Injured Sesamoid: Email Advice

This email was received 8/11/13 for time reference.

Hi Dr Rich

I have been following your blog for some time, as I have an injury to my tibial sesamoid bone on my right foot for 8 months. Like many people with this injury it I have spent a long time looking for positive information online, and yours is the most helpful source of advice on sesamoid injuries. I was hoping I would never have to email you but as time has gone on I would really appreciate your thoughts on what I do next. My story.

• December 2012- I suffered a fall from a 1.5 ft height and my foot was very sore/I was limping. I could bear weight and doctors saw nothing obviously wrong. 

• February 2013- my GP commissioned an XRay which showed nothing

• March - I referred myself to an orthopedic foot and ankle surgeon  who suspected sesamoid injury - I googled it and freaked out (!), visiting a podiatrist who confirmed the diagnosis and told me  takes 18mths-2years to be totally pain free.

• Had an MRI showed no edema. Dr Blake' comment: Edema means swelling, which is a sign of injury and the body's healing response. I believe it is impossible to have a fracture without bone edema, so perhaps you do not have a fracture. 
•  Surgeon diagnosed bone bruise but commissioned a CT scan - the report said there was a small area of cortical break involving the plantar surface of the medial sesamoid. Dr Blake's comment: Not sure what it looks like, but the plantar surface can be normally irregular and look like a cortical break (just a possibility, and hope!!)
•   I asked about a boot/crutches and was told if he had seen me originally at the acute phase he would have put me in a boot, but now there would be little point. He told me it would heal in time and suggested 6-8 weeks of offloading using dancers pads. I decided to be more cautious and asked his opinion on a podiatrist (I didn't want to go back to the first one) and he referred me to a colleague. This podiatrist was positive - told me he could almost guarantee in 3 months I would get better and told me to do calf stretches three times a day (apparently I have super tight calves) and I was given temporary orthotics and told to walk with a heel strike
• In the meantime I followed your advice - taping my foot, icing/contrast bathing, ensuring proper vitamin supplements as much as I could. I cut out running, heels (the most upsetting part for me as I am only 5ft) and rested as much as possible. I sought out stories of people who had this injury too - a professional footballer who had this injury from impact too and after three cortisone injections considers himself healed. I also spoke to a former model who broke her sesamoid bone in half through wearing heels but finally saw a recovery after 2-3 months using a bone stimulator (wanted to include these stories in case it helps keep others positive). My surgeon was very conservative about cortisone but did say a small amount via ultrasound guidance might be sensible down the line
• April - I received custom orthotics. These raised my arches (I was told my feet pronate and are flat, aggravating the sesamoids), but actually stopped right behind the ball of my foot - something which I always questioned. I was told the weight was being offloaded down the metatarsal head. 
• May - No real improvement - pain would start up as soon as I walked any distance - My surgeon offered cortisone. I asked him about  bone stimulators - he confessed not to be an expert/use them, but said they would do no harm. So I managed to source an exogen express from the ebay and used it for 3 weeks. I then contacted a sports orthopedic surgeon who promoted the use of exogen for as a second opinion. My new doctor commissioner a new MRI - he said he was immediately skeptical of the diagnosis (said if you stared at a scan too long you can convince yourself of non-cortical fractures). Dr Blake's comment: I agree so far!
•  I went to see a physio therapist who said  I had modified my gait to protect the sesamoid, She told me to try and walk from heel to toe, exactly as I did with my other foot and strengthen the foot with glute and balancing exercises and walk barefoot as much as possible. I did this, but the proper walking aggravated the injury.Dr Blake' s comment: What ever I tell a patient, if their body tells them differently, it is always best to listen to your body and the signals it gives out. 
• June - my new doctor studied my new and old scans for a long time. He also asked a radiologist colleague to do the same separately. They both concluded there was never a fracture, but that sesamoiditis/inflammation had built up over time. He suggested cortisone to break the cycle of inflammation and told me to stop using the bone stimulator as it would counter-balance the cortisone. He also referred me to a different podiatrist who said my orthotics did nothing to offload the sesamoid area 
• July - I had the cortisone injections (20mg in two joint areas) and started to wear new orthotics -  modified to include a forefoot dancer's pad
• The cortisone has made some difference, but I still have pain when I walk if I don't wear trainers (especially when I try to walk 'properly' - its like a constant toothache in my joint, along with occasional sharp pains down the joint at the side of my foot . My foot  lack a lot of strength and I often feel pain in my little toes, side of foot and ankle too - I feel like I need to click the joints often etc. I emailed my new doctor and he has suggested another injection. I've also been going to the gym in the last month to try and build up strength through cross-training.

