my best orthotics/met pad, take short steps, and walk on the outside and heel of the foot to keep pressure off the joint, and I also keep the foot flat to avoid extension of the big toe. For anything more strenuous, like driving my truck with clutch, I wear my heavy hunting boots with orthotics/met pad to distribute the load over the arch and outside of foot, continuing to avoid big toe movement. This way, I've been able to avoid all but intermittent light pressure on the sesamoid.

Dr Blake's comment: You are a better rehabilitation specialist than anyone you have seen. 

In the meantime, I've researched the condition online and find that time is of the essence in treating a fractured sesamoid without surgery. I'm already three months into this condition and I've read that four to six months is the window for preventing nonunion and potential avascular necrosis.

Dr Blake's comment: Sure, you want to catch them early, and you are doing good things. Try to create the 0-2 pain level environment for healing. I have seen them heal or not heal after 3 years undiagnosed, so there are so many factors like biomechanics, bone health, work, etc. 

My next appointment, to receive and discuss results of the CT scan, is July 6. I am EXTREMELY frustrated with how long this problem has been recurring, and how bad it's gotten, without adequate attention, diagnosis, and treatment. I'm concerned that my local doctor may only give me the option of debilitating surgery, and I've learned from previous experience that our local physical therapists have limited experience and limited availability, usually with a month-long waiting list.

Dr Blake's comment: See what he says. Bring in a copy of my blog post attached on treatment thoughts. 

http://www.drblakeshealingsole.com/search?q=Sesamoid+General+Rules

I'm open to traveling anywhere, for example back to the Bay Area, for more aggressive treatment to keep the use of my foot. I've read about treatments like hyaluronic acid injections, platelet-rich plasma injections, rejoining a fracture with wire or screws, arthroscopic debridement, shock wave therapy, bone stimulator, biomechanical analysis, gait analysis, spica taping - none of which seem to be available here. Here, I haven't even been given a walking boot to keep the load off the sesamoid.

Dr Blake's comment: I do not do the PRP or surgery, but can establish in 2 weeks a good program. I would want to make the appointments if you can come in on a Monday and leave the 12 days later. I would have you see our surgeon, me several times, our physical therapist, and bone stim guy, to name a few. 

Do you think I should be patient and wait for a local diagnosis on July 6, or should I be looking into outside options ASAP?

Dr Blake's comment: You can mail the CT Scan to Dr Rich Blake 900 Hyde Street, San Francisco, Ca, 94109. Definitely have a long discussion after reading my post above with the podiatrist. 

And regarding outside options, it seems that sesamoid conditions are often difficult to treat. Should I really be looking for a medical team with deep experience in sesamoids, or do you think any general podiatry practice would be sufficient?

Dr Blake's comment: You just need a good rehab person, who can take the information, protect your foot, give it time to heal. You need an MRI 6 months after the first to check its progress, and another 6 months later. Anyone can do this, but they have to want to do it. Good luck my friend. 
Thanks for your consideration!

Dr. Blake,

This is the patient you replied to on your blog on June 27 - the 65-year-old hiker in a small town in New Mexico whose fibular sesamoid was removed a long time ago and is now having problems with the remaining bone.

I've put in a request for my CT scan to be sent to your office. They say it will go out this week. My local podiatrist says that all he can tell from the CT scan is that my remaining tibial sesamoid is arthritically deformed and enlarged, and the only treatment he can offer is surgical removal. He agrees that I might have better options in a big city, and I'm skeptical about arthritis and the need for surgery, since this problem became acute rather suddenly after years without symptoms.

Therefore, I'd like to initiate the intensive two-week round of appointments with you and your team that you mentioned in your response: "I would want to make the appointments if you can come in on a Monday and leave the 12 days later. I would have you see our surgeon, me several times, our physical therapist, and bone stim guy, to name a few."

How should we proceed? Would you like to wait until the CT scan arrives so you can review it first and decide on a plan?

Thanks!

