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Monday, November 25, 2013

Post Sesamoid Removal Problems: Email Advice

Hi, Dr. Blake,

Your blog has been a WEALTH of knowledge for me this past year... I had a chronic foot injury that went undiagnosed (properly, at least) until March 2013. At that time, my expert ortho surgeon and I decided that my medial sesamoid would be removed, as it was fractured/fragmented. I also needed my bunion repaired and hammertoe (second toe) fused to allow a plantar plate tear to heal. The surgery took place in April 2013, and it is now Nov 2013.

 I have had MANY ups and downs since then. I've done everything I can to heal the right away--PT, acupuncture, swimming, orthotics, TENS machine, etc. I just had a follow-up visit last week, and I'm just disappointed with my progress... I seem to have "decent" and "bad" cycles of pain, and have been in a fairly bad one for the past few weeks. Prior to that, I thought I was turning a corner and started doing some more "challenging" activities like some light hikes in the woods and testing out some jumping activities, but always with orthotics on and atop thick Pilates mats! 
Dr Blake's comment: Flareups are very difficult to take during the 2 year rehabilitation course you are on, but you must get through them. Sounds like you are doing everything well. Do your orthotic devices protect the sesamoid area well? Develop a short Immobilization routine you do as soon as a flare strikes----typically removable boot and icing in some form. Remember, flareups are normal, normally not a sign of anything dangerous, and just means you misread what you thought you could do safely. I seem to be an expert at that scenario. 

I was doing great, I thought, but as of a couple of weeks ago, the remaining sesamoid region in the left foot started to bother me a bit. My ortho is quite positive it is NOT fractured--everything has healed VERY well on X-rays (screw in big toe is still in place and looks normal), but he said I could get a CT scan just to set my mind at ease... I'm not having a ton of swelling--I actually have not since surgery, but I DO have pain...
Dr Blake's comment: There is no indication of fracture, but the demineralization process from disuse can make the bones more sensitive. Motion of a still healing joint cause cause swelling in that joint. In the big toe joint, the swelling drapes over the sesamoids causing sesamoid pain when the sesamoids are fine. I hope these are part of your problem---fixed by walking, good diet, and icing/contrast bathing. 

 Part of my pain is related to my tendency to produce EXCESSIVE internal scar tissue when I've had a traumatic injury or surgery. When I fractured my right tibial plateau back in 1998, it took years to feel "normal" again, and I've had flare-ups. THIS is worse, though, as it's my forefoot and taking more pressure than even my knee! ;) At any rate, my ortho is very knowledgable about folks who are prone to excessive scarring (it's definitely genetic for me, though my scars LOOK fine externally!), but there's not much more he can do. My main fears right now are: 1) that I HAVE fractured the other sesamoid and 2) that I'll never feel less pain due to this excessive scarring... I really cannot bear it if I have to wear a CAM boot AGAIN for most of a year to see if yet another fracture will heal. I am praying it's just scarring/bruising/sesamoiditis, b/c at least I can "manage" that somehow... It's hard to know at this point what is "new" and what is just related to my body continuing to "rehab" from the surgery! I know I had rather extensive procedures done, but I guess I had hoped to be in a better place by nearly 8 months out. My doc said it could take my foot up to 2 years to calm down. Any suggestions at this point? Hoping to hear from him today re: ordering me a CT scan! I really don't want to have a totally sesamoid-less foot, but I can't really fathom going through my entire life worrying I've damaged the remaining little bone! ;) Help! Thanks in advance! 

Dr Blake's comment: First of all, you need to put yourself back in the Immobilization Phase with a Removable Boot with Accommodation, an EvenUp for the other side, and 3 times a day ice pack, until the symptoms of this flare calm down. For flareups, you really should be prepared to do this on a regular basis as soon as possible since it calms things down so much quicker. 
     Scar tissue maturation, when the external and internal scar thins out and gets in the way much less, always occurs from 9 months to a year. This will give you a better, less scarred, big toe joint, but will not even start until late Jan 2014 and end early May. You have over 2 months before that process begins, so I would be kind to your joint between now and May 2014. I would immobilize with flares, work on joint range of motion, work on foot strengthening, weight bear only with protection, increase your cardio (biking, swimming, etc) without jumping!!
     What has the PT said about your range of motion? How is your foot strength? How is your bone strength? You always get transient demineralization with casts making the other sesamoid and foot prone to stress fractures, so you must be getting your calcium and Vit D3 and know where you are at bone wise. 
     Get the CT scan and let me know what it says. Begin your own self mobilization as the video shows below. Have the PT measure you so we can have a starting point. This is very important if you are worried about internal scarring. 


  1. This is beyond awesome and helpful, Dr. Rich!!! Thank you SO much for taking the time to respond! I am waiting to hear about the CT scan order, and praying my doc didn't forget he'd offered it to me! I have increased my foot strength every time the PT has measured me, and I'm getting closer to "normal" in that respect, but I can get hard numbers for if that helps (I know both ROM, strength, and some flexibility have all improved, though, and steadily)! I don't have totally wonderful flexibility overall, but I think that is more because I normally have "hyper flexible" toes! My other foot is VERY "flex-y"! ;) I am not sure about my bone density at this point, all I know is that my surgeon said my bones healed really well from surgery and everything looks "normal" in that respect... But obviously the scar tissue is not so "normal"!
    Would it be okay to use Dankso clogs with a dancer's pad (I have a gel one) or should I strictly use the CAM boot in a flare-up phase? I seem to be doing a little better since I have been going back and forth b/w the CAM, Skechers rocker shoes, and my Danskos the past several days! My pain has calmed WAY down. Also, is it "normal" that I will still have SOME form of pain when doing every day activities, even swimming? I feel like kicking can cause some issues, but the past few days again have been better. I'm also trying to tape my foot in the water, but none of the tape stays put! So, I have purchased Neoprene booties in the hopes that will keep my toes from flailing around!
    Also, do you feel that the lidocaine injections/nerve blocks could be helpful as I go forward--I already haven appt. set up for a consult in early December.
    Wow, it makes so much sense that the remaining sesamoid could be more sensitive given what you explained to me!! I have been beyond terrified I could have fractured it... But even if I have, I guess I would NOT want to have that one removed as well, correct?
    Thank you again!

  2. Dansko clogs are okay if they provide the same pain free environment as the boot. Keep the pain level between 0-2 the best you can, so some pain is okay. Nerve blocks are okay, but hard to advise you from afar. Definitely try to keep the other sesamoid!!!! 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.