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Wednesday, April 13, 2011

Sesamoid Fractures: The Road Can Be Long

This email was just received on 4/13/11 regarding a sesamoid injury that may be healed, we hope?!? Here is the original blog post when Kathy consulted me.

Dear Dr. Blake,

Just home from another visit to my podiatrist. Last X-ray was January 5. It revealed some very good progress as mentioned in my February email below. Today, however, the X-ray they took didn't reveal nearly the "closure" of the fracture that the January image did. He told me right off that of course the angle of my foot this time may have been slightly different when they took the X-ray but it did appear that it could be a little worse. Ugh. BTW not sure I ever mentioned but this is a tibular sesamoid fracture (is that right?). It's the one nearest to my second toe over.

So here's the deal. I'm one of those people who will take pretty great care in healing but THEN when all seems pretty well (if physical activity is involved that is) then off I go usually pushing myself a bit too hard. My foot doesn't necessarily feel worse today then it did in January BUT I have done little to care for it since then other then still bearing some of my weight to my outer foot edge, only wearing stiff souled Ugg sheep lined moccasin style slippers when in the house as opposed to barefoot, and not trying anything like downward dogs in yoga or hard right angle bend type movements sports or walking wise to the toe.

Overall my flexion up and down of the toe has seemed to continue to heal but I have a severe addiction to beach walks! My usual for the last 10 years prior to injury was 3 miles per day. All but a few walks only since the injury was all I took to help with the healing UNTIL Januaryish when cast came off and by mid to late February of this year began 3 to 5 mile walks as I could handle them. First once or twice a week but then several times a week. No real pain has ever ensued and I aim to walk carefully but have had days where the sesamoid definitely talks to me a little during walk (with little twinges here or there) or afterward when I return home (a few subtle aches...but still very sporadic). All the time when walking whether fitness or otherwise I try to correct my foot by not turning it in, not walking so much on outer edge, and relaxing my toes upon each step (so as not to push off too severely ever).

So I'm not icing, taping, taking calcium (but do eat VERY healthy and probably do okay with the cheese/greens I consume) and overall yeah...maybe not doing the best job with things. Today podiatrist will try to get me a both growth stimulator but not sure my insurance will allow the 3500k deal so could be on my own as far as that goes.

So some questions if you can spare the time. Do you feel like this injury will see results from the stimulator? Do I need to just get back on the regimens of ice, taping, rest, and easing up? Is perhaps the subtle amount of pain actually the "good" pain? I mean it's never agonizing. At one point my toe got sort of folded over once when I was in bed, about mid Feb I think. It created a bit of a tender pain but no pop and no residual pain after. Scared me a little but seemed okay. I imagine that could've opened the fracture up a bit but if I had a true re-injury wouldn't it go back to that hideous pain I had at the start? Should I just give up and have the thing removed or is this ALL just a game of patience and 6 more months if I'm careful the thing might actually be good?

Sorry to be so long winded. Your email to me was SO helpful and such a relief and today I just feel totally deflated after 6 months of restraining from all the things I love. I know of course things can always be worse but nonetheless a tough road this has been. Would love to hear any insight you may have and truly appreciate your time. Your blog is helping so many people know about one of the least understood injuries out there.

Thanks Dr. Blake!

Hey Kathy, Thanks for your email. At this stage, you can not use xrays to tell you anything. That is probably being a bit dramatic, but true for most people. When following sesamoid injuries, you can really only use MRIs to document healing (with CAT Scans being my second choice). Based on what you told me, the xray changes were only a slight change in the xray angle (would you then trust them next time if they looked better??)

     I find most patients over restrict themselves during these 2nd 6 monthes of the typical 1 year rehab from a sesamoid fracture. This is totally fine since you must listen to your body and trust it. These next 6 monthes need to be a gradual increase in function, even if you get some symptoms, and you will. On a pain scale of 0-10, you should keep the pain down to 2 or 3 max. Sounds like you understand Good vs Bad Pain, but do not really believe the principle. Believe it and own it, and you will rehab better. Your symptoms will give us more info than any doctor, or xray, or any MRI.

     I hope that you have inserts that protect the sesamoid. I hope you will start the Walk/Run Program as outlined in a different post. I hope you will ice 3 times a day for 10 minutes to control the symptoms related to inflammation. This may dramatically change your symptoms. I love the walk/run, because once you are running 30 minutes straight, you are at a different point in your injury, and decisions can even be more solid.

     None of your pain mentioned above is more then level 2. And there has been no residuals. And you have passed the 30 minute walking test, so you are ready to run. I make non-runners do the walk/run program since they get so empowered by it. I sure hope this helps the next few months at least. Thank you Rich Blake


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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.