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Thursday, July 25, 2013

Sesamoid Injury: Email Advice

Hi Dr. Blake,

Your blog is the best resource I've found for sesamoid injuries. Thank you for giving me hope.

This has been a frustrating injury. I am a female runner, 29 years old, and I went to a podiatrist after feeling some pain in my left foot during plank and downward dog in Pilates.  After an initial mis-diagnosis, via an x-ray he found that I'd fractured one of my sesamoid bones. I went a month without running, but the pain didn't go away. I was even beginning to feel it when I walked up the stairs at work.

I decided to seek a second opinion, and went to see an orthopedic surgeon who specialized in feet and ankles.  He did more x-rays, and advised me that my fracture was worse. He then gave me an air cast (walking boot), and advised me to see him in 4 weeks.

After 4 weeks in the walking boot, I went back to the doctor, and he advised me to try walking without the boot.  After 3 days I was limping, and was in pain.  This was so frustrating because the entire time I was in the boot, I was pain free.
Dr Blake's comment: With sesamoid fractures, you need 3 months in a removable cast, followed by a 2-6 week gradual wean out process keeping the pain level between 0-2. There is normally no skipping corners with this tricky injury. 

I put the boot back on, and called the doctor.  His assistant advised me to leave the boot on for another 4 weeks, and to then see him again.

It was durning the second 4 weeks in the boot that I found your blog.  I was concerned that we couldn't really see the bones in the x-ray, and couldn't tell how I was actually doing. On the follow-up appointment with the doctor, I requested an MRI as you'd suggested in your blog, and had an MRI the following week.

On another follow-up appointment the next week, upon reading the MRI, the doctor advised me that the bone had healed, but that it had then necrotized.  Looking at the bone on the MRI, it was darker than the other bones.  What didn't make sense to me was that the bone would heal, and then just die.
Dr Blake's comment: That is typically a mis-read. The bone is inflamed for months and months even after healing, which makes it look darker on T1 images (bone is white), and whiter on T2 images (bone is dark). 

I read in another part of your blog that bone growth can be misdiagnosed as necrosis on an MRI.  Do you think this could be the case?   Should I have a CT scan done?  What is the difference between an MRI and a CT scan?
Dr Blake's comment: CT scan shows only bone anatomy in 3D, and MRI is great for showing soft tissue and fluid within the bone. I would just wait a minimum of 3 months for a followup MRI to see if these bone changes look better. MRI changes are much more predictable for this injury. 
I've been in the boot for 2 1/2 months now, and still feel tenderness and some pain if I land wrong on my foot. 
Dr Blake's comment: The key line is "if I land wrong". The sesamoid is going to be tender, especially if you land wrong, for months and months. This is not a sign of poor healing. This is the time to be designing a shoe insert that you are going to be wearing to off weight the sesamoid post cast. It is essential to weaning successfully off the cast. You place that insert in the boot also while you continue to wear the boot. 

 The doctor is suggesting surgery to remove the bone, but that makes me very nervous.
Dr Blake's comment: Average sesamoid surgery, which is done rarely BTW, is over 1 year after injury. Fight hard to save the sesamoid. It is important.

  I have a copy of my MRI, and am seeking a second opinion before considering going under the knife. My mom had a sesamoid removed, and said that she still has pain from the surgery after many years.  I'm not ruling surgey out, but I don't believe it will only have a 2 month recovery time that the doctor is suggesting.  If the bone is actually dead, I want to make the best decision that will lead to a pain free and active life.
Dr Blake's comment: I would be happy to look at the MRI, but any elective surgery should get a 2nd opinion. Look at the AAPSM website for a fellow or member near you. These are sports minded podiatrists that typically share my anti-surgery zeal unless proven it is needed. Email me with your city and perhaps I can narrow your search. I hope this helps. Thanks for all your kind words. I think you you need to investigate icing, contrast bathing, orthotics, taping, bone stimulators, dancer's pads, etc. Rich

Thanks for all your help.  Your blog is wonderful, and has really helped me understand what is happening with my foot.

Take care,

1 comment:

  1. Thanks for posting my email, and for your response! I emailed you my city. I ordered a dancer's pad yesterday that I read good reviews about, and should have it next week. I'm icing as I type this, too. I'll continue posting my progress as a response to this thread, and will write about the insert once I've tried it.


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.