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Saturday, June 1, 2013

Fractured Sesamoid And Possible Avascular Necrosis: Email Advice

Hi Dr. Blake,
I have a fractured left tibial sesamoid. It probably started as a stress fracture from running in a new pair of shoes last September. I didn't get an x-ray until January, at which point it was shattered into 3 pieces. My first doc (sports med) told me it would never heal and that I'd need to learn to manage the pain. I pushed back against that a little, and he suggested no running for 8 weeks and a follow up x-ray. The follow-up showed it still fractured, so he sent me to a podiatrist for orthotics for pain management. 

The podiatrist put me in an air cast and prescribed an exogen bone stim machine. Unfortunately, insurance made me wait until the 90 day point to get the bone stim machine. So, I wore the cast, partially non-weight bearing (anything outside the house I did on crutches) for 6 weeks, and waited for the bone stim machine. Got the the 90 day x-ray and it showed, "further deterioration." I've now been using the bone stim machine for 30 days and got the follow up x-ray to see if it's working. The bone is still further deteriorating and my doctor suspects avascular necrosis.

I'm scheduled for an MRI on Monday to get a better look at what's happening. But, he's saying that the chances of healing are minimal at this point and that the best case scenario is that my body absorbs the dead bone and I can avoid surgery. 

Thoughts on that?

I don't have direct access to my x-rays, but I have seen them and there is a clear progression of the sesamoid becoming fainter and fainter on x-ray, to the point that this week's x-ray it's hard to see the contours of the bone.

Thanks for any feedback.

Dr Blake's comment:

     Thank you so very much for the comment. You are doing all the right things right now. The bone stimulator should be used for 9 months total, while you continue to ice, wear orthotics, spica tape, and gradually increase your activities (keeping the pain between 0-2). In this case, you may have lost the sesamoid, or it may be just demineralized due to non weight bearing (like the astronauts!!--bad joke sorry) and surrounding fluid can make it look non existent. Take it one month at a time continuing to see what you can do to increase your activity painlessly. Give it the full 8 more months. Don't keep getting more xrays, they lag behind in the actual healing. The MRI is better right now, but it is only the baseline for one 6 months later to check progress. Good luck Rich.
BTW: How is your bone density and Vit D3 levels? Probably a good time to get this checked out. 


  1. I asked my primary about getting a bone density scan, and she didn't want to, as I've not reached menopause. My last D3 level (which was a while ago) was ok, but I've been supplementing with both calcium and d, though now that it's sunny out I've quit the D and concentrated on just making sure I get outside a bit each day.

    A couple of follow up questions - if I lose the bone, will I eventually be without pain? I still have significant pain on palpitation - like a 7 - and my toe audibly clicks and catches when passively flexed.

    1. Since you have a bone injury, I still suggest a bone density. It is a simple test, so I am not sure why the reluctance. I have 20 year olds with bone density of 80 year olds, and it would sure be nice to know now. If you have no predisposing factors like poor diet as a teenager, family history of osteoporosis or osteopenia, and periods of absent menses then your doc is taken an educated guess.
      If you lose the bone, I am not sure what will happen. You hope the inflammation dies down completely. From this point on do not use anything but function to decide how you are doing. Analyze your pain levels walking 20 minutes, standing with clogs in the kitchen for 30 minutes, running errands to the supermarket, and 30 minutes of elliptical, biking, swimming, and treadmill. Hope this helps. Rich


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.