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Thursday, February 19, 2015

Sesamoid Fracture: Email Advice

Hi Dr. Blake,

My name is Martha (name changed), I am a Southern California/NYC resident. I am a professional actor performing in a show until a stress fracture of the inner sesamoid on my left foot caused me to have to take a break from the show. 

I injured the foot back in November of last year, and have now been off of the foot and not bearing any weight for 2 weeks, prior to that I was pretty active doing the show 9 times a week. I am currently in an air boot and crutches, as well as using a magnet for healing several times a day, calcium supplements and am waiting for a bone stimulator to be approved. 

I wanted your advice on how to best heal and about how long I will be out of the show. In the show we mostly do pedestrian dancing, walking, running, etc. I want to heal as fast as possible as this show means a lot to me, and I desperately want to go back soon. I have several questions for you, if you have the time to answer them! 

1. How can I best heal, besides what I am doing? 
Dr Blake's comment: Basically creating a pain free environment (0-2 pain level) with protected weight bearing (removable boot, orthotics, dancer's pads, stiff sole shoes, etc), anti-inflammatory measures of icing and contrast bathing, bone healing measures (like Vit D3, Calcium, zinc, bone stimulator), lower extremity strengthening including cardio (typically orchestrated with a PT), and gradually increasing weight bearing. 
2. What is the likelihood of healing vs. surgery? 
Dr Blake's comment: I would need to see MRI imaging. With sesamoid injuries, you typically get a baseline MRI and then 3-6 months get another to see how much healing is occurring. If you have a disc, you can mail to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109 and I will try to let you know what it says. Without that information, it is hard to tell. Only 10% of my sesamoid fractures require surgery, but as you read in the various blog posts, there are so many variables. If you have had sesamoid pain for 3-4 months, and you are not responding, you are considered a surgical candidate. I know many of the professional athletes (and you fit that category) get surgery much earlier in the game to get them back onto the playing field faster. It is really a judgement call case by case. What makes sense for you. And what are your risks.
3. What is the timeline for going back to the show (assuming I have custom orthotics?  
Dr Blake's comment: Too many ifs, ands, and buts!!! As you go from Immobilization to Restrengthening to Return to Activity, you have to keep pain free (0-2). You have to be 2 weeks in the removable boot with no crutches walking fine, before you can start to wean out of the boot. The weaning process can take 2-6 weeks, so you have to have the boot with you at all times, and you have to keep the pain between 0-2. What helps you wean out of the boot the fastest----anti-inflammation measures of icing and contrast bathing, keeping your core strength, spica taping, dancer's pads, cloughy wedges, orthotics, shoes that protect and cushion.  
4. Even after my foot has healed will it feel "normal" again? Or should I expect some pain? (I read the article on good vs bad pain, is it safe to assume the good type of pain will be typical? 
Dr Blake's comment: Patients who heal from sesamoid fractures have no pain and are fully functional. That process from you to no pain can take up to 2 years, hopefully shorter. The healed sesamoid can remain strong, but sensitive due to bone swelling and nerve hypersensitivity. The patients who remain sensitive can not ignore the symptoms, so have to tape, ice, avoid barefoot, etc for longer periods, even if they are back to full activity. Read the post on the Magic 80% Rule. When you are 80% better, you can be fully functional, but you still have 20% of the symptoms to deal with. