Sesamoid Fractures with Slow Healing/Reflares: Email Advice

Hi Dr. Blake,

Thanks so much for your past responses; they have helped tremendously (physically and mentally).  Though all the ups and downs, I seem to be on a downward slope again.

A few months ago (January 2013), you had replied to my below email regarding a reflare/set back of my left tibial sesamoid fracture (initial injury September 2012). Per your advice, I put myself back in the boot and I was out of it in 1.5 weeks and have been (left foot) pain-free ever since (so between 3-4 months).  THANK YOU!  I took your advice and never stopped icing, have been using the bone stimulator daily, and taking vitamins.  About 2 months ago, I starting removing the carbon fiber plate from my shoe and have been using primarily a toe spacer (occasionally), a dancers pad (all the time), and custom orthotic with arch support (most of the time)... sometimes all three together.

The last x-ray taken was in March and the top view of the sesamoid basically looked like a snowman (so two connected balls... key being fairly connected).  Last week (7 days ago), I reluctantly decided to walk to/from lunch (0.75mi total) without any dancer's pad or orthotic.  This was really the first time I walked any distance without the dancer's pad as I regretfully thought I was healed enough to walk without it.  It absolutely the classic "too much, too fast".  I did not feel any pain while I walked to/from lunch, but rather it progressively got worse over the next 1-2 days.  It also was unseasonably hot that day/night in Chicago, so both feet were pretty swollen that evening.  

Anyway, I'm SUPER worried that I reinjured my sesamoid as I'm having varying pain from a constant 2 and occasional throbbing up to a 5-6 (keeping in mind it was at a constant 0 for months... I might be hyper sensitive right now). 

Dr Blake's comment: Unfortunately, with all injuries, we have to test them. You did nothing wrong, and the force produced by that walk would have irritated, not reinjured the sesamoid. I am sure you will be fine. Just, once again, back in the boot, etc to create that pain free environment. 

 I notice in the shower that it doesn't hurt so much when just standing barefoot, but when I lift my foot up, I get pain.  Also, the cause of the reflare in January (riding bike) vs this current one (walking 1st time without padding), indicates more potential for reinjury (from my perspective).  Anyway, yesterday, I put myself back into the boot and have been aggressively contrast bathing (3 times a day) and icing.  Given your extensive experience, it also helps to know what you have historically seen with people who have had sesamoid fractures and have felt NO pain whatsoever for 3-4 months (actual injury 7months ago) and did everything initially correctly.  

Dr Blake's comment: Unfortunately (sorry I have to use this word), I have too many patients like you with flares, but they seem to 95% get through them the way you are. There is hope, and it is not false hope. If your last MRI was over 6 months, get a new one. If not, wait until the 6 month interval. 

After going through your blog in the past 7 months, I have not found any exact similar circumstances.  Should I be getting an MRI? (never had one on the left foot given the positive progression of symptoms and x-rays). 

Dr Blake's comment: Yes, MRI crucial to follow this. I would rather follow symptoms than X-rays at this point. 

 Would an x-ray in the next few days reveal any bone damage indication or give us much to compare back to in the March x-ray?  Should I cut out the contrast bathing and just ice?  

Dr Blake's comment: I love three times a day of something. Try three times a day of a simple 10 minutes ice pack under your foot, and compare how you feel with that vs how the contrasts made you feel. Some version of icing and contrasts should feel the best. 

Should I concentrate on off-loading?  I know I should probably give this 2 weeks in the boot and go from there, but it's hard to face this music right now.  I feel like I totally screwed up here and am looking for your guidance, thoughts on potential harm I may have caused, and future plan of action.  

Dr Blake's comment: I know this sucks, but do not be so hard on your self. Off weighting with orthotic and dancer's pads are fine if they create our pain free environment, or back in the boot with you for 3 days longer than you think you need it. I find that the length of time you have to be in the removable boot with each flare, is a strong indicator (better than X-rays) of how much irritation you caused. Remember each day from the initial injury this bone is getting stronger, and less fragile, so it takes alot more to reinjure it. I can not imagine you re-injured it, only irritated it. 

Thanks so much Dr. Blake,

Luke