Dr Blake's comment: Yes, let me see the CT Scan. I will put some of the best images on this post. Our surgeon is gone from July 24th to August 14th. I am here except several days in Sept. When we you thinking of coming, after 8/14 is best. Rich

Sesamoid Injury with possible AVN: Email Advice

Dear Richard,
As so many others I found your blog and I agree that it is one of the most valuable sources about sesamoid problems. Thank you so much for providing it! You are truly one passionate doctor. As many others I am suffering from sesamoid pain and I would be very thankful if you find the time to answer to my message.

The entire black sesamoid (black is normal for this image) is seemingly demineralized and has this white shape

Summary:

• 45 year old athletic man, working as a professional mountain bike guide in the summer (not riding with cleats!). Office job in winter time.
• First subtle pain at the ball of the foot started around 1.5 years ago when wearing fancy shoes in the city. Plus some pain on the side of the big toe joint, mostly when pressing on it.
• First saw a doctor in October 2017 (which is 14 months prior to this dictation). X Rays were done, showed no arthritis in the big toe joint. Doc said it is an inflammation in the joint plus the tendon of the lateral sesamoid. Prescribed Arcoxia pain killers for one week, rest and orthotic insoles with stiff extension + gait analysis. Approx. 4 weeks later I started carefully with cross country skiing again, I cannot remember major pain so I continued sports with only very little discomfort. Dr. Blake's comment: So, this was the beginning of it bothering you, but it was manageable. 
• August 2018 aggravation of pain on the side of the big toe joint and at the ball of the foot when biking and walking. Difficult to walk normally. I began to walk on the side of the foot not trying to bend the big toe. Dr. Blake's comment: I am assuming it was fine, or at least slight between November 17 and August 18. 
• End of September new appointment at doctor, ordered MRI. Diagnosis = the lateral sesamoid has problems with the blood supply. New orthotics and rest prescribed.
• November 2018: went to 2nd doc. He looked at the MRI and said the lateral sesamoid is „mushy“, dead and damaged (AVN). Very pessimistic, also about surgery. Started shock wave therapy with this doc on Nov 22nd cause I found good case reports about it. Also send MRI to a friend/radiologist who said there is bone marrow edema but no fracture and only maybe AVN and I should try shock waves. Dr. Blake's comment: Yes, conservative management is fine at this stage. I am not qualified to assess shock wave for this however. My read today would be CT scan ASAP to see if you truly have AVN, then Exogen bone stimulator, and contrasts and acupuncture to get the bone healthy over the next year. Weight bearing is crucial for mineralization. Assessment of Vitamin D levels to make sure you are not deficient. Even bone density especially if the Vitamin D is low or low normal. Experiment with Hoka One One shoes, off weighting orthotics, biking shoes with embedded cleats, all in attempt to have you do as much weight bearing while keeping the pain level between 0-2. 

I am attaching some photos of the MRI. If helpful I am happy to send you the full pictures via wetransfer/dropbox etc. What is your opinion about the condition of the lateral sesamoid? AVN? Fragmented? Or just edema and still in one piece? Dr. Blake's comment: Please send me a disc of the MRI and CT scan when done at 900 Hyde Street, San Francisco, CA, 94109. 
My plan of action is following:

