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Tuesday, June 24, 2014

Sesamoid Injury: Being Pushed Towards Surgery

Dear Dr. Blake,

I am a normal healthy 19 year old college student. I played sports in high school but in college I have stayed active by going to the gym usually 5 times a week. Going for runs maybe every few weeks.

I started feeling pain in my toe around April. I got x-rays done that showed nothing. I later got an MRI that showed swelling and bruising of my sesamoid. My doctor is very unclear when she tells me issues with my feet. I will be seeking a second opinion. From what it sounds like this is a fracture. I have been in a walking boot for 8 weeks and I have no signs of improvement. 
Dr Blake's comment: It is normally hard to tell at this stage how you are doing. Sesamoids do heal usually, but the soreness in the area from swelling, stiffness, nerve hypersensitivity, muscle tightness can make it difficult to gage. 

I have been on my feet maybe a few hours a day ( not consistently)  My doctor is heavily pushing surgery. That is my last option.
Dr Blake's comment: Surgery is done when the chance of healing is over. You have alot of healing ahead of you. I would want to see a CT Scan with definite bone fragmentation to even start a discussion on surgery. 

 It is already late June and I would not be in good health to walk all around my college campus come august. If I get the surgery I would have to take a semester off. I am in a great deal of pain. 
Dr Blake's comment: A big question is why are you in a great deal of pain. You should have 0-2 pain in your removable boot with some off loading pads or hopefully an off loading orthotic device. This would be the same orthotic that will help to wean you off the boot. Over the next month, while remaining in the boot, make sure you are ice packing for 20 minutes twice daily, doing a full contrast bath once a day, learn to spica tape, and have some great orthotics made. If the CT scan shows the fracture line, no fragmentation, ask for an Exogen bone stim for 6 months to help with the healing. 

I got a walking scooter to hopefully take the pressure off my foot. I have knee pain in the other leg since I've been in this boot for what seems forever.
Dr Blake's comment: Please make sure you have an EvenUp for the other shoe to help balance you. Typically at the 3 month mark, if you have a good pair of off loading orthotic devices, you begin to wean gradually out of the boot. This can take 2-6 weeks, and you must keep the pain level between 0-2 the whole time. The more you actually off weight the area, the more it swells, and the more it hurts. So, off weighting is a good way of being convinced you need surgery. 

What is your opinion on this? 8 weeks seems like a long time to see no progress. At times I get a throbbing pain that lasts for a few minutes at a time. Have you seen success with the bone stimulator in situations similar to mine? 
Dr Blake's comment: Definitely, I would go to the bone stimulator as soon as the diagnosis is made of sesamoid fracture, but it is great to start it now, especially if someone thinks that surgery is going to be needed if the bone stim fails. 
I am trying to stay off my feet for the next two weeks but my doctor said if there is no improvement in 10-14 days she wants surgery.
Dr Blake's comment: Golden Rule of Foot: Never be pushed into elective surgery. It has to feel it is the right thing. Remember she made be totally correct, but there is no harm in giving it more time, more chance to heal, adding more diagnostics, second opinion if she pushes, more anti-inflammatory, diet discussion about Calcium and Vit D3, good orthotics (which you will need post op anyway), etc etc. Hope this helps. Rich



  1. Dr. Blake,
    I would like to encourage this young student. Following your strategy of creating a pain-free environment was crucial to success in what has been a long recovery process. I am still not completely recovered. But I can walk almost completely pain free, and I can run to some extent as well. I have to warm up for both activities, but I can do them, which was not the case for about 7-8 months. I had a sesamoid related injury in July 2013, which steadily progressed until I could not walk by the end of August. With no clear diagnosis from two Dr.'s, except that something was swollen around the sesamoid area, I found your blog. I walked through your suggestions with my podiatrist, and he got me an aircast walking boot and orthotics. I sculpted padding to offweight the area precisely and laid them over the orthotics. I then inserted this insole arrangement into the walking boot. The combination of off-weighting the pain in the walking boot allowed the area to calm down, precisely as you said. I was no longer making it worse everyday.
    I spent about 3 months in the walking boot. I also iced 3 times a day and contrast bathed at night. I tried anti-inflammatories, but I think for chronic issues like this, they are worthless. Ice worked. Icing routinely to get ahead of the swelling cycle really worked. Thanks for all these suggestions.
    I am now 90% healed. I can run a couple miles with lots of warm up. 6 months ago, i was starting to think I would never walk, much less run, pain free again. There is still some pain, still some stiffness. But full recovery seems to be reachable. I hope the student holds on and gives this regimen a real chance to work.
    I do have one note about Even-ups. I used an Even-up and it really does work well. Walking without one while using an aircam is horrendous on the hips. However, I think they are too heavy. After two months with the extra weight on my shoe, the tendons at the back of my right knee (the one with the Even-up) started to tweak in pain, which started to really irritate after a week or so. So I cam up with a low-cost alternative. I duct-taped a flip-flop to the bottom of my New Balance Walking Shoe. I looked like a dork, but it worked great! And it only cost $6.
    I hope things go as well for the young student as they have so far for me.
    Thanks for all you do, it is truly God's work.
    All the Best,

    1. Thank you so very much Shaun. I hope the message does get across. Thanks for the tip on the Evenup. 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.