Sesamoid Fracture Followup: Email Correspondance

Blogging on Tuesday is Email Correspondance

Rich,

About a year ago I emailed you about a sesamoid injury I had (still have).  Originally we were debating on fx vs. tripartite.  Both you and the podiatrist I am seeing agreed it was a fx. 
Dr Blake's comment: Sesamoids can become painful. When xrayed, sesamoids can be in more than one piece. It seems that no one agrees on how to treat these, relying on one generalization or another. The patient's pain should be treated, a pain free environment created quickly, and serious fractures will heal slower than bruised bi- or tri-partite naturally occurring bones. 

Tibial Sesamoid in 2 pieces. Broken???

 Looking back now a year later, it prob really didn't matter what it started out as, over the past year it hasn't been stable.  On the axial view the width of my injured sesamoid has spread from about 8mm to just over 9mm.  I have included a comparison view of the films I have taken over the past year. 
Dr Blake's comment: Due to privacy, I did not include the images since it identified the patient.

Overall the pain is less than when I first injured it, however it still bothers me daily.  (Some days more than others.)  And I have altered my gait and the way I adjust (I'm on my feet at work all day) to compensate.

Dr Blake's comment: Any pain that causes you to compensate is considered bad pain. The compensation (favoring) can cause more problems in the long run than the original injury.

Here is a brief rundown of the things we have done with it over the past year.  Some of which you recommend and some of which you prob would have advised against.  I have been icing it and taping it throughout the whole process.  Some times more faithfully than others.  When I tape it, sometime it's with regular athletic tape and others with kinesio tape. 

 Also before I first saw my pod I added a Dancer's pad to my orthotics that I already had. 

 After about a month of no improvement my pod ordered a different orthotic which gave more cushion and a met pad was added to offload the 1st MTP joint.

  They helped more than what I had been doing before, but pain still there.  (Bad patient, I know) I just dealt with it for a while.  Not running was driving me crazy, (even worse patient...) so about the beginning of the year I started doing about 1/4-1/2 mile at the gym.  When I'm running it is actually better than walking, but then afterwards is another story.  So I didn't keep up with this very long.

Dr Blake's comment: When doing any activity, assessing the pain produced during is easy, but afterwards harder. It is still considered bad pain to have increased pain after an activity. I like when rehabing a patient to have them run every other day to see if they can establish an amount that does not aggravate the injury. With this as our base, we can experiment with various treatments to see what helps. Much better than experimenting when the pain is out of control, or when you are not exercising at all. So, I do not have any problem with attempting to find this base.

  This was about the time I started noticing more intense deep throbbing pain that will last a few seconds or a little longer (less than a minute), but I notice this when I'm not on my foot.  Over the past few months this seems to have gotten more intense and happens more often. 

Dr Blake's comment: This has the sound of cartilage wear and tear. 

 I went back to my pod in Feb, we then added a Morton's extension plate under my orthotic to limit the motion it had.  This did limit it, but it still moved due to the profile of my shoe being low because of the added thickness of the orthotic.  After no real changes with the extension plate we decided to do a cortisone injection to hopefully knock the pain and allow me to function normally. 
Dr Blake's comment: Cortisone in a joint that has the potential to heal should be done very carefully. Feeling better now may, in the long run, not be the best. 


 (As a chiropractor this was very difficult for me... our profession is based on the fact that the body is self-healing and self-regulating, so to do something to just cover the pain was hard.)  It had increased sensitivity and tenderness for about 2 weeks after the injection, then it was back to pretty much the same as before the injection.  And that's where I am now...

Things that have not been done... obtaining an MR, being in a boot, being non-weight bearing, or using a bone stimulator.   Now that it's been a year, I'm not sure if anything will help. 

Dr Blake's comment: Whether one year or two years, or more, there is still a chance of healing these injuries, and let no generalization convince you otherwise. See what general rules apply to you as an individual. Yes, you may need surgery, but you may not. We definitely do not have enough info, and will not for 6 months. If you feel you are spinning your wheels, you will not heal, because you will just ignore what your body is telling you. Put all the positive energy towards creating a pain free, no limping, environment that you can coexist with for the next 6 months. 

 I want to believe that it truly wants to heal and that's why the injection didn't do anything, because my body was telling me not to continue to aggravate it.  If I end up ordering an MR for it, I'll be sure to send you info.  Obviously I want to avoid surgery.  

Just sending you an update... even if this goes into the file of how NOT to deal with a sesamoid injury... LOL

(Being a physician myself, I have tried to just be the patient on this one, but now looking back at last summer and I probably should have done some things differently, just because I knew they would have been the right thing to do.)

Thanks, Tiff

Dr Blake's response:

     Tiff, Thank you ever so much for helping others by this honest sharing of woe. I can tell you are a great healer of patients. This is what I would recommend now.


First of all, get an MRI and send me all the images (X-rays plus MRI), at the same time you review with your podiatrist. The MRI will need to be done twice, now and in 6 months to check healing, but the immediate one will tell us a lot on what is going on now. We can hopefully discuss the images on this blog.


Secondly, make sure your Calcium and Vit D3 intake is normal. If there is any chance you have osteopenia, get a bone density screen. 


Thirdly, continue to try to create a pain free environment with experimentation of shoes, inserts, removable boots for non work hours,  work standing positions, daily icing, etc. 


Thanks again, and hope to hear from you soon. Rich