1. Continue shock wave therapy (6 more sessions 3 radial and 3 focussed, then rest and give the bone time to revitalize)
2. Wear insoles at all times in stiff soled shoes (longer walks 5 mins+ in heavy mountain boots). Will try dancer´s pads. I read your advise not to be barefoot at all, however I have no pain standing barefoot on my foot? It is even more comfortable than in shoes. Dr. Blake's comment: With general rules, you have to see what applies to you. Listen to Your Body and how to attain the 0-2 pain levels. Sound like Barefoot for you is just fine. 
3. Contrast baths daily Dr. Blake's comment: Very important to flush out that bone edema. Try twice on weekends. 
4. Vitamin D + 750mg calcium daily
5. Taping the big toe joint so the joint is stabilized when longer walks are required.
6. Massage the area. Passive stretching of the big toe helps, but I read not to bend the big toe at all? Can I bend it passively? Dr. Blake's comment: This is one of those that has to do only with pain levels. Typically you restrict the toe motion while exercising to limit the pain, and you keep it loose when you are at rest. 
7. Thinking about hyperbaric oxygen therapy. Have you any experience with it? Dr. Blake's comment: If you find an article supporting its use in AVN, I will run it by the doctors here that run our HBO program. 
8. Make a control MRI in 3-4 month (6-7 month after first one). If no progress to be seen consulting foot surgeons about surgery options. I have heard very contradicting opinions about the surgery. People who are totally happy and returned to sport activities and others who had even more pain. What is your experience? I am afraid about losing my profession and outdoor life. Dr. Blake's comment: The few patients I treat with sesamoid surgery typically are happy with the procedure, so I do not feel bad about recommending it if it comes to that. The failures are from bad luck, bad surgery, inadequate evaluation of what is causing the pain, etc. The inflammation in your MRI is excessive and will distort the viewing of the bone and the decision making. I would get a CT scan now, start Exogen, contrasts, pain free activities, perhaps acupuncture, get another MRI in 6 months, and probably another CT scan in 12 months. Some of my patients cycle with the weight on the pedal not the ball. See the posts on how to design weight bearing floats for the big toe joint so you can do yoga, Tai Chi, stretches, etc without irritating the sesamoid. 

Is there anything else you can recommend me? I read you are recommending the bone stimulator, does it make sense in my case? Bioventus Exogen seems to be available here in Germany.
Richard thank you so much for your time and hopefully short answer. Of course you can publish this message on your blog.
Now I wish you a merry Christmas and hope you will spend it with your family and friends and that you are having a good time!
Best wishes from Germany,
Dr. Blake's comment: Good luck to you my friend!! I hope this helps you. 

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I came across your blog while researching fractured sesamoids. Thanks for all the great information! I wanted to tell you about my experience and see if you had any additional insights int my condition or thoughts about my treatment thus far.   

I’m a 45 year old male and fairly active. I woke up in March with some pain and discomfort in my big toe. I wasn’t paying very close attention to it but my impression at the time was that I thought I had slept on it funny, maybe did something like hyperextend it in my sleep or slept with it bent back for a length of time that caused me to wake up sore. It wasn’t incredibly painful though, so I didn’t think too much of it. In fact, I sort of figured the best thing to do was to work and stretch the toe as I normally would. That day I did the orbital machine at the gym as well as some shadow boxing and weightlifting, all of which put pressure on the toe.
Dr. Blake's comment: In some ways, this is a good sign. You did something in the presiding 3-4 days that the big toe did not like, but it took several awhile for the swelling to collect enough for it to hurt when you got up. The morning is the classic time to hurt since all night long when you are still, the swelling from an injury has time to settle into the tissues. The pain is for the inflammatory part of the pain. The injury happened without you noticing it a lot, so maybe a good sign!!?? Can you think back to these 3-4 days? Did anything stress the joint out of ordinary? 

I went to bed that night and maybe an hour or two after I fell asleep, I was awoken by excruciating pain. Throbbing, sensitivity etc.. I took some anti-inflammatories and iced it but could barely sleep. I hobbled to work the next day and taped my toe to restrict the movement of the joint for, what seemed to me, maybe some sort of turf toe but I did not see a doctor at that time. The taping helped and the pain subsided over the next few weeks. I was able to do yoga and box and was in a little discomfort but not bad pain.

Dr. Blake's comment: Again, good sign!! Most joint flares, if arthritic, occur over 4 days to 2 weeks if you are treating the flare-ups. They can last longer if you choose to ignore or to select inadequate treatments. We do not know what you did, but this pain is still inflammatory and not the injury itself. Inflammation is the response of the body to heal. You are trying to heal something? Perhaps it is gout or arthritis? Have you had recent uric acid levels? 

Maybe 5 or 6 weeks after that episode ( after 2 long intense bike rides which definitely put pressure on the toe and another intense workout) the toe pain came back and I was again having trouble walking. At this point, I found a podiatrist and went in for an appointment.

