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Sunday, July 29, 2012

Sesamoid Injury: Email Advice

Hi Dr. Blake -- I came across your blog and would love to ask you a few questions about my sesamoid injury. I'd prefer to keep my name and personal information anonymous.

I'm a 29 year-old female and injured my tibial sesamoid in my right foot in September 2011.
There are 2 sesamoid bones under the first metatarsal of each foot. The thumb also has this arrangement. They are designed to not only protect the main joint, but actually improve the muscle function. The pen points to the medial or tibial sesamoid. The one closest to the second metatarsal is the lateral or fibular sesamoid.

 I am not exactly sure how I did it (either too much walking on concrete in improper shoes or jumping rope) -- I also have a very high arch (14 degrees) that could lend itself to this injury.

Dr Blake's comment: High Arches have a steeper slope to go from the arch to the ball of the foot. This steeper slope can lead to more pressure on all or some of the metatarsal heads depending on other factors. Also, the higher the arch, the more the weight bearing is on the heel and the metatarsals only. A Flat Foot (aka Fred Flinestone foot) is more democratic with its weight bearing responsibilities. 

I went to a podiatrist about a month after the onset of the pain and he took a basic x-ray that indicated a fracture.
Dr Blake's comment: Golden Rule of Foot: An Injured Sesamoid normally needs an MRI, X-rays can be very misleading. 

 He told me to wear a dancer's pad and that I should heal.
Dr Blake's comment: The French love their ballet. In the 1700s, and probably before, the first mention appeared in the French literature of a pad that helped ballerinas with sore first metatarsals. Such a pad is fairly universally called a "dancer's pad". 

Here a dancer's pad to take pressure off the big toe joint and sesamoid area is glued to the undersurface of shoe insert. 
Dr Blake's comment: In treating injuries, from apparently minor to major, the goal is to create a pain free environment for healing. The question is whether the dancer's pad did that for you. If you were pain free for 3 months wearing the dancer's pad, most fractures should heal, but some do not.

 In May 2012 I was still in pain, visited another podiatrist who sent me for an MRI. The MRI showed that I had a non-union fracture of my tibial sesamoid. I decided to follow up with a surgeon, and he put me in an aircast for 7 weeks (with bone stimulator twice a day) in an attempt to heal the bone.

I just went for my follow-up appointment with him two days ago and the x-rays indicate the the sesamoid may be necrotic.
Dr Blake's comment: This means that part or all of the bone is dying. Bone Stimulators increase blood flow so much to a fracture area, that the necrosis that they are seeing, could definitely be actually bone healing. MRIs over read these changes as necrosis. If curious, I would rather you push for a CT Scan to document the injury without all the soft tissue shown on MRI in the way. 

 I'm having another MRI on Tuesday to confirm. The surgeon took me out of the boot and said I can graduate to tennis shoes now, but not other shoes, and that I should continue using the bone stimulator. If there were any chance of natural healing left (and he indicates there is given the recommendation to stick to tennis shoes and the stimulator) why would he also take me out of the boot?
Dr Blake's comment: I agree, stay in the boot for 3 months completely, than wean out of the boot gradually, over a 6 to 12 week basis, as long as you maintain a pain free environment. The weaning process is never cold turkey, it is gradual, and there will be less chance of flareups. Flareups are so psychologically damaging that unnecessary surgeries are done due to the frustrations. Are you out of pain now, or do you still have pain in the cast?

The surgeon has told me that surgery is elective but should eliminate the pain. The surgery, because of my high arch, would be fairly complicated -- removal of sesamoid, yes, but also a number of other modifications to lower the arch and reduce load bearing on the remaining sesamoid. Frankly, the surgery sounds like overkill and maybe a more drastic thing than I'd be willing to do (removal of muscle tissue from other parts of my leg, etc).
Dr Blake's comment: Our office occasionally has to take out a broken sesamoid that will not heal, but we relie on orthotics, etc, to do the rest. If you have to have the tibial sesamoid removed, see my post on preventing bunions, since the tibial sesamoid and corresponding tendon counterbalance the forces that make bunions. 

My questions for you are:
1) If I go back to normal behavior (regular shoes, regular exercise), is it simply a matter of dealing with the pain, or would I be causing long term damage?
Dr Blake's comment: Step 1: Create a Painfree Environment (Has this been accomplished?)
                                Step 2: Once the Environment is Painfree, gradually increase function over as long a period as necessary to keep the pain level between 0-2.
                                Step 3: With each plateau in function below normal, and with a pain level between 0-2, search for ways to improve function.
                                 Step 4: If a plateau is stubborn, have your treating doctor send you to several respected healthcare providers (not necessarily in the same discipline) for 2nd opinions. 
                                Step 5: If surgery seems imminent, and all stones have been turned over, do the surgery that is the simplest to get rid of the problem (KISS--Keep It Simple Stupid). 

