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Saturday, December 1, 2012

Sesamoid Fracture: Email Advice

Hi Dr. Blake,

First of all, I cannot express how much gratitude I have for you and your blog. It feels like my only source of relevant information. Thanks again for being such a caring medical professional and invaluable resource. 

I've attached two images of my MRIs (one from my left foot and one from my right). Do you mind not posting the MRI images on your blog?
Dr Blake's comment: The MRIs show injury to both tibial sesamoids. It was difficult for me to see if one side was worse. 

After about 2 months of wearing special insoles that have cutouts around the sesamoids to unload them (my first doctor made these insoles for me), I had an appointment with a second doctor just to get another opinion. My second doctor put a walking boot on the left foot and instructed me to walk with partial support with crutches. I'm also using a bone stimulator (exogen 4000). I had a few questions if you have time.

1. Does it make sense to put a boot on the left foot (because it generally hurts more) even though the MRI shows much more damage to the right foot?
Dr Blake's comment: When both sides hurt, you really have to try to minimize pain the best possible in creating a pain free environment. If that means treating the foot more than the MRI, I would do that. Many times the foot that looks the worse hardly hurts, and the one that looks fairly normal hurts a lot. So, go with whatever works. How something looks on MRI is only one indication of how much it may hurt. 

2. There seems to be increased pain in both feet, but esp my right. I'm not sure if it's my imagination since I'm thinking about them much more. But is it normal for the feet to hurt more when using the bone stimulator?
Dr Blake's comment: First of all, what is on the right side? Hopefully a tennis shoe with insole and dancer's pad. The crutches should take weight off your feet, and on to the shoulders, elbows, wrists, etc. The crutches should not be used to put more weight on the right since that side is also injured. Make sure you are getting even weight on both feet and let the crutches off weight the feet, the removable boot limit the motion in the left big toe joint, and the dancer's pad off weight the right sesamoid. You have to decide if you need more off weighting in the boot of the sesamoids and with the insert and dancer's pad. Perhaps you need higher arch support on the right along with a slight increase in the dancer's pad. And, yes, the bone stimulator can increase pain in the sesamoids, but normally the trio of 2 fifteen minutes ice packs and 1 session of contrast bathing per day for each foot minimizes the symptoms and does not allow the inflammation to pool and cut off the normal circulation vital for your overall healing.

3. My doctor told me to cease all exercise. But exercising is important to me for other health reasons, both physical and mental. It's not clear to me how biking (with my heel on the pedal, not my forefoot) or swimming will impede the healing process. If anything, in the past exercise makes my feet feel better. 
Dr Blake's comment: It is so important to maintain core strength during this time. I allow as much biking and swimming (no pushing off walls) as possible during this time. Keep your core strong, cardio strong, and just listen to your foot. You will know if you are aggravating the problem in any way. You would really need to try hard to hurt yourself. When you do an activity, ice for 15 minutes afterwards (within 2 hours max). Listen to how you feel. You will need to perfect this skill as you move forward anyway, and probably already have. The stronger the core, the more your legs lift you off the ground, the less stress on the bottom of the feet. This is a well recognized part of any physical therapy practice when treating foot injuries. 

4. My first doctor told me there's a chance the seasmoids will never heal and I will never play sports again because he didn't see much, if any, healing when comparing my first (Feb) and second (Aug) MRIs. How do I know if this is the case? The pain has always been pretty mild. I thought I was nipping something small in the bud when I first went to see a doctor so it's surprising that my diagnosis has become so dire.
Dr Blake's comment: It is common and unfair for the medical profession to counsel based on the worst case scenario. Doctors, and everyone in the healthcare community, tend to remember their failures and their last patients with similiar injuries. A failure to the health care provider is much more memorable if they were promised complete healing and it never happened. The patient is mad at the provider, the patient assumes the provider made a mistake, and then the provider can very protective when the next similiar case comes through the doors. And then, some doctors want to do surgery and push for surgery in subtle ways like saying conservative treatment will not work. They actually may be telling the truth in their minds. They actually may have never seen a case of this type of injury ever heal completely. And, it could have started when they started their practice and were counseled by practitiioners older, wiser, but without the modern day resources we have today to get things to heal. Golden Rule of Foot: Listen to Your Body First, healthcare provider second. It applies to me and my patients too!! I have certain biases, or too small amounts of time to analyze every detail, I may make a judgement call that is incorrect. My patients need to have some much trust in me that they can tell me I am barking up the wrong tree!! I hope they always feel comfortable to do that. 

5. I had this bruise on my left outer shin/calf about 6 weeks ago. Although the bruising is gone, when I touch the area it still hurts as if a bruise is present. Is this possibly related? I'm asking mainly because the left foot hurts more than the right foot even the MRIs show the left foot has milder injury than the right. I also had issues of my left big toe tingling as if it was asleep as well as pain underneath my other toes on the left foot. I'm wondering if all this signals some potential nerve injury?
Dr Blake's comment: The bruising is probably from the straps or metal stay on the boot hitting into you. The numbness and tingling is related to the circulation compromise that always occurs with these boots and the velcro straps on the leg that hold the boot on. The injury causes swelling, and veins return the swelling back to the heart. Removable boots compress the leg veins and inhibit the flow of blood back to the heart. This is why I recommend icing and contrast bathing. I also recommend periods of time each day to take off the boot, massage the calf and foot, and perform some foot elevation and calf pumping like they teach on airplane videos to avoid blood clots. Sometimes the friction from the boot liner alone can cause local nerve irritation and changes in the liner/footbed can help. I sure hope all this helps you. Rich

Any thoughts you have would be greatly appreciated! Thank you SO MUCH!

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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.