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Saturday, December 4, 2010

Sesamoid Fracture: Email Advice

Email sent to  on 12/2/10


My name is Kathy  and on a whim I’m hoping you might be able to offer me some hope.

I was diagnosed with a sesamoid fracture on 9/22/10. Acute onset of pain (for no particular reason) preceded by a few months of achy in ball of left foot. I believe it’s the tibial or sesamoid closer to other toes.

My first xray indicated a small crack in the bone smack in the middle of it, it reached the wasn’t split totally in two pieces. I have been in a walking cam boot deal since. My xray follow up on 11/22 showed the same crack only slightly wider and maybe fractionally deeper. Pain DOES feel better but still unable to fully bend the toe (as in taking a normal step with full weight). My Dr. looked very confused by the xray comparisons.

I live in a semi remote area. Podiatrist not a sports med guy. My insurance will only cover folks in the vicinity, but really I can’t find ANY podiatrist anywhere who can seem to give me any kind of hope for this hideous thing.

I’m 38 have surfed avidly for 10 years, done yoga for 15+years, and snowboarded for almost 20. No heal wearing ever but lots of flip flop wearing.

Is this bone dead? Will it ever heal? I would love any help or advise you could offer. I am going crazy, lol.



Sesamoids are 2 little bones under the first metatarsal at the ball of your foot. They are named the tibial (closest to the outside of your foot) and fibular (closest to the 2nd metatarsal). The pen is pointing to the tibial sesamoid. Sounds like Kathy broke her fibular sesamoid (the less vital of the 2!!)

Here is a broken fibular sesamoid that shattered and needed to come out next to a normal looking tibial sesamoid. The sesamoid help protect the first metatarsal and, like the knee cap, function to separate the tendon to the big toe away from the bone thus increasing its lever arm of more greater power.

Here is an MRI showing a bipartite tibial sesamoid (a congenital abnormality often misdiagnosed as a fracture), and a fractured fibular sesamoid (see the fracture lines). The MRI slices are just entering the bottom of the foot so you see parts of the other toes and metatarsals. The fibular sesamoid on Kathy's xrays probably look like that. I will have her email a photo.

Hope Kathy can learn some form of spica taping (my best You Tube video).

Kathy, thanks for the email. A fractured sesamoid takes 3 to 6 months to heal  so you are probably doing fine. The removable cast you are in should be giving you total painfree function, and if not, can be modified with various pads. But it is a must that you are in that removable cast for 2 months painfree before you begin to wean out of the boot.
Here is an insert with a dancer's pad to float the sesamoid that can be used in the removable boot also.

Inside the boot you can also do the Kinesio spica taping to help, and you may need the Evenup for the other side if your back starts getting out of whack.

Injured foot with Evenup on the other side to level the hips and base of the spine.

Kathy, xrays can not be used to follow the progress of sesamoid fractures, except as a comparison 6 months down the line. Xrays actually look worse for 2 or 3 months because the healing process brings with it alot of fluid into the fracture site. This gives the fracture site a more washed out look for awhile during very healing, and is constantly being misinterpreted as poor healing. Palpation of the bone will also be sore for several years, so not a good indication of healing or lack of it. MRIs give very useful information and can be followed in 3 months. Before MRIs we just followed the patients symptoms, and that normally worked well. Truly function is the best indicator of overall healing.

Kathy, I would start the next phase of your co-existence with this injured bone by getting these several things accomplished:
  1. Put your foot on an ice pack 3 times daily for 10 minutes to reduce inflammation. You want to have all some symptoms from the break and none from the surrounding inflammation. Avoid anti-inflammatory meds since they can slow down bone healing.
  2. Talk to your podiatrist about getting a bone stimulator from Smith and Nephew called Exogen. You place on your foot 20 minutes twice daily. The bone stim company will work with you insurance company so you know what you have to pay beforehand. The bone stim will probably for the next 6 months.
  3. Discuss you Calcium and Vit D levels/intake with your internist to make sure they are not a problem. I would consider a bone density screen, and especially if you have any family history of osteoporosis. Get your Vit D 25 levels.
  4. Make sure you can make that removable boot into a painfree environment. All podiatrists know that one well.
  5. Learn how to do spica taping as shown on the video above.
  6. Get a baseline MRI. Plan on another one 3 or 4 months later.
  7. Have a PT show you some simple strengthening exercises to start doing now. Everyday you are losing strength, and it will take longer to get better the weaker your foot is, but you can not produce pain. My blog has ample exercises that you can review with the physical therapist including playing the piano, metatarsal doming, flat footed balancing, and inversion/eversion resistance band exercises.
  8. Read my blog post on good and bad pain and become good at this analysis.

    This should be a good start for you. Good luck!! Rich


  1. Dear Dr. Blake,

    You are wonderful!!!! This information has been SO helpful, insightful, and more than anything SO REASSURING! I have no idea why my own podiatrist or the one I sought a second opinion from could not have provided me just some of what you explained above in terms of the way the fracture heals etc. A light at the end of the tunnel is nice to have when dealing with a debilitating have given me mine and indeed I do feel I am on track for the healing of this. I had stopped ice packs a couple weeks back but will resume! Thanks again!!! -Kathy

  2. That Evenup sounds like a lifesaver. Sure wish I had one of those back when I was in the boot!


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.