He took an X-ray which didn’t show anything and said his hunch was that it was gout, but that he would send me for both a blood test and an MRI. I also was given a 5 or 6-day pack of prednisone anti-inflammatory steroid.

Dr. Blake's comment: The thought was good. You do not want to take prednisone, even NSAIDs if you are suspicious for bone injury. Do not make this your way of handling bone/joint injuries in the future. 

The steroid cleared the pain up very quickly. I was hopping around barefoot and everything seemed good. The blood test came back before I could schedule an MRI and the uric acid read 8.1 which all seemed to point to a gout attack.

Dr. Blake's comment: First, do you know what the range is of normal for this lab. Please send. Gout attacks can occur with high uric acid when trauma occurs. So, just because there was a possible gout attack, you still could have a stress fracture that caused inflammation that sparked the gout attack. A twofer!!

When the course of prednisone was over, the pain came back with a little swelling. I was then able to get the MRI, which showed a comminuted fracture on the medial sesamoid. 

My podiatrist put me in a darco low top shoe with a few cutouts to isolate the sesamoid and told me I’d be in that shoe for 4 weeks. From everything I read that seemed optimistic and sure enough, I'm at the 5-week mark now and after an appointment yesterday, the doctor suggested 2 more weeks based on the fact that the area was sensitive to the touch yesterday. He says that progress is really just based on clinical diagnosis of comfort. The problem with that is, the more I try to give the area with attention, massaging and movement, the more sensitive it is after. 

Dr. Blake's comment: Here I will comment on the some of the images you sent me. First of all, when you use Prednisone, you should ice for 10 minutes three times a day after for the next 2 weeks. This helps to make the effects of the Prednisone last longer. 

Noting the inflammation in the first metatarsal above the sesamoid

When you push down, the sesamoid can push up against the first metatarsal causing injury. The arrow points to the darkened or inflamed first met head. This is a stress reaction, bone bruise, or stress fracture of the first metatarsal head. The stress fracture can actually heal much faster than the others!!

This image shows that the bone edema of the first metatarsal head is the most significant injury, not the sesamoid. 

This is not a fracture, but a bipartite sesamoid with a smaller piece nearest the toe. It looks a little inflamed in this view. What is also interesting to me is that the joint is not really inflamed. Gout usually shows intense inflammation, another reason to get the MRI when things are still inflamed (not being drugged up!!)

I wear the darco shoe whenever I’m outside but mainly I’m trying to stay off my feet and not walk a lot as the darco alters my gait enough that it’s uncomfortable for other parts of my feet, knees, etc...

Dr. Blake's comment: As long as you have something with a dancer's pad to off weight the sesamoid area, various the stresses with stiff soled mountain bike shoes, anklizer removable boots, Hoka One One shoes, stiff hiking boots. You must maintain the pain at 0-2. You should spica tape and cluffy wedge. You should get an Exogen bone stimulator for the next 9 months for the first metatarsal, not the sesamoid.

I still go to the gym but am doing the stationary bike in a way that puts no pressure on the upper foot or other exercises that do not involve the foot. When I'm home I’m barefoot but I walk on my heel and side of my foot and don't ever let the sesamoid hit the ground. 

I also got an exogen bone stim and am using that twice a day along with calcium supplements. 

Dr. Blake's comment: At home, try the Oofos sandals as house slippers. Hopefully, you can put down more normal weight. It is okay to put a dancer's pad in the oofos. Get your Vit D levels. Any osteoporosis run in the family? Bone health may be the issue in any bone injury. Consider a bone density screen if your diet is irregular, or chronically low Vitamin D, etc. 

I am trying to massage the area a bit and introduce a little motion to the joint but the times give done that, there is pain and more swelling the next day. My thought is that it should be ok to bend the big toe down but that I should not flex it up as that would pull the tendon tighter against the healing bone. Is that right? Yes

I’ve read about people in casts and much more restrictive boots for a fractured sesamoid. Is the darco shoe not conservative enough? I will say that I do not put pressure on the sesamoid nor do I flex the big toe when I’m walking. 