Sorry this is a long email - but I wanted to give you the full history in the hope you might be able to give me your expert thoughts on some questions.( I would love to send you my scans but whilst I have them on CD I don't have the software to open them on my computer):

Dr Blake's comment: Just ask the place to give you a copy with a reader for a PC. You can mail to me at 900 Hyde Street, San Francisco, Ca, 94109. 

1. Was my first podiatrist right? Does it just take a really long time to recover? And have you actually seen people  recover fully if they have a tiny hairline fracture/bone bruise?

Dr Blake's comment: I would have not expectations at you not healing. You do not have an injury that tends not to heal well. However, being a specialist in biomechanics, I do know you could have a difficult foot to get the right orthotic for that truly off weights the area well. If that is the case, then you keep re irritating things over and over again. See who in your area is great at orthotics. 

2. As Dr's disagreed with the diagnosis but not the treatment - I still have a niggling doubt there is an resolved tiny fracture and was I wrong to stop bone stimulator? Could I restart this or is this out of the question now I have cortisone in my system? If so, would there ever be a time when I could?

Dr Blake's comment: Please try to heal without cortisone if possible. I would prefer you to ice and contrast daily and take NSAIDs then to use cortisone. It can mask pain too much. Short acting cortisone is fine, and the initial shot to get ahead of the problem/inflammation was fine, but I would not go there again. I love the bone stimulator, but sounds like no fracture, so there is no place for the stimulator. The bone stimulator actually stimulates the bone, important for fractures, but stimulation can also increase bone inflammation and pain/sensitivity. It could actually keep the bone sensitive to pressure that you do not want.

3. My second doctor said I could have up to 3 injections - I know you are no fan of cortisone, but icing/taping/orthotics have given me no obvious improvement - its been only thing to push me into some form of recovery (if temporary/misleading) - would a second shot be a bad idea?

Dr Blake's comment: Just remember how long it can mask pain, and give you a false sense of security. What are your other options? Physical Therapy with cortisone in iontophoresis? Acupuncture? Better orthotics? More daily icing/contrast bathing? I would feel more comfortable with cortisone if your orthotics were perfect, and you had no other options. As you walk, do you feel that the orthotics take weight off the injured area 0%, 50%, 90%, or 100%. You want the weight in the middle of your foot and off the sesamoid area. Put lip stick on the ball of the foot under the sesamoid, carefully put your foot in the shoe, walk down the hall or outside, take the shoe off, does it look like the weight is off the sesamoid. I know alot about orthotics, and it can still take me many attempts to design the best orthotic for this function. 

4. Is walking barefoot/foot balancing helpful or should I offload wherever possible- it doesn't hurt at the time, but can afterwards.

Dr Blake's comment: I find no purpose in walking barefoot. My blog is loading with foot exercises to get the area strong. One of my patients sent a great video recently on FHL eccentric strengthening which looked great. The exercises should not hurt during or after. You have to experiment. Try rearranging books to stand on for single leg balancing where you float the big toe area. Ice after any exercises to calm down the irritation for 10 minutes. 

 Any thoughts you have would be really appreciated and I will of course make a donation to your blog.

Dr Blake's comment: Thank you so very much and I sure hope this helped some. Rich

Please do not comment on the stomach rolls!!! I am doing sit ups every day!

Thanks so much (if you could keep me anonymous that would be appreciated)