Sesamoid Fracture and Conservative Treatment: Email Followup

Hi Dr. Blake!  I wanted to take the time to give you an update on my condition.  I first wrote you back in September: (http://www.drblakeshealingsole.com/2011/09/sesamoid-fracture-email-advice.html), and am happy to report thast I appear to be on the road to healing!  I switched yet again to another podiatrist who is "the running doctor" of Houston and appreciated taking the most conservative approach possible.  I  have been using the Exogen once a day since mid November, recently got out of the air cast and into a custom athletic shoe orthodic (which I use inside of Sketchers shape ups to be extra conservative, albeit not very stylish with suits!).  So far everything seems to be going well.  I did recently send my orthodic back because one section just seemed to be too high right around my sesamoid (in front) so I got nervous and he agreed to lower that part.

So my questions at this point are: 1) Would you expect the athletic orthodics to have a cut-out for the sesamoid? The one I have simply has a raised (forgot the technical term) part in front of the sesamoid to alleviate the pressure, but I feel as though that small "mound" caused more pain in a new area. 

Dr Blake's comment: The goal of the orthotic device is to place the weight into the middle of your foot (2nd and 3rd metatarsals) as you move across the metatarsals in push off. This is the job of the plastic itself. Then, several additions can be used if the patient still feels first metatarsal pressure: cutouts to float the first metatarsal head (the sesamoid is under that), and metatarsal pads on top of the plastic to get more off weighting of the sesamoid and more centering of the weight. You definitely want your orthotic adjusted if it is causing more pain somewhere else, and you definitely want to feel the sesamoid is protected and your weight centered. If not, the provider may adjust what you have or go back to the drawing board. I love the art of all this. Some health care providers do and some don't. But, get what you need done!!

2) After going to the orthodics/sketchers, I felt some discomfort generally in the area, but it was very difficult to pinpoint if it was in the arch, around the sesamoid, in front of the sesamoid, etc.  It was also transient and seemed to hurt in different places on different days.  Is this just my foot re-adjusting to a new shoe after being in the aircast for so many months? 

Dr Blake's comment: Definitely if you were hurting the sesamoid you would not feel any difficulty describing the pain source. Sounds like you are in the good pain zone (read the blog post Good vs Bad Pain again if you have not). You have signs of cast disease or more aptly put "cast rot". The sources of various pain from prolonged casting are muscle weakness (make sure you are daily doing several of the foot and ankle strengthening exercises listed in the blog), muscle tightness (start doing pain free calf, plantar fascial, hamstring, and quadriceps stretching--all listed in posts on the blog), nerve irritation (your nervous system is trying to figure out what is happening, and swelling (chronic swelling in the injured and non injured areas can take awhile to work out, and could require physical therapy). 

3) My current doc at this point has only taken x-rays.  He says that he can see good ossification around the fracture.  I read on another of your blogs that a fracture would always appear to be a fracture on an xray and it was best to take an MRI for a definitive answer.  He does not agree with this and I was curious if I should be concerned and demand an MRI?  Can the trained eye see any healing on the x-ray series? 

Dr Blake's comment: X-rays can show healing given enough time, so your doc is right. X-rays can show a fracture line when technically the fracture is strong enough to do everything you want. So, there are many misinterpretations of X-rays that I do not want patients to fall victim to. An MRI in your case would be important if the symptoms increase to see what is going on, but it is normally the 2nd MRI that is truly the most useful 3-6 months down the line, showing a positive change in the healing of the bone. So, in actuality, I normally get an MRI so I have something to compare to 6 months later. You would get an MRI now, if your doc was good at interpretating it based on your symptoms, and 2, if he/she expects your symptoms to go for awhile and wants a test to compare findings to in 6 months. 

4) My Exogen appears to be on the out now after 180 uses.  Do you think I should push to get a replacement and continue the therapy, or would you think that the exogen has done it's job by now and I can discontinue? 

Dr Blake's comment: I would stop the Exogen when you are back to full function for 2 straight months. Alittle extra strength never hurt the bone. Hope this helps you. Rich

You'll probably giggle but while he has my orthodic to smooth down the bump in front of the sesamoid, I'm back in my Birkenstocks and feel great!  :)  Foot hasn't felt this good in a long time! 

Thanks so much for your continued information and service you provide via your website and blog! 

Regards,

Victoria