Dr. Blake's comment: You have to do whatever to create the most normal gait with a 0-2 pain level. I love also having three possibilities for shoe gear to alternate because you never really know if something is working if you are only trying one. See my comments above. The bike shoes and anklizer are both about $50 each (if you look around). 

Any insight or suggestions you have would be really appreciated! I'm a little unsure of my podiatrist's ability to provide nuanced advice based on what I’ve experienced thus far and if I don't get this healed properly I won't be able to work. I’m also unsure of his approach in taking additional x rays to monitor progress when an x-ray did not find the fracture in the first place.

Dr. Blake's comment: Definitely, you can go on symptoms, and then repeat the MRI if needed in 6 months. Hopefully, you do not need to. Follow up xrays could be taken once, and if it shows no change, it verifies that it is not the sesamoid. Also, if your symptoms keep flaring, consider the CT Scan which just looks at the bone to see if the bone injury is subtle or more involved. However, if it shows a change, then the sesamoid is more involved. Good luck. Rich

thanks a lot

I'm attaching some frames form the MRI as well as the report form that MRI:

"There is nondisplaced probably comminuted fracture involving the medial sesamoid with associated diffuse bone marrow edema within the and focal edema within the articulating plantar metatarsal head. There is trace focal edema within the plantar aspect of the lateral/!fibular sesamoid. The intersesamoid ligament and bilateral sesamoid phalangeal ligaments are intact. There are thickening and heterogeneity with a linear increased T2 signal at the origin of the medial collateral ligament (series 6, image 11). The joint spaces and alignment are maintained. The articular surfaces are intact. There is no aggressive osseous destruction. There is no joint effusion or synovitis. 

Tendons: The visualized extensor/#exor tendons and ligaments are intact. 

Miscellaneous: Ill-de!ned soft tissue like signal intensity within the second intermetatarsal web space possibly represent small neuroma. Plantar plates are intact. There is no abnormal signal in the musculature to suggest atrophy or denervation. The subcutaneous tissues are unremarkable. "

Dr. Blake's initial response:

     Thanks for reaching out. I will work on my comments over the next several days. I would definitely get a CT scan since the bottom of the first metatarsal looks injured above the sesamoid. Rich

The Patient's Response: 

Hi Dr Blake,

Thanks for the response on your blog. Here are my responses to your questions :

I can't recall anything specific that I did to the toe in the days immediately before the first symptoms but I suspect that I sometimes exert a lot of pressure on that toe area when I ride a bike so perhaps that is related. I had definitely ridden that week. I will be mindful of my technique in the future and perhaps get different shoes for riding.  

I do have a history of low vitamin D and had taken extra vitamin D in the past but not faithfully. in 2016 my vitamin D was 22.6 when normal range was described as 30-100. Clearly, a possible culprit here and I wish my primary physician had described the risks of low vitamin D. There is no history of osteoporosis that I know of. 

Dr. Blake's comment: This is such an epidemic, and at your age of 45, I would get the Vitamin D level, and a bone density test. These can change the course of treatment if abnormal. 

I think my podiatrist gave me prednisone because his initial thought was that it was gout. It seems like it was either was not gout or it was a secondary ( first time) gout attack brought on by the bone injury. The lab says that uric acid levels up to 8.5 falls in the normal range but elsewhere I've read that one should really keep them below 8.0. Mine was 8.1 at that time. The MRI was done about 11 days after my initial visit and 6  days after the prednisone schedule was over ( also about 7 weeks after the initial pain) and I was walking with some, but not major pain at that point. 

Dr. Blake's comment: In gout attacks, which can be brought on by trauma like breaking a bone, the uric acid levels in your bloodstream drop over 1 point. So, if you were 8.1 in a gout attack, you were really running at 9.1 to 9.6. The key now is to retake the uric acid one month later and see what is happening. If you are still 8.1 then you just run high, but if you are 8.7 or higher another gout attack is in the making. 

http://www.drblakeshealingsole.com/search/label/Gout%3A%20General%20Treatment%20Thoughts

I realized I probably have a bipartite sesamoid but are you saying you don't see any fracture in the sesamoid?

