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Sunday, November 20, 2011

Sesamoid Injury: Email Advice After Complete Removal Both Sesamoids

This is an email I received 3 weeks ago. I apologize for being way behind right now with no end in sight to catch up. Any advice I give in situations like this must be generalizations only, and may not truly apply the individual I am corresponding with. I do hope some of the information however will be very helpful. I must always defer to the health care provider that has personal knowledge of the case.

Dear Dr. Blake,

I recently discovered your blog...a bright light in the midst of my deteriorating foot odyssey!

Can you help me with orthotic fitter guidelines? I had a complete sesamoidectomy 10 years ago, resulting from a barn/equine accident that completely fractured both sesamoids. The podiatrist recommended removing both as the only option. I consented, not being fully informed of the problems sure to arise. Over time my great toe has drifted, exerting increasing leverage on the second toe. I have used toe separators, as well as regular stretching of scar tissue (yoga) and the crooked toe joint. I wore 3/4 length, rigid custom orthotics.
Dr Blake's Comment: Any surgery, on any joint, weakens that joint. Over time the weakened joint can shows signs of problems with changes in position (as commented here), pain, or problems elsewhere due to compensation for the weakness.

Metatarsal pain has developed over the past 3 months. I manage discomfort with Birkenstocks, Birkenstock inserts, layman's padding, and limited exercise. It was a very happy day when I discovered Hapads on your blog.

A respected orthopedic surgeon in my city suggested osteotomy for 1st metatarsal and toe joints, screws, etc, but I absolutely lack enthusiasm for foot surgery. He also recommended new orthotics for proper pain relief and foot stabilization. My radar went up as the fitter took imprints with a styrofoam box...needless to say they are not doing the job. They are full length, bulky, soft laytex fused to a cork bottom, wrapping around my heel and arch while providing remarkably little support. I miss the fit of my old orthotics as they beautifully supported my high arches.
Dr Blake's Comment: The Styrafoam box technique will always flatten the arch over a suspension cast taken in a non weight bearing position. Patients, and especially those with high arches, need to have all of that arch supported to take weight off the ball of the foot. It is the orthotist's job to maximally support that high arch while making it comfortable. Even though I have been doing this for 30 plus years, it can still take me several attempts to get it right in this situation. But, it can be done.
I'm left with these questions...

Can I prevent further progression of the dropping metatarsals?
Dr Blake's comments: Yes, definitely, si, and yes again. The right orthotic device along with foot exercises to strengthen your foot painlessly can make great improvements in your stability and stabilize the collapsing problem. Exercise routines like yoga and Tai Chi can also greatly help.

In my quest for range of great toe motion could Down Dog yoga position and plank position have contributed to metatarsal instability?
Dr Blake's comment: Yes, forced dorsiflexion of the big toe joint for prolonged periods could increase joint instability. However, it is not definite, and may have enabled you to go 10 years without significant problems post surgery. Do not give yourself any guilt on that one! From this point on, use painfree activities as safe activities for your foot.

Can an orthotic be made providing firm support for my arches, as well as off loading and softer suppport for the forefoot?
Dr Blake's Comment: That is the simple RX for any orthotic device for this problem: Off weight the sore area by transferring support to the arch, and soften/cushion the sore area in the front of your foot. Every orthotic maker knows these 2 basic rules.

Can I be sure an orthotic fitter knows how to accurately get an imprint of my feet?
Dr Blake's comment: Whether you use the same fitter, or another, at least you have these goals and a pair of orthotics that do not provide enough support. I have my preferences like semi-rigid plastic 3/4 th length for the arch support part, and then soft topcovers full length with accommodative forefoot extensions to float sore spots. It is hard to know if the orthotic fitter was accurate, but having a conversation per manufacturing around these 2 things should help you.

How can I find an excellent orthotic maker in my area?
Dr Blake's Comment: In the Indianapolis area, there is a great lab called Allied/OSI. My contact there is Darlene. She should know who is good, really good, to help you. The good people usually demand the most out of the lab, ask the most questions, etc. Should she not be available, talk to the lab owner, or plant director. They are known world wide for their expertise. Show them this email.

I appreciate any ideas you have. I am increasingly limited and deeply worried about further structural deterioration of my forefoot.
Thank you,

Indianapolis, Indiana...will travel to the right foot doctor and orthotic creator, especially Chicago and DC areas.

1 comment:

  1. Thank you Dr Blake for the nice compliments! We are honored to help your patients with their custom orthotic needs.
    Jacqueline Keen
    Allied OSI Labs


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.