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Thursday, September 6, 2012

Sesamoid Fracture: Email Advice

This is my 3rd or 4th correspondence with a patient whom 6-7 weeks ago broke her sesamoid bone under the big toe joint. She is still in the Immobilization/Anti-inflammatory Phase of her healing which should go on for about 5 more weeks in the removable boot, than up to 12 more weeks weaning out of the boot keeping the pain level minimal. 

Hi Dr. Blake,

It's me again. I'm glad to say I've seen SOME improvement with my sesamoid fracture. I'm finally able to put my the whole surface of my foot on the floor. I've been very hesitant to put all my weight on my foot but I have been testing slightly, solely for reference purposes.
Dr Blake's comment: Patients really feel with this injury that their foot is made of fragile glass which will break easily. I normally find that patients will protect the injury more than they probably need to, but I am not complaining.  

I'm still using the boot for when I do a lot of walking outside of my house. At home, however, I usually don't use it just so I can see how well I'm doing (plus I don't walk that much at home).
Dr Blake's comment: This is not advisable since you really want to stop all motion across the big toe joint at this time. But, my second best case scenario is that the patients at least do not increase pain when they are out of the boot. We are trying to create a pain free environment for the best healing.

- I'm noticing that I still don't have mobility in my toe as far as bending, it's very slight.
Dr Blake's comment: You are in the Immobilization Phase of Injury Rehabilitation. There should be no attempt at increasing range of motion. You need to quiet the joint down. The joint will get looser initially as you begin walking without the boot, and the second time as you begin running. Now is not the time to try to increase range of motion. 
- The swelling in the ball of foot area is still there. When I touch it, it feels pretty solid. Not squishy like the natural padding in a foot. This makes me wonder if it's actually swollen or if it's something else?
Dr Blake's comment: Swelling is the natural process of bringing it healing tissue. Since you are immobilizing to a large degree, it is hard to move the excess swelling out of there. Keep icing and contrasts to maintain and not let the swelling get out of control, but it is impossible to reduce it now since it is part of the day in day out healing process.
- I've continued to ice it and was doing the contrast baths like you recommended. However, I can't tell if they're working or not since the swelling seems the same.

As for my podiatrist. I saw him after 4 weeks, he checked the pain in ball of foot area. He kind of put some force and asked if it still hurt, I said yes but not as much as my previous visit 4 weeks ago. He didn't really say much, he just said to come back in another two weeks.

He also gave me some spenco insoles. I think he mentioned that if I felt it improving I could try seeing how it felt with the insoles, if not just stick to the boot.

Anyways, the point of this email is just to see if everything I mentioned is normal. I know you mentioned it was going to take at LEAST 3 months if not more for it to heal. 
Dr Blake's comment: Everything does sound normal for this time, but this is a time to get the right protective orthotics, learn how to spica tape, find a physical therapist to help you in the 3 to 6 month Restrengthening Phase. The true Return to Activity Phase is started in the Restrengthening Phase, and will take you up to the 1 year anniversary of the injury. 
I'm trying to keep track of my progress but sometimes it's hard to know if there's been actual improvement or not since this whole thing is slow and frustrating. 
Also, the actual ball of my foot doesn't LOOK like it's improved because it still seems to look swollen. I'm mostly concerned with this since it makes it seem like it's not improving. My podiatrist isn't very reassuring with the whole healing process, he doesn't communicate very well with me. I'm actually debating whether I should switch to a different one. Any recommendations for the Monterey Bay area?
Dr Blake's comment:  2 of the Podiatrists I know in the area are Bobbie Yee and Gordon Hamblin. I know that they have the skill level to help you along this path. Good luck. Rich

Deidre (name changed for privacy)

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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.