Dr. Blake's comment: From the views I see, there is evidence of bipartite, not fracture, although the bone is bruised. The main bone problem is in the first metatarsal head, and it treated the same as a broken sesamoid. It is the sesamoid pushing on the metatarsal that causes pain. This will take a while to heal. 

Here the tibial sesamoid lights up on T2 imaging meaning it is bruised. This is not the intensity of bone inflammation you typically see in a stress fracture. The uniqueness of this situation is the bone edema in the first metatarsal head signifying arthritis or stress fracture. The sesamoid pushes up right on the inflamed first metatarsal.

I've been slightly altering where I line up the Exogen bone stimulator. Sometimes under the sesamoid pointing up and sometimes more on the side pointing toward the joint. Is there a specific place you’d recommend to address the metatarsal?

Dr. Blake's comment: Since it has a 3 inch penetration, you can place on top of the metatarsal head and then walk around and multi-task. But, where you are putting it (bottom or side) is closer and either are fine. 

How do I know when I can start flexing the toe and pronating again? I dont want to inhibit the healing process or cause any further damage but am anxious to get everything working again in a way that wont make it worse. How will I know when I can put normal weight on the sesamoid without a pad? 

Dr. Blake's comment: This is the typical rehab question for any injury as we increase activity. It is important to make one change at a time, and probably one month apart is safe. Most athletes with this stay with the mechanical supports well into their athletes, and when they have leveled out the activity, start lessening the things that helped them get there. With sesamoid injuries, you can have cluffy wedges, spica taping, rocker shoes, orthotic devices, dancer's pads, etc. You have to stop one at a time in a logical order when you are doing all your activities and feel you are healed. 

I think/hope I am almost ready to segue out of the darco boot but how will I know for sure? I had bought some hoka one one bondis last week so I will start with them with a dancers pad. 

Dr. Blake's comment: This is how us rehab people find out what people need to move forward. What does it take to achieve a 0-2 pain level while we move the patient back towards a normal existence? If I had 100 patients at one time with the same injury, they would all be slightly different in their needs. There are general rules, but each individual has to be individualized. 

I went to the gym a few days ago and made a sesamoid relief platform so that I could work on my balance and address atrophy in other areas of my foot. It felt great and contrast baths helped with the swelling afterwards.

Below are the pics of the ( very simple) workout platform and some additional MRI images just in case they show anything additional.

Thanks again!

Sesamoid Injury: Email Advice (General Rules to Go By)

Hello!

I'm a surgery resident from Finland and I have a problem with my foot, for a little over two months now. I'm writing to you because it seems I can't get adequate advice here. I would be extremely happy with any insight. I realize though that there are tons of people writing to you every week. But if you decide you could spare me a few minutes, here is my story.

I'm 33 years old woman, and I love sports, especially road cycling. During winter it's not possible here, so I had a trainer with my (older) road cycle on it and rode it with clip-less pedals as usual, with the road cycling shoes I've had for a few years and ridden thousands of kilometres without any problems.

 Well, I did a few sessions that were a little harder and then one morning after a session I had pain in my right foot, right under the 1st MTP joint. I didn't think a lot about it, the pain subsided during the day and I forgot it. But the next morning I woke up in pain. I then began to worry and read my books and googled, and it sounded like sesamoiditis, with pain when dorsi-flexing or plantar-flexing the toe. I changed to a hard sole shoe (hiking shoe) and when I got to work, I taped my big toe and added cushioning to my shoe (shaped to unload the sesamoids). Also I iced (2-3 times per day) the area and took ibuprofein and rested.

