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Sunday, April 21, 2013

Post Sesamoid Surgery in Pain

Dear Dr. Blake,

Our son had a soccer sports injury at 17 where his sesamoid fractured.  Unfortunately it never healed and the bone died. We live in on the East Coast near Boston. So it was removed and afterward my son spent many months in rehab trying to get to a point of comfort so he can run again. 

He hasn't been able to run or walk without discomfort and pain since.  He's had countless visits to experts doctors that have tried to help.  But no luck or real progress.  So we've since gone back to our referring orthopedic physician to try again.  He said that my son has full range of motion and doesn't think it's the sesamoid area because that area is healed properly.  The doctor feels it inflammation and recommend stiff shoes and maybe ingested cortisone to help with the inflammation.  But at this point basically nothing has worked as prescribed and it still hurts even when he walks normally. 

He's 19 years old now and we don't know what else to do.  So I'm looking around for someone that's the best at foot therapy to find a way to get him back to where he was prior to surgery.  We've used orthopedic foot beds, Physical therapy, cortisone injection, rest, hydro dissections and no luck.  We feel the doctors we have know what they are doing but they have stated that my son might be that 1% who just isn't going to be able to heal properly.  I can't accept that and I'm now looking for alternatives.

Any thoughts and ideas would be welcome.

Dr Blake's initial response:

Michael, thank you for the email. I am sorry for your dilemma. It is very rare to remove the sesamoid and still have pain. Since the sesamoid is removed, that is no longer the source of pain, so what is the source of pain? Could it be that the sesamoid was never the source of pain? Nerve entrapments, bursitis, tendon injuries, joint capsule injuries, metatarsal head injuries have all been mistaken for sesamoid fractures non healing?  Does he feel he has the same pain as before surgery? What are the recent (last 6 months) tests that I can look at? If you put local anesthetic into the joint (diagnostic injection) does all his pain go away (see the post on diagnostic injections)? Does he feel the inserts off weight and protect the area? It is important to analyze each thing at this point. If we can put 10 things together, which all make 10% improvement, we may get some improvement. What are the things that have helped him even a little? Does the area look normal compared to the other side? Does a graphite plate or spica taping help? Any answers to the above will help me. Rich


All good questions which I will look into.  I'd have to secure more details on tests, x-rays and such.  Let me speak with my son on these topics and get back to you.

Dr Blake's comment:

     There is always a source of pain, and identifying that source of pain seems the most important task right now. Testing with bone scans, MRI, xrays, CT, thermography are commonly used. Diagnostic injections with local anesthetic can test small and different areas at a time to see if numbing up one spot, like a tendon, can give complete temporary pain relief. Physical examination of tendon function, joint motion, areas of soreness, nerve sensitivities can help identify what is wrong. Partial or complete symptom relief with all the measures of treatment utilized can also help identify the problem based on what makes it feel somewhat better (off weighting, nerve gels, icing, taping, rigid shoes, etc). 

     I just saw a patient Evan (name changed) that I have not seen in 5 years. He was 16 when he had a fractured sesamoid removed. When he was 17, almost 1 and 1/2 years post surgery, he was still in pain. He was a very good runner (4:26 miler pre injury). His treating surgeon was great, but had no answers to why he would still hurt. Physical therapy did not help. Evan went on to run 4:13 in college, and will run competitively for years to come. How did he get better? By analyzing his gait, I found that he crushed his big toe joints into the ground at forefoot loading. So inserts to protect that area (the area of the sesamoids) were custom made for him (which he no longer needs). By ordering every test imaginable, I discovered that his joint, the other sesamoid, the capsule (ligaments), the tendons were all fine, and he had no bursitis. The area rarely swelled even with level 9-10 pain. I suspected nerve entrapment, and diagnostic nerve injections gave complete relief of the pain for 3-4 hours. When Evan told me, that the pain he was having post surgery was the same as pre surgery, I began to also think the sesamoid was not the original source of pain, so removing it would have logically not produced pain relief. I suspected the nerve was continuing to be irritated every time he tried to run both before and after the surgery. When Evan related that he hurt the same during and after running, I decided to see how much he could run without making him worse. So, after 2 years of not running, Evan started a Walk Run Program to get up to 30 minutes running. Then Evan processed to running 60 minutes straight, and he was released to go back to Track for his senior year when he was up to 10 miles straight. Evan understood that he could not run through sharp pain, pain that increased while he ran, and could not limp. Those were all signs of bad pain. Evan's pain stayed the same through this 6 month course of training. And, if you asked Evan what his pain level was, he would say 7 or so. The custom orthotics protected him, but the nerve remains very sensitive to any pressure for a long time (several years). But, Evan nerve did heal eventually, he learned to run softer and apparently faster. 

     Evan is a great example of why when I rehab athletes who run as part or all of their sport, that I want them to run at least 3 times a week. Can they run one mile or 5 miles before the pain increases? There are hundreds of possibilities during rehab created by this procedure. So, Michael, for your son, that is info I would also love to know. 

     I sure hope this helps you focus on getting over this hurdle. Rich

Part of Diamondhead seen along Waikiki Beach

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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.