2) Assuming the MRI confirms the diagnosis that the bone is necrotic, are there any non-surgical treatment options left? Custom orthotics, etc.?
Dr Blake's comment: If you are treating a sesamoid injury, you should be in custom orthotics with dancer's pads to protect the area, you should be able to spica tape the toe, you should wear shoes that do not place too much pressure on the area, and you should be icing 3 times a day to control the inflammation. I do not get excited about necrosis without a CT scan, but let us see what the MRI shows since they will be able to compare. Whatever the final conclusion, see my 5 steps above and try to follow. Necrosis is rare with fractures, but present when bone health is not present. If you ask a bone to heal, but you are not giving it the right nutrients, it may not heal. If you got a fracture, and you are not sure how it happened, and you now are being told that there may be necrosis, may you should at least have your Vit D3 levels taken, a bone density screen, a good family history of osteoporosis, diet irregularities like vegan, etc.I hope all this helps you. Rich

I really appreciate any advice you can offer!

Best regards,
Julie (name changed for privacy)

Julie's response to my questions came the next day.

Dr. Blake -- Thank you so much for taking the time to answer my questions and help me think through my sesamoid issue. I can't thank you enough!

In answer to your question about whether I am pain free, well, I am not. By week 7 in the boot, I thought I had reached a point of experiencing little pain (in earlier weeks, I would mostly experience pain when taking the stairs and at random moments of foot pivoting). However, when I removed the boot a few days ago per my doc's recommendation, the pain returned and actually at some points the pain was quite intense -- worse than what I was feeling prior to getting in the boot and starting the bone stimulator. I'm not sure how to explain that, but I've taken your advice and am going to wear the boot until I'm pain free.

Dr Blake's comment: If you are in a healing mode with the sesamoid, there is a lot of circulation which brings in healing cells, minerals, proteins, etc. This increased circulation collects under and around the sesamoid and hurts to walk on. Bone stimulators which improve even the normal circulation make this worse. So, you had 0-10% chance of having survived going cold turkey from the boot (even when everything is fine!!). The weaning out of a removable boot can be a very delicate matter. You need to do it gradually, you need to have the right shoes and inserts on that protect the sesamoid, you need to ice 10 minutes 3 to 5 times a day to reduce inflammation, and spica taped. The first goal to weaning out of a boot that you have worn for 3 months is to wean out of the boot into normal athletic shoes. The second goal, after 2 weeks of being okay with athletic shoes and full time out of the cast, is to introduce another variable: increasing distance, adding another type of shoe, etc. But, you have to wean out of the removable cast first. I tell my patients while they are weaning out of the cast, they have to have the cast to put on with them always. This is true for 2 weeks longer than you think you need the boot. So, Julie, next time you attempt to wean out of the boot, go gradual, have the boot with you, ice, tape, pad, shoes, giving yourself the best bet to make it. 

A few follow-up questions:
1) I'm getting another MRI tomorrow (and plan to take your advice in asking for a CT scan as well). Would you mind if I sent you my MRI results to examine? I could also send you my MRI results from 8 weeks ago if that would help, and I have of course of plenty of x-rays that I could share too if that would also be helpful.
Dr Blake's comment: This is great. Mail to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109.

2) I used to practice yoga regularly and have since stopped because I thought it would aggravate the sesamoid (especially standing poses and lunges). If I were to tape the toe and heavily pad my foot, do you think I could carefully return to yoga and some of these poses? Or could I try doing it in a shoe?
Dr Blake's comment: Yes, tape, pad, and listen to your body. Find what you can and can not do. The more you can do, the better you will feel. The better you feel, the less upset you will feel, if you are limited for a while. Listen to Your Body!!! And, do not do in shoes. Ballerina slippers is okay if helpful with the padding. 

3) On that note, as I'm sure you and the many readers of this blog know, being in a boot can be highly frustrating! Is it acceptable to wear other shoes occasionally assuming that I have everything properly padded the foot and don't experience pain while walking? Additionally, I'm wondering how far you would say is acceptable to walk in the boot? 
Dr Blake's comment: The key is no pain, and listening to what your body says. An EvenUp for the opposite side can help you keep level if you are having problems with shoes accomplishing this. Go to There is a weight problem with the boot, but walking normally to slightly slower is okay for long distances (many miles) if you feel even. 
4) I live in NYC and would love to visit another doc. Do you have any recommendations? I use United Healthcare.
Dr Blake's comments: The 3 sports medicine podiatrists I know well is New York are Karen Langone, David Davidson, and Robert Conenello. The link is below. Good luck. Rich
Again, I am SO appreciative for your advice and look forward to your thoughts.

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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.