My foot did not improve and a week later I took an x-ray, which was perfectly normal, no bipartite sesamoid or anything. Then I went to see a sports surgeon, who confirmed my diagnosis, the fibular (lateral) sesamoid seemed inflamed. He recommended orthotics for my shoes and physiotherapy. He suggested it was because when I cycle hard, I curl my toes and had overworked the sesamoids by doing this, with indoor cycling there are no natural pauses like there are when cycling outside.

 I went and bought Sidas insoles (I have a high foot arch), which made my foot stop hurting while walking in just a few days. I went full-weight bearing the whole time, no crutches, and I also have been working the whole time. The foot-specialized physical therapeut I got to see a few weeks later, he examined my foot, and said that my 1st metatarsal-tarsal ray was lower and more mobile than on the other side and did not work as normal, like when dorsiflexing my ankle, the big toe lagged behind compared to all other toes. I got exercises to correct this as well as new custom orthotics, that support the arch and try to raise the 1st metatarsal ray upwards. Both the sports doctor and the therapeut said I could cycle with the orthotics if I wanted to.

I still iced the area, did all my exercises and got a few new ones to correct the alignment of my whole leg - I seem to have my whole right foot pointing naturally slightly out. Most days the foot was quite ok, did not hurt much at all and I was able to walk normally. I went to a congress a few weeks ago, where I had to stand up and walk a lot during the day, and the toe became worse. I treated with ice and rest, and the pain subsided again.

 I started aqua-jogging to do SOMETHING (I love sports), and I've continued to go to the gym the whole time. Last week I had a good week with only a few stings of pain, and really felt I was getting better. Last weekend I was able to go cycling for a short, 10-mile ride, which did not really hurt (just felt the stupid foot being there) during or afterwards. Also I use kinesiotape, my therapeut showed me how, to "rise" up the 1st metatarsal ray (taping from under the 3rd metatarsal joint, then the tape goes across the dorsum of my foot and up the lateral aspect of the ankle), don't know if that has been helpful or not.

I was pretty hopeful that this would heal. But yesterday, when I forgot to put the tape on (don't know whether this has anything to do with it or not), it started to hurt again. No excess use - actually, I got a lumbago a few days before this and could not go to the gym either - no further trauma. Now I feel a kind of a burning sensation coming and going, extending all the way up the plantar aspect of the big toe, independent of whether at rest or standing/walking. It hurts more to walk than before. The fibular sesamoid is still a bit sore when palpated, but moving the toe does not really hurt. I've been wearing hiking shoes with very stiff, cushioned soles the whole time, and I have now Birkis shoes for work, they are also very stiff and quite thick and I use them with my orthotics. I'm losing my patience with this. I asked an orthopedic surgeon at my work about my foot, about whether to get an MRI scan, but he said that it would make no difference, that sesamoids heal notoriously slowly/badly and that he thinks surgery is a very bad idea anyway, so no help there. I found your blog, and read everything I found about sesamoiditis, and started to do the contrast bathing as well. But a lot of my questions go unanswered.

Sorry about the long story. I would like to treat this once and for all, properly, to get it healed. I'm just so tired of my foot feeling either painful or just not normal, and sometimes even I think amputation would be a great solution... Should I get a MRI scan done - what is the benefit? Is this pain relapse just a part of recovery? Can I ever cycle again - and if so, should I switch my cleat position to midfoot (road cycle shoes don't have much lee on this) or do other adjustments. Do you have any suggestions for me to promote healing? I'm desperate for help - and if I lived in the same continent, would definitely book an appointment.

Thank you a lot anyway, if you got this far in my long e-mail...

Dr Blake's response:

     Yes, I made it through. You explain everything very well. And, I think you are doing well for what we know. You have to treat the worse case scenario without the benefit of a MRI and CT scan. X rays are notoriously poor for diagnosis of sesamoid injuries. The worse case scenario, and definitely my diagnosis of choice, a sesamoid stress fracture. I love MRIs as a baseline of image, so push for that, and if we can see the images, it may change some of my thoughts. 

So, what do we know about sesamoid injuries that may help? Here are my top 20 plus pointers when teaching about sesamoid fractures. 

