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Tuesday, March 19, 2013

Sesamoid Injury at 4 months: Email Advice

Hi Dr. Blake,

Can't stress enough how helpful I've found your blog over the past few months. Thanks so much for taking the time to respond to people and share the exchanges on here. I've learned so much about sesamoids and have many of your blog posts to thank for that!

I suspect I fractured my right tibial sesamoid during a cross country running race on November 24. It was at the very end of the race and I felt a definite crack, but the physiotherapist at the finish line assured me that my foot wasn't broken. (I think it might be salient to mention that I'm almost exclusively a forefoot striker and that this race was a couple kilometres longer than the 5ks I'm used to doing.) I limped around that night, but by the next morning, the whole foot was throbbing and I couldn't put any weight on it. Went to the emergency room and got an x-ray. The doctor said the sesamoid was likely broken, but that "it wasn't serious" and should heal in 6-8 weeks. They sent me out with crutches.

Receiving this diagnosis, I saw no need to go to another doctor, so I iced and pool ran patiently for 8 weeks. After the first week in the crutches, it started snowing a lot (I'm from Montreal) so the crutches became quite dangerous outside. Since the initial trauma, my foot had calmed down a LOT by week 2. It only hurt when I put all my weight on it and I could walk almost normally by placing a bit more weight on the sides of my feet, so I did that and shuffled to and from school. Because there was so much early progress, I assumed it was okay to wean myself off the crutches like this. My assistant coach is a podiatrist so he made me a dancer's pad to put in my running shoe. It didn't help a whole lot. In hindsight, I should have asked for a medical boot ASAP.

As 8 weeks turned into 12 and 14, etc, I began to get frustrated over why the bone wasn't fully healing. On February 22 I got another x-ray which came back saying, "no sesamoid fracture." I asked my doctor for a medical boot anyway. (Neither this doctor nor the one in the emergency room had suggested it, but I insisted). I've now been in the boot for a couple weeks.
Dr Blake's comment: There is nothing totally magical about the boot. You have to create a pain free environment, and it sounds like you were. So as of  Feb 24th, you should be at 3 months into healing.

It's now been over 3 months since the fracture occurred, but I've had little to no observable improvement since week 2. Got an MRI tonight, but will have to wait 2-3 weeks for the report to reach my sports doctor. I asked for a CD of the images so I could look at them myself and compare them to those online and in medical journals. Reading your posts about other injured sesamoids on MRIs, I can see that its lighting up on the T2 images could be a sign that is has a stress fracture. It shines pretty brightly!
Dr Blake's comment: Remember the MRI is now our baseline of treatment. If the MRI is positive for bone edema (bright T2 images), we have to wait a minimum of 3 months before we can get another one to check on progress. X rays are poor indicators on healing, as is palpable soreness.

My questions: How can I tell if my sesamoid has an acute fracture or stress fracture? Because the injury happened so suddenly, I thought for sure that it was an acute fracture, but since nothing showed up on the x-ray and because I have put repeated stress on the bone for 9 years of distance running (I am 22), it could very well be the latter.
Dr Blake's comment: First of all, the fact that the xray does not show a fracture line means that it is definitely not a displaced fracture (hard to miss), and has the opportunity to completely heal. A stress fracture sometimes can not be seen, and therefore misdiagnosed as sesamoiditis  (non serious inflammation of the sesamoid with no break) all the time. By your history, you had an acute break, and the MRI now documents the bone edema consistent with that. We can leave the xrays out of the equation now, since they ruled out a displaced fracture, and you now have a baseline MRI.  

I may have made some early mistakes with abandoning my crutches too soon and not getting the boot soon enough, but for the majority of this 3 month period, I haven't been causing pain to my foot.  It simply hurts to put all my weight on the area by leaning inwards, and certainly to run on it (though I haven't tried). Given my situation, when might I realistically hope to be running again?
Dr Blake's comment: You were creating a healing environment, so you should have no guilt there!!! However, I would be overly cautious with sesamoid injuries, and spend the next 2 months in the boot. It will take 4-6 weeks to then wean out of the boot. 6-8 weeks weeks should be then spent biking, walking, swimming, elliptical to regain your core. Then you are ready for a walk run program, if all goes well. 
     You are putting yourself in the Immobilization/Anti-inflammatory Phase of Rehabilitation by going into the boot to be extra cautious, and I think that is good. The immobilization part is the boot, but you can find Hike and Bike Shoes or Hiking boots, or even the New Balance 928 to try and see if you get the same immobilization with these (the same pain relief). The anti-inflammatory part is 2 times a day 10 minute ice pack and 1 twenty minute contrast bath (see my blog). During this time you need to have some insert made that protects the sesamoid for your future runnning. The insert will typically have some arch support to put your weight in the center of your foot at push off, and some form of dancer's pad and maybe even a metatarsal pad.  That can take the whole 2 months to get accomplished. You can also learn spica taping (see my blog) and purchase a carbon graphite plate for the shoes post cast. 

 Is there a reason why some sesamoid fractures take 8 weeks to heal, but others seemingly take over a year?
Dr Blake's comment: The main reasons for delay of healing are (in no particular order): (and these have to go through my mind when I am treating these hopefully)

  1. Delay in diagnosis leading to further separation of the fragments
  2. Inability due to insurance issues to getting a bone stimulator
  3. Inability to design inserts that protect the sesamoid post casting
  4. Poor shoe selection allowing too much pressure on sesamoids
  5. Inability to restrengthen foot after the immobilization period ends
  6. Some dietary problem leading to inadequate building blocks for healing
  7. Inadequate anti-inflammatory measures on daily basis to control swelling in tissues
  8. Technique errors (poor running form with sesamoid overload, etc)
  9. Inability to grasp concept of Good Pain vs Bad Pain (see blog post)
  10. Nerve hypersensitivity developing in area
  11. Inability to perfect spica taping, dancer's pads, etc, a lot of seemingly little things

I've been given foot strengthening exercises to do by a physio. Should I be doing these at this point?
Dr Blake's comment: Theoretically, The Immobilization Phase and The Restrengthening Phase are separate entities, but if you can develop strengthening exercises that do not hurt, you should be starting the minute you hurt your foot. So, keep them painfree, but continue to strengthen for the next year. Challenge yourself with more and more sets, reps, or difficulty. 

 Because my school has a reading week, I have the opportunity to spend up to 8 days without walking AT ALL. Do you think this might speed things along? 
Dr Blake's comment: It is pain free activity that heals due to the good stresses it places on tissues, not pain free inactivity. But, a balance is okay also. 

And lastly, is there anything else I should be doing to ensure I'm creating the right environment for my sesamoid to heal? I don't have access to a bone growth stimulator, but I could start icing again, if that might help.
Dr Blake's comment: Yes, good diet, some sun exposure for Vitamin D, pain free foot and ankle strengthening, inserts that protect, learn spica taping, check out shoes that limit motion (listed above), icing twice daily, contrast bathing each evening, work on core exercises, and some cardio with biking (best to place pedal in arch if normal stationary bike). 

I'm attaching some MRI images for reference. Let me know if you can't open them!

Thanks so much again,

Michelle (name changed)

Fracture (non displaced) is seen easily in the darkened bone. Here is a T1 MRI image where normal bone is light colored.

This T2 image shows a brighter bone with swelling nearby. In T2 images healthy bones on black, and fluid is highlighted whiter or brighter.

This T1 image shows that the injury is to the medial or tibial sesamoid only.

This T2 Image shows the bone edema in the tibial sesamoid that we need to flush out with icing and contrast bathing. Comparing this to another MRI in 3 plus months will really tell you if you are on the way to great healing. 

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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.