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Tuesday, December 18, 2012

Sesamoid Fracture: Email Advice

Dr. Blake,

I have a tibial sesamoid fracture that was diagnosed about 9 weeks ago.  I really have no idea how I fractured it - I had not been running for 10 months because of a back injury, but was very active (elliptical 4-5 days a week with core strengthening and stretching).  My best guess was too much flip-flops all summer long. 
Dr Blake's comment: The pressure created from the elliptical machine on the ball of your foot due to its hard unforgiving surface, especially if you use the arms and go up onto the ball, can create abnormal stress enough to fracture the sesamoids. 

 I have been WBAT in a short cam boot since the first MD visit, with promising healing on X-ray as of 2 weeks ago (instead of a definite jagged fracture line, about 1/4 of the bone was filled in and the other 3/4 is much closer together than on initial x-ray.  It is also MUCH less tender to palpation!) 
Dr Blake's comment: Tenderness to palpation and xray evaluation are something to go on, but are not reliable. MRIs are best to follow these things, and without that, how you feel in function is the next best thing. You make sure you are painfree in the removable CAM boot (hope you have your EvenUp for the other side) for 6 weeks before trying to wean out. 

 The doctor and I discussed the use of a bone stimulator to help speed up the healing.  He was not convinced that it would help much, but ordered it anyway - insurance won't cover it because it is considered experimental still for just about everything except tibial fractures and wrist fractures.  
Dr Blake's comment: I love bone stimulators for this pesky injury. It is definitely worth the $500 self pay that patients have to pay here in San Francisco. 

I am a Physical Therapist, and am really getting tired of not being able to exercise.  Any suggestions on what form of exercise would be OK without prolonging the healing process any more.  I am still stretching and doing core work, but any form of cardio that I have tried seem to make the foot sore afterwards - which I am trying to avoid.
Dr Blake's comment: Since you can do a stationary bike with the arch on the pedal to float the big toe joint, that would be my primary cardio. If you have not done a lot, try 30 minutes twice, and then increase every 3rd time by 5 minutes. Gradually increase the tension. 

I have tried the taping, but since the foot does not hurt much to begin with, I haven't seen much difference with it on.  I have a "gellin" insole in the boot because it was MUCH more comfortable than just the boot.
Dr Blake's comment: Golden Rule of Foot: Create a painfree environment at each stage of the recovery. Right now you are in the Immobilization/Anti-inflammatory Phase: So create a painfree environment with your boot and other inserts. The next phase is the restrengthening which you should be dabbling in now also. You are doing your core, cardio with stationary bike, and walking with your boot. Add single leg balancing 2 minutes 3 times a day where you balance on 1 inch books with your knee slightly bent and the sesamoid is floated. See the photos below of the basic idea. I sure hope all this helps you. Rich

 Here the platform is created to float the big toe joint area with books.

Here my wife Patty is doing her single leg balancing exercise with no weight on the sesamoid area. 

Any and all suggestions are welcome!

Thanks a lot!

Constance (name changed)

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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.