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Tuesday, January 28, 2014

Tuesday Question of the Week: Fractured Fibular Sesamoid under the Big Toe Joint

Dr. Blake,

Thank you so very much for your willingness to hear my story!  That alone means more than you know.  Here it goes.

I picked up running in 2011, ran my first half marathon in 2012, and did two more by May 2013.  I started having slight discomfort from the arch of my right foot up to my big toe (mostly when I flexed it) in December 2012. It felt like a sore muscle, so I chalked it up to bad shoes (changed them) and ran through it.  I never expected to be told there was a fractured bone in my foot.  The discomfort was intermittent at best, bothersome but not very painful.

I finally saw a podiatrist in September 2013 as a precautionary measure before training for another race.  He took x rays and told me my fibular sesamoid was fractured

The sesamoids are two little bones under the first metatarsal head in the ball of the foot that consistently get injured. In this MRI image (not this patient), you can see how they stand between the ball of the foot and the ground. The arrow is pointing to a bursitis (fluid sac) which was misdiagnosed as sesamoid pain. 

 I was put in an aircast for 6 weeks.  At my second follow up appointment he told me the bone had healed and cleared me to run and wear heels again. 
Dr Blake's comment: Rarely, maybe this fast, but typically 3 months in removable boot, and 1 to 1 and 1/2 weeks to wean out of the boot into protective orthotics and shoes. 

 He gave me no instructions regarding how to safely get back into running. I tried to ease into it slowly by run/walking short distances with a stiff soled shoe insert he gave me and an ace bandage with a gel cushion under the ball of my foot. 
Dr Blake's comment: I like dancer's pads much better, minimal under the sore bone, and more under the 2nd to 5th metatarsals. 

 That was late October.  I ran a little here and there throughout November and early December 2013.  The dull discomfort was less noticeable than before the boot, but it came back after I'd run a mile or so.  I stopped running and decided to see a different podiatrist.

The new podiatrist took x rays the week of Christmas 2013.  She could tell the bone was cloudy looking but couldn't say whether that was calcification or something else.  She suspected avascular necrosis and ordered an MRI.  Upon reviewing the radiologist's finding (my understanding is that she never reviewed the actual images), she said the bone was beyond healing and that my options were surgery removing the bone now or surgery later, whichever was more convenient for me.  She told me to run my heart out and that it would eventually bother me enough to want the surgery.
Dr Blake's comment: It is so hard to make that ascertain. I would start you on a bone stimulator from Exogen, get your biomechanics in order, and see how the next 9 months went. 

To get another opinion, I saw a well-regarded orthopedic surgeon in Dallas on Jan 23, 2014 who specializes in foot injuries.  He took an x ray and said the bone looks unhealthy.  He also reviewed my MRI but mumbled something about the cuts being 4millimeters apart and not terribly helpful.  He said that unless I stop running entirely, surgery is likely inevitable.  He said I could go back to running now because I won't make the situation worse (what?! how is that possible?).  He gave me no instructions for caring for the injury and said to call him if/when the bone bothered me enough for surgery.
Dr Blake's comment: Yes, you can make the problem worse. Fractured sesamoids can produce damage to the underside of the first metatarsal leading to a hugh mess, and a longer recovery time. Spend 2014 trying to get this injury healed with activity modification creating 0-2 level pain, orthotics to off weight, bone stimulator daily, icing twice daily, contrast bathing once daily, spica taping when you are going to be athletic to protect, 1500 mg Calcium daily, and 1000 units Vit D3. 

Dr. Blake, I have never experienced the pain many of your patients have.  My pain is minimal at best, and basically non-existent at this point, as long as I'm not running on it or wearing heels.  Surgery seems dramatic and it scares me, both because of the initial pain involved post-op and the unpredictable nature of the outcome.  But I miss running, and being inactive is weighing on me.  
Dr Blake's comment: The athletic part of your rehab program should not emphasize impact sports or too much toe bend. But, you should run every other day with good orthotics and dancer's pads, even if it is only 5 minutes to develop a baseline. You must stop running if the pain comes on during the run meaning you hit the threshold of injury. Pushing through that type of pain can injure you further. Cycling, swimming, and swimming should all be good, with a little modification if necessary. 

My questions for you are:
  1. What is your assessment? Dr Blake's comment: Listen to your body for we need to protect these bones. I am happy to look at your MRI by mailing to Dr Rich Blake 900 Hyde Street, San Francisco, CA, 94109. 
  2. Can a sesamoid bone with supposed AVN be healed?  If so, how? Dr Blake's comment: An AVN is still fixable if the bone does not collapse. Bone collapse can be helped with bone stimulator, pain free protected weight bearing, calcium and Vit D3, contrast bathing and icing daily. 
  3. Will a bone stimulator help at this point? I had not used one before seeing any of these doctors, but a co-worker offered to lend me her Exogen device.  I started using it 20 min-daily a few days ago. Dr Blake's comment: Definitely 2 sessions of 20 minute with the Exogen for the next 9 months.
  4. Even though the doctors say I can go back to running, I have chosen not to in hopes that my bone just needs more time/care.  Is there any benefit to be gained from staying off my foot, or am I wasting my time with a dead bone that will not heal? Dr Blake's comment: I will try not to discuss Lazarus from the Bible, but no one can be certain that this bone is dead. Treat it as if it were dying due to lack of blood flow and go from there. As long as the MRI shows that the bone is not fragmenting and degenerative, you have a good chance a saving it.   I downloaded the xray image below and it showed a fracture, but the MRI will be a better way to interpret. The radiology report of the MRI talked about AVN (dead bone) and fragmentation, so let me see how severe. 

I have a hard copy of my MRI disk that I am glad to send you.  The report is attached, as are the x rays I have from the first doctor who suspected a fractured sesamoid in Sept 2013.  I can request the most recent x rays from both follow up doctors if you'd like to see them.

Thanks again for your time.  It is much appreciated.

All the best,


  1. Dear Dr Blake,

    I'm extremely happy to have come across your blog, thank you so much for sharing your experience and knowledge!

    I have AVN of of the sesamoid on my left foot, it has been misdiagnosed until now. 1 year since the injury, I understand it as a dead bone that "has" to be removed. I am told that I need surgery and I am uncertain as to whether I can "re-vive" a dead bone or not. I have had MRI's and x-rays, the MRI from 31.07.2014 shows the same as the most recent in May 2015. In the MRI it shows black and in the x-ray's it shows as white. Is there any hope in helping the sesamoid or would surgery be the only way forward?

    Many thanks for your time and patience.

    Best regards,

    1. Nouschka, Thank you so very much for your question. I wish I knew the answer. The Exogen once a day bone stimulator for 9 months, with good diet of Vit D and Calcium, and the creation of a pain free environment seems to have worked for many. The design of a good protective weight bearing insert and stable cushioned shoe are crucial. Good luck. 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.