1. They rarely do not heal (and never need amputation!!!)
2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
5. Followup MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.
6. The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis (self pay MRIs of this area are $500 in the San Francisco Bay Area).
7. Since we are dealing with bone, we must look at diet, Vit D3 levels, calcium/zinc/magnesium, and bone density.
8. Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Restrengthening, and Return to Activity. 
9. When the patient is in the Immobilization phase, the treatment should be thinking about the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, cardio. 
10. Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase). 
11. One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.
12. As treatment starts, the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc) that maintains 0-2 pain level.
13. The initial goal is too create this pain free environment for 3 months by whatever means it takes.
14. Non weight bearing (crutches or RollaBouts) always increases swelling, so protected weight bearing is crucial. 
15. The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed. 
16. If you are basing treatment on x-rays alone, you may be way off base.
17. Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques.
18. Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. See the foot strengthening exercises all over the blog. Keep the joint/foot flexible and strong.
19. Patients with sesamoid injuries are prone for set backs so do not get discouraged. 
20. If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months, some not. Self pay for Exogen Bone Stimulator is around $500. 

I hope this helps you. Rich

Patient's response: 
Hello again!

Thank you so much for the previous answer. I hope you could be so kind to answer a few more questions.

I went and got a MRI taken today and watched it through with the radiologist right away. It appears I have fractured the medial sesamoid (and I thought the pain was in the lateral one, oh well...). The fracture is a simple one, so the bone is broken in two (diagonally), and it appears that it might already be healed from one side (one third of length of the fracture). No other problems were found. So, you were right, and thank you for that, now I know what I'm facing. I'm attaching an image from the MRI here for you to see.

The bone swelling in the fractured medial sesamoid appears white in this image

The medial sesamoid is seen with a crack line running diagonal. 

So it has been 11 weeks now since I supposedly injured the sesamoid. I haven't known what I have had so I probably have been treating myself wrong and been treated and adviced wrong. The whole time I've been to work and wearing stiff, thick-soled hiking shoes with orthotics. I can walk for short distances, slower than usual though, without pain. But if I walk too much, or stand for too long, the pain comes back (of course I try to avoid this), but the pain isn't too bad, I haven't been needing painkillers. From your posts, I see that I should be in immobilization phase? Is what I'm doing enough, or should I get a walking cast or something?
Dr Blake's comment: Yes get the boot, you are in a delicate time right now for healing. I would wear the removable boot with an EvenUp on the other side for the next 6 weeks as much as possible to insure the fragile fracture has a good chance of complete healing. You must side on conservative. Put your custom orthotics in the boot. 

I'm icing twice a day, and also contrast bathing every evening. Fortunately I can move my toe without pain, so I've been doing strenghtening exercises for the foot and the joint isn't stiffening. I eat a lot of dairy, and also take calcium, vitamin D and magnesium supplements. I go to the gym, to mainly do upper body exercises and core, and do aquajogging as cardio.
Dr Blake's comment: Sounds great. The next 6 weeks will bring you a more healed sesamoid, a less inflamed joint, a stronger foot and maintain your cardio. 

What can I expect? Do you think I'm progressing right with the foot? When could I go to Return to activity-phase and try to start cycling, or walking longer distances, and how? The radiologist suggested that a CT scan shows bone healing much better, so later on I might be going to get one. I'm also going to enquire whether I could get a bone stimulator (Exogen).
Dr Blake's comment: Definitely you want the 6 months of bone stimulator. I like the CT scan, but you could wait on that for now, since you are subjectively doing very well. Remind with the cycling the injury could have been produced by pushing down on the big toe joint too forcefully, so I would wait for at least another six months. You could do a stationary bike with the pedal in the arch now. Walking in stable shoes and orthotics, with a progression to a walk/run program, to progression to long distance running is a more controllable program from my distance with you. A physio there many look at your cycling mechanics and say you are fine to cycle, or recommend modifications to cleat/orthotic/clip, etc. Good luck. 

Thank you again so very much, you are a footsaver :)