Dear Dr. Blake,

First off, thank you!  Your blog as it has been very helpful during my personal healing process.  

I am 29 years old and moderately active.  I fractured my tibial sesamoid in late September 2012 
while doing "box jumps" in very thin-soled, non supportive shoes 
(didn't want to take an extra 10min to go home to get my real gym shoes). 
 I saw a podiatrist a few days later on October 1st for x-rays, 
discovered that the sesamoid had broke into two separate pieces, 
and was put into a CAM walking boot with a dancers pad. 
 I also started with an Exogen bone stimulator 1-2 times per day on November 1st. 
 I never got an MRI, but my x-rays showed improvement during every 2-week checkup. 
 After 9-10 weeks, I began to wean from the boot and into a running shoe 
with a flat carbon fiber insert and dancers pad. 
 Around the 3 month mark (Christmas time), 
 I was fully out of the boot and things were feeling pretty great with the carbon fiber insert. 
   I tried MBTs but did not like the instability in the heel. 
 I was told that I was cleared to begin riding a bike (with my insert). 
Five days ago, I rode to my bike to work (3 miles) with nothing wrong, 
but on my ride home, the sesamoid unfortunately began to hurt. 

I saw my doctor yesterday and the x-ray showed the same results from 2 weeks prior 
and that I had not "fully refractured the sesamoid". 
 She said I could have "episodes of pain" for the next 6 months 
and told me to begin icing again and stop riding the bike (though stationary is alright). 
 Though, she did warn there is a possibility that I have a stress fracture on top 
of the original fracture and to get a checkup in 2 weeks. 
  As you know, the sesamoid recovery is an emotional roller coaster 
and I was finally seeing the light at the end of the tunnel until 5 days ago. 
 I am continuing with the bone stim, icing, and now back wearing the boot here and there. 
 I just wanted to know your thoughts on this. 
 Should I be back to the boot? 
 Should I have an insert made that has a slight curve (vs flat) so it fits in a shoe better? 
 Do you have shoe recommendations? 
 Do you agree that one can be fairly pain-free, then go back to an "episode" of pain 
without having done major damage? 
 How long should I give this new "episode of pain" until we 
determine additional fracture and prepare for months back in the boot? 
 Given that's it's been 5 days of pain, I'm concerned that this is more than inflammation.

Thanks so much,  
Luke (name changed)

Dr Blake's comments: 

Hey Luke, thank you so very much for the email.
Unfortunately, I have many patients on this roller coaster with you.
The flareups are normally explained by how the bone and joint 
look on an MRI, but it is okay to go for now without one.
It can take two or three flareups to look for a pattern.
With each flareup, you must re-create a pain free environment ASAP.
Definitely do 9 months on the bone stim.
Ice twice a day for 10-15 minutes for the next year, whether it hurts or not.
Go back in the boot if needed for pain relief, or try New Balance 926 or 
another stiff soled shoe. 
Experiment with the different inserts for stiffness and off weighting.
Yes, one can be totally pain free and have a flare without more damage since
the joint is not perfect for a few years (if ever).
It is hard for patients to know how long flareups will last, 
but the rule is 2 weeks in the cast pain free, before attempting to go back
to more normal shoes with each flareup.
5 days is nothing unfortunately, and does not mean anything serious. 
Make sure during this rehabilitation period, that you are getting good off weighting
orthotics, learning how to self mob, continuing your daily bone stim and icing, and
starting daily pain free foot strengthening exercises. 
The foot strengthening will come in handy 3 months from now when 
you really begin the ReStrengthening Phase. 
Hope this all helps some.  Hang in There. 
Dr Rich Blake