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Sunday, October 16, 2011

Sesamoid Injury: Email Advice

Hi Dr. Blake,

Thank you so much for your blog, I appreciate the information I have found there. I have a question for you about a sesamoid fracture that I believe is fibular one, on the pinky toe side.

Sitting under the first metatarsal at the ball of the foot are two sesamoid bones, which have the same function as the knee cap. These bones protect the big toe joint from impact and create more power at push off by increasing the lever arm of the tendons under the first metatarsal. So, if you talk about sesamoids, you normally talk about power and protection. The one closest to the 2nd toe is called the lateral or fibular sesamoid.
 I was sparring in karate and stepped on someone's foot, rolled mine, toes under, and stomped on the top of the foot. It is now seven months since the injury and I am still walking on the outside of my foot due to the pain when walking directly on the flat foot.

The pain is better, but still causes a limp and is red and slightly swollen. I had an MRI 4 months ago which is when they saw the fracture. I have used the bone growth stimulator now for 52 days and I have worn a boot for 4 months but am now mostly wearing tennis shoes for work with my foot wrapped to prevent the toe from moving upward.

 I am at the point where the ortho says the next step is to do a bone graft and wrap it with wires to hold the graph in place but he wants me to see a podiatrist first, which I will in two weeks. I have seen on your site about removing the bone all together, but not a bone graft. My question for you is this- do you have any information about the bone graft?
Dr Blake's comment: I have heard of a bone graft for a non-union of a large bone, but never for the sesamoid. The problem with this is that if the joint between the sesamoid and the first metatarsal is not smooth with normal cartilage, arthritis will set in causing just as much pain as with the broken sesamoid. I can not imagine how they could predict the amount of new bone that would form with a bone graft. Again, I am not a surgeon, and I have just never seen this in anyone. Therefore, you would want to talk to patients whom have had it and returned to normal activity before entertaining this novel approach.

You mentioned that the fibular sesamoid is the less vital of the two, what do you mean by that?
Dr Blake's comment: When I went through my surgical training, the fibular sesamoid was removed routinely during bunion surgery, and patients did well. The fibular sesamoid helps pull the big toe towards the second, and the tibial sesamoid pulls the big toe towards the other foot. They are in harmony working together to keep the toe straight in normal situations. As we age, and begin to develop even a early stage II bunion, the role of the fibular sesamoid can speed up the formation of the bunion. This is one of the reasons if you were to lose one sesamoid, most feel it would be better to lose the fibular sesamoid. And, as we use our first metatarsal to push off the ground, the tibial sesamoid normally takes more weight than the fibular sesamoid as the metatarsal plantarflexes and everts, thus more important in weight bearing during pushoff.

If the bone is removed what will be the consequences?
Dr Blake's comment: You remove the bone to eliminate the pain allowing a return to full activity, to hopefully prevent arthritis from developing under the first metatarsal due to the poor fit of the previously broken bone and the cartilage, and to re-establish proper biomechanics to the body without favoring/limping/etc. Your trade-off is that you weaken the joint by removing a vital component and performing the surgery. Any weakened joint must be protected by foot strengthening, types of shoe gear, padding, orthotics, etc, really whatever it takes to move painfree and biomechanically sound. The joint will never be perfect again, whcih is why we want to be 100% sure when we do surgery that the area would be better off by the surgery (normally the surgeon assumes that without surgery some permanent damage will occur, so surgery is the least of the 2 evils).  And when we remove the tibial sesamoid we also deal with the increased risk of bunion formation.  

I have pain in the ball of my foot on the inside and outside of it, the arch and the top of the foot, the big toe is numb most of the time and has very little range of motion. One of my students bumped the toe of my foot with her shoe and it was very painful and this last week I have had a cramp in the toe off and on. Is there a possibility that I have other injuries other than just the sesamoid bone?
Dr Blake's comment: When you fail to create a painfree environment, the pain gets heightened to protect you, the body feels constant attack so increases the swelling and you favor to protect by using all sorts of muscles and tendons in an improper way. I would much prefer someone walk normally with a removable cast and crutches if needed, then limp in tennis shoes for this reason. Therefore, all the various pains you have are pretty typical for a 7 month injury, in some stage of healing. The MRI should have caught other injuries if present, but I know that is not perfect.

 I completely understand that you can't give me specific answers, but any other information you can send would be greatly appreciated. I am very concerned about having surgery, but then again I can't keep dealing with the injury as it is. I have been practicing karate for about 10 years and kick boxing for about 1 year and since the injury I haven't been able to have my fun and exercise which is driving me crazy!
Dr Blake's comment: Not being an expert in martial arts, or marital arts, I can not imagine getting back into training for awhile. Surgery to remove the sesamoid is your best bet, but can you wear some type of dancer's pad (see blog) to protect it. When the sport does not allow protection, it takes much longer if at all to get back. But, one day at a time.

Hapad company ( makes some great pads to off weight the sesamoid or other areas of the foot. These are Small Longitudinal Medial Arch Pad with an adhesive backing used right behind the sesamoids to off weight.

Here is your classic dancer's pad, but if you feel better, martial art's pad.

 I really hope this is not the end of my martial arts career as I had planned to test for my third degree black belt this winter. Thank you for you help.
Dr Blake's comment: correction next fall at the earliest.

Tammy, Good luck, and I hope this helps. Rich

1 comment:

  1. Thank you for the information Dr. Blake. I saw the podiatrist this week and he suggested removing the bone all together. He mentioned using an incision on the top of the foot and the bottom of the foot. He prefers the top so there is not a scar on the weight bearing part of the foot. Do you have information of which would be the better way to go? Do you have pictures of the actual procedure? I think I am coming to terms with having surgery. Is there a specific amount of time to wait that is suggested before surgery? I know you mentioned it would be acceptable after three months, but is there a golden time frame? Thank you again for the information your blog offers.


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.