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Saturday, September 10, 2011

Sesamoid Fracture: Email Advice

Dr. Blake, I have been diagnosed with a fractured medial sesamoid bone. I wish I had a good excuse, such as training for a marathon or heavy duty salsa dancing, but I think I have to chalk it up to simply being a lover of high heels for most of my 35 years of life.

I went to 1 podiatrist, who after 1 month of electrotherapy and taping, recommended surgical removal. I sought a 2nd opinion from another podiatrist, and he thought it was simply sesamoiditis. He started by putting me on anti-inflamatories and gave me the short orthodic boot. 1 month later, and not much better, he recommended heavy duty steroids for a week. I went back in and still felt pain. He then recommended the weight-bearing air cast, which I wore for 1 week. I woke up one evening in the most pain I have felt since I started with this problem.

I called the next day and demanded an order for a bone scan to determine once and for all if it was inflammed or fractured. Results confirmed it was indeed, fractured.

1) In your experience, could the use of the air cast have actually made it worse? I swear I feel more pressure on my sesamoid using the walking air cast, than simply wearing my Birkenstocks.

Dr Blake's Comment: Yes Victoria, the boot could place more pressure and aggravate the problem. I need to modify these boots all the time like in the photos below. Some boots are too rounded in the front forcing the big toe into too much bend. Other boots are constructed okay, but the patient wearing it tries to bend the toe naturally as they walk, driving the broken sesamoid into the stiff (somewhat hard) base. Unfortunately, it probably felt comfortable wearing it. And it was not until after that the symptoms occurred. If one does get a medical device for some purpose, and it causes pain, it must be discarded as good idea, or modified to create a painfree healing environment.
Accommodation of a Sesamoid (Big Toe Joint) placed on a removable insert that can be placed into a cast.

Adhesive Felt to accommodate (off weight) a sore sesamoid bone under the big toe joint.

Example of an accommodation with 1/4 inch adhesive felt for a fifth metatarsal fracture placed into a removable boot to create a painfree environment.

1/4 inch felt sheet prior to cutting into shape (customizing).

This type of accommodative pads for pain under the foot can be crucial in creating a healing environment for the injury.

2) All in all, nothing seems to have helped my foot more than wearing Birkenstocks. Besides being a great marketing story for Birkenstock, is there science behind this?

Dr Blake's Comment: I find that pain in the front of the foot (where the sesamoids are) is influenced by many factors. Each of these factors can produce a positive or negative body reaction. The rule is too see what seems to effect the injury at hand the most. These factors are: Heel Height, Cushioning, Flexibility, and the Combination of these 3. Some injuries need no heel height to transfer weight forward, others it is okay. Some injuries need alot of cushion, others it makes little difference. Some injuries need maximal flexibility, other max stiffness (rigidity) immobilizing the injury. Some injuries seem to have a delicate balance with these 3 variables: the right heel height, the right cushion, and the right flexibility. And now we should add the 4th variable of forward roll that some shoes like Sketchers seem to produce and all removable casts have that should roll you easily through your foot.

For you, birkenstocks probably provide just the right amount of minimal heel height and forefoot stiffness, that cushion is not an option.

3) No one has ever suggested taking extra calcium or simply going all out with a plaster, non-weight bearing cast with crutches. Would this be overkill? I am a very patient person, and would rather try every alternative possible before resulting to surgery.

Dr Blake's Comment: Thanks for your intelligence on this simple fact. You need to produce a painfree environment for the next 6 months, while you work on the bone strength (Vit D and calcium and possible bone stimulator), muscle strength (daily foot strengthening exercises), anti-inflammatory (daily icing and contrast baths whether you hurt or not--total of 3 sessions daily of something that reduces inflammation), perfecting spica taping for the next year plus, and getting orthotic devices that off weight the sesamoid (which should be worn for strenuous activity for 2 years to protect it, and will enable you to wean out of the cast sooner).

I would greatly appreciate any insight and recommendations you have. I have read about all the risks of removing the sesamoid bone, and besides being vain and wanting to avoid bunions, I am ready to get back into an active lifestyle to lose some baby weight and get back in to a healthy lifestyle. Thanks much in advance-


Here is a chronically broken medial sesamoid that developed nonpainful non-union. We may have to surgically remove someday. Patient is completely active at a high level without pain.

Was it the heels that caused the injury? Probably not, but they are sure painful when you are dealing with a sesamoid issue under your big toe. At least I have been told!!

Dr Blake's comment: Hope all of this helps. For now, stay in the Birkenstocks which seem to give you good protection. 


  1. Thank you so much for your response, Dr. Blake. I appreciate you taking the time out of your schedule to help educate! Such a breath of fresh air.

    I have since this post, starting using the Exogen Bone Stimulator twice a day for 20 minutes, and have also incorporated contract baths when possible. I have noticed a new "sharp" feeling around the sesamoid area that I'm having a hard time deciphering if it's "good" or "bad" pain. It's not terrible, but I can definitely feel something "off" while in my Birkenstocks.

    I don't know if this could have anything to do with it, but when I first put my foot in a tub of extremely icy water, the ball of my foot felt as though it were cramping. I continued to alternate between cold/hot water although I don't think I could stand the minute sessions with the water as cold as I had it. (I since then read that it doesn't have to be this cold, but I have vague recollections of doing this same exercise in just as cold water in high school after I sprained my ankle in basketball, so thought it should be just as icy).

    Follow on question: Could healing involve a little bit of sharp, but good pain? Or would you be more skeptical and assume it's bad pain?

    Do you think the ultrasound therapy could have any adverse reactions? i.e, should I consider using it only once a day vs twice?

    Do you think I should now ditch the Birkenstocks?

    Thanks so much in advance, and I may be calling you soon to pay you an in-person visit! I think you and your blog are just wonderful.


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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.