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Saturday, September 8, 2012

Sesamoid Injury: Email Advice

I desperately need a 2nd opinion, but my insurance won't pay for one. I was hoping you could help! I have been dealing with dysfunctional sesamoids since April 2010. I developed sesamoiditis after running 2 marathons in the span of 8 days. (Probably not the smartest idea, but I was in great shape at the time).
Dr Blake's comment: I prefer my patients run one marathon every 6 months, because the 1-2 months of maintenance running right after a marathon is crucial to repair tissue that has been stressed out in the process. 

 I quit running completely, was non-weight bearing in crutches + walking boot for 3 months and returned to normal activity shortly thereafter (but never returned to running). I was never completely pain-free, but it was only sporadic and I have a pretty high pain tolerance, so it was easy for me to ignore.
Dr Blake's comment: High pain tolerance is great at times, but not when recovering from an injury. I try to keep patients in the "good pain" range of 0-2, but that may not be a good gauge for these patients. They either become hypersensitive to their injury, or keep the pain level at 0. Even though we strive to create a pain free environment for healing, in actuality that is an environment in the good pain range of 0-2.

 I just (incorrectly) assumed that quitting running would solve my problems, and it would eventually heal. Fast-forward to May 2012.. I wear painful 6-inch heels (bridesmaid requirement) for my brothers wedding and am nearly unable to walk the next day. I go back to my doctor and MRI and CT show a fractured sesamoid with complete destruction of the cartilage around metatarsal and resultant cyst formation in the metatarsal.
Dr Blake's comment: I am assuming that these tests were never done before. If anyone has a diagnosis of sesamoiditis, and undergoes the course noted above, and is still in significant pain after 6 months when stressing it (ie running, high heels, basketball, etc), then one of two things is occurring. The sesamoid is not being protected well enough with orthotics and dancer's pads, or the sesamoiditis is really a fracture, or both.

 My doctor (physiatrist) prescribed 3 months non-weight bearing in a cast and crutches. I got the cast off yesterday and am currently in more pain than ever before. He now wants to fit me with a graphite shoe insert for 6 weeks before even considering referring me to a surgeon. Is he on the right track? I don't really have any options to see another doctor (this guy is supposedly the best person to see for my injury under my insurance), but I would really appreciate another opinion. Thanks for your time!!
Dr Blake's comment: I am so sorry for your dilemma. And, I will try to get you focused on what should happen in the next few months. Remember that you were doing fairly well for a while even when the MRI showed all of that stuff. That stuff was lurking below the surface before you put on those 6" heels.The hope is that you can get this calmed back down. I am not sure that graphite plates are appropriate, since they immobilize, but place alot of pressure on the sesamoid. You are more likely to be helped with orthotics and dancer's pad to float that area. A good podiatrist or pedorthist should be able to manufacture one. Even if you have surgery, you will need orthotics to off weight the area for a long time, so you might as well get them now. 
     The logical progression of immobilization, and you are still in the Immobilization/Anti-Inflammatory Phase due to your pain, is Non Weight Bearing Casts/Crutches until there is no pain, then weight bearing casts and sometimes crutches until there is one month of no pain, then a slow weaning off time gradually going from cast to athletic shoe/orthotics/plate ?/dancer's pad/spica taping. This gradually progress can take 2 to 3 months since you have to keep a painfree environment that you are establishing with each new level.
     The anti-inflammatory part right now should be contrast bathing one time a day (usually evenings), and ice pack twice daily. See the various blog posts on the hows and how muchs.
     The Golden Rule of Foot that applies: You take the first MRI so you have a basis of comparison with the second MRI. A second MRI should be done in 6 months to see if you are improving and by how much. A recent patient Jen, even though she has had a flareup, was still 70% better with her followup MRI. That gives us great hope for complete recovery. If you decide to avoid surgery and remove the sesamoid, you should wait 6 months to get a followup MRI. It will tell you alot.
     So, in my perfect world for you I would keep you in the removable boot for at least another 2 months, while I got a bone stimulator approved and started using, got some great orthotics, learned how to spica tape, iced/contrast bathing 3 times daily, had PT help you advance from non weight bearing to weight bearing, and I would be happy to review any CDs of xrays or MRIs you want to send. 
     I can not emphasize enough, so I am leaving it for the end, that you may very likely co-exist with some of that stuff seen on MRI and that some of it (if not all will completely heal). You desperately need to begin to put weight on your foot. Non weight bearing is very very hard on an injury. The nerves get hypersensitive, the muscles weaken, the ligaments tighten, and the bones decalcify. Your rehab, and this is true even if you have surgery, must include nerve desensitization, gradually weight bearing, gradually re-strengthening, anti-inflammatory, and mechanical support. Another Golden Rule of Foot: For 1 Day in a Cast it takes 2 Days to Rehab (it is even longer with non-weight bearing).
     I love working with physiatrists since they attempt non-surgical treatment. Really sounds like this doc is trying hard to avoid surgery. See if he/she can work with a physical therapist and podiatrist or pedorthist to get the other parts of the treatment going. I sure hope this helps you. Rich


  1. Thank you so much for the great advice! I have an appointment with physical therapy on Wednesday & I will definitely ask them about all of the things you mentioned. I had never heard of the spica tape for sesamoid injuries before I read your blog, but that sounds like it would really help! Also, I didn't realize that for every 1 day in a cast it takes 2 days to rehab, but it makes sense. I honestly thought that when I got the cast off I would be up and running within a week. Ha! Guess I'm in for a much longer rehab than I thought. When my doctor first diagnosed me with sesamoiditis, he said, "We call sesamoids 'little bones that cause big problems'". He was so right. I really appreciate the time you took to answer my questions so thoroughly! Thank you so much; you gave me some really great information that will definitely help me on my road to recovery! I would love to send you my scans... Where should I send them?

    1. Please Send to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. I am glad it helped. Rich

  2. p.s. your blog is awesome!! :)


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.