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Sunday, June 23, 2013

Sesamoid Fracture: Email Advice to MRI or not MRI

Dear Dr. Blake,

Thank you for creating this wonderful resource, which helped so much. It's been extremely helpful as I recover from a fractured fibular sesamoid. You often recommend a baseline MRI with follow-up at 6 months to monitor healing, and I'd like your opinion on whether I need one. 

I'm female, early fifties, and was hit forcefully near the ball of my left foot 3 months ago.  I was out of the US, and was prescribed rest, ice and elevation after a fluoroscopy showed no fracture. I had a huge bruise, and swelling at the ball of my foot and base of my toes, which was mostly gone after 3 days. 

After 10 days the pain was minimal, and I stopped limiting my walking. Unfortunately a week later I developed swelling and pain after carrying a heavy bag on the way home.  The x-ray (3 weeks after initial injury) showed a sesamoid fracture and I was put in an aircast with dancer's pad. I'm forwarding them with two later sets in case they're helpful. After 2 months in the cast I'm now in athletic shoes, and am allowed to swim and do more walking as well as the stationary bike. My orthopedist predicts a very slow healing process, but that I won't need surgery.

With the dancer pad I sometimes feel mild aching or burning (up to 2, rarely 3) on the sole at the base of my first two toes, and some tingling across the top of my foot.  So I've started trying just a thick cushioned insole without padding, to remove pressure there. Should I be concerned about this? Overall, pain is 0-1 when exercising.
Dr Blake's comment: No, sometimes with fibular sesamoid injuries, the one closest to the second metatarsal it is hard to not have the edge of the dancer's pad hit the injury when turning, etc. You, however, as you increase your activity, may want to go back to a thinner dancer's pad (under 3rd through 5th metatarsals). 

Thanks to this blog I'll be getting a bone stimulator and bone density and vitamin D tests. However my doctor doesn't see the need for an MRI, and I'm not sure whether having one might change my treatment in any way.  Could there be something important that may be missed without one?  Should I pursue this, by getting more opinions?
Dr Blake's comment: I never regret getting a useless MRI. What is a useless MRI? It is one that someone without an injured sesamoid says you do not need. It is a baseline for another MRI possibly 6 months later if needed. When it is needed, you are awfully happy you got the first one. And we are not just talking about the sesamoid. You had blunt trauma, which can produce more unpredictable problems, so the MRI is even more important in your case.

Further comments by Dr Blake: She was kind enough to send me xrays from 4/13, 5/13 and 6/13. Both sesamoids had irregularities, and the big toe joint itself looked slightly arthritic. This is going to make MRI interpretation more difficult, thus we may be opening a can of worms. However, I still think it is a good test for her to have. The sesamoid injury showed no fracture displacement, so healing so be complete at some time. 

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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.