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Tuesday, May 15, 2012

Email Correspondence Tuesday: Notes 5 Months Post Sesamoid Fracture Removal

Blogging on Tuesday is now Email Correspondence Day

Hi Dr. Blake,
It has been about two months since we last emailed and I have a few more questions for you.

 Right now I am at five months since surgery after removing the fibular sesamoid bone from my right foot. Things have improved a bit since the last time we talked, I have gotten orthotics that sort of help but I haven't managed off setting the sesamoid bone area.

The fibular sesamoid is the one closest to the 2nd toe and the one shown here irregular, not round like the tibial sesamoid. Both lie under the first metatarsal protecting the main joint from trauma, and helping the tendons which travel into the big toe to work better (same two functions of the kneecap). 

Dr Blake's comment: Needs to be more arch support designed into the orthotic device or more of a dancer's pad. Very crucial at this stage and pre-op in attempting to prevent surgery in the first place. 

 I have started going to acupuncture which has not really helped with the pain but is definitely relaxing I wont ask her about icing though :),

 and I am still going to pt to which he has been working on breaking down the scar tissue in order to increase the mobility of the great toe joint. It appears that the joint is mobile, but the scar tissue around it prevents the movement. It seems I have created a mass of scar tissue that is not going away without a fight.
Dr Blake's comment: See the blog post on Hallux Limitus/Rigidus Self Mobilization. It normally gains 10 degrees if done daily. Have them measure the joint range of motion of dorsiflexion (see photos below). You need 60 degrees to walk normally, and 75 for most sports. If you are quite restricted, you could have local anesthetic shots to numb the joint, and the doc or PT right after do the same mobilization work. This is normally done once a week for 4-5 weeks, or until normal range of motion is obtained. If you can find out what the Range of Motion of dorsiflexion and plantar flexion is now, that would help seeing progress over the next 7 months. This mobilization technique gets at the deepest scar tissue around the bone within the joint well. 

 I am heading to see the surgeon this week for another follow up and the pt would like me to ask his opinion of other options for dealing with the scar tissue. Pt feels like he has gotten as much as he can broken down and is concerned about damaging the upper layers in order to get into the deeper scar tissue. During the pt sessions I have not used the equipment like I see other patients using other than the bike to get my foot warmed up and he has spent the rest of the time using several other ways to heat up and manipulate the area to get things moving.
Dr Blake's comment: Range of motion of the joint post operatively improves in 3 waves. The first improvement is during the first three months as the swelling and pain resolves (you are behind right now). The next improvement is slow as activity naturally bends the joint, but the improvement plateaus from 3 to 9 months (with few degree changes per month). Then, the final improvement is from 9 to 12 months as the nature maturing process of scar occurs and the scar thins externally and internally as it loses most of its fluid. The scar on your skin changes from red to white and shrinks in size. So, but 1 year you have done through the 3 nature driving forces to improve the range of motion. It is up to the health care provider to tell you if you are behind that nature curve or not. If measurements are taken before surgery (rarely), that would be great to compare. But, if they are started now, you can at least go from here. 

 I have been a good patient and using ice and heat, stretches, working on breaking the scar tissue and strengthening my poor little foot. In the last two weeks I have begun to participate in karate class either going through the motion of kicking the heavy bags (without contact and mostly kicking with the noninjured foot) and doing katas with not so great stances, and of course I have to work all day on my feet.

 The podiatrist I consulted with before surgery suggested to go in through the top of the foot rather than the bottom to help reduce the amount of scar tissue and right now with the amount I have gathered I am very pleased the surgeon went though the top, I don't need any more scar tissue in there. My pain level is consistently at a 5 and still goes up to maybe an 8 on really bad days. I believe I have a pretty high tolerance to pain and am not a big sissy, but maybe not. :)
Dr Blake's comment: Pain leads to swelling and muscle tightness. You have to control the excessive pain to get it into the Good Range of 0-2 for a 3-4 month period. This may require a weight bearing removable boot. Whatever it takes!!

So in a round about way I am getting to my questions. Do you think I may be expecting too much and too soon as far as doing too much workout wise?
Dr Blake's comment: Definitely since you are not able to keep the Pain Level in the Good Pain range. Just because you had surgeon, you can not ignore pain levels above 2. It is discovering what you have to do to keep your pain between 0-2 that you discover good treatments and true measures of disability. You also can gauze in a positive way how you are doing month to month. 

I am generally at the dojo 2 to 3 times per week and if I work out it is for about an hour, otherwise I am modifying an exercise video a day or two a week and riding the boring stationary bike.

 My other question is what are your suggestions about breaking down the scar tissue? I am smashing and massaging my foot in order to break it down. The pt guy mentioned that there may be other ways to help with that which may include a shot of some kind or numbing my foot and essentially get it moving. This scares the hell out of me considering this saga of my life has gone on for 14 months now and only for the last month maybe have I worn regular shoes with the orthotics and without along with the spica taping all day during the work day.
Dr Blake's comment: A small amount of local anesthetic is placed into the top of the joint, then the same mobilization is done that is on my video. These are directions that you want moved to free up the deep scar tissue. They are not the normal motions of the joint. Mobilization takes 2-5 minutes at most. Short Acting Local called Lidocaine or Xylocaine, starts in 5 minutes and lasts for 1 hour. You ice pack for 10 minutes after and go about your life. Any podiatrist and PT could do it if they watched the video. The joint dorsiflexion and plantarflexion is measured before the injection each visit spaced 1-2 weeks apart. After 4-5 sessions, you wait one month to rest the joint, but continue everything else. 

When measuring the big toe joint dorsiflexion (aka first metatarsal-phalangeal joint), the landmarks used are the bisection of the toe in relationship the bisection of the first metatarsal (see the two lines marked)

A goniometer (something that measures angles) is used to measure the dorsiflexion bend of the big toe joint. The toe is moved on the stationary first metatarsal to firm resistance and then the angle measured. 60 degrees for normal walking is needed on average. 75 degrees needed for high heels and most sports requiring you go up onto the ball of your foot (i.e.. tennis, etc).

When I get home I take the shoes off and begin the evening of icing and stretching.Do you know about any of these methods to get my foot moving? Its almost like if it could just be shaken out like a towel then maybe we could have more mobility.
Dr Blake's comment: The 25 minute routine I would do each evening is 5 minute hot soak, 2-5 minute self mob, and 10 minute ice soak or pack. Gentle cross frictional arch massage from ball to heel with massage oil for 5 minutes before the ice pack would also help. Do not try to push the joint through normal range in pain at any time. Walking tends to stretch the normal direction just fine. 

 Finally the outside of my calf has been killing me and the ankle continues to feel weak while walking. The pt said that the calf is connected in some way to the arch area of the foot (which is always achy) and is sore because I have been using the foot more than I had been. I thought I have another question, but it is gone at the moment.
Dr Blake's comment: If you are in pain, you will compensate and strain the ankle and leg muscles. It is normally the outside or lateral ones when you are trying to favor the big toe joint (medial or inside). Get the pain under control ASAP. 

Again I really appreciate your willingness to help those of us online who need more information and suggestions of what to do next while we try to heal from breaking this nasty little bone. If I lived in Northern California rather than Southern, I would definitely be knocking at your door and have thought several times about a road trip to visit you. Yours is the only blog that I have found where I have gotten good information that I can use immediately in order to help make things feel better. Thank you, thank you in advance for your help!

Dr Blake's comment: Remember a couple of things about post op joints (applies to feet, ankles, knees, and hips). First of all the first year post op is to regain range of motion, begin a workout program, manage all swelling and scar tissue issues, and develop tone back in foot muscles. But, it is the 2nd year that is truly the Restrengthening Year. This is the year from 12 to 24 months post op that the power, quickness, endurance, agility of the foot and lower leg muscles make their triumphant return. You are gaining strength now, but the main focus is pain control, re-establishing your base of exercise, and removing all unwanted scar tissue and swelling ( all this can not be accomplished unless you get the pain under control. I sure hope this helps. Rich

Stacie (name changed to protect the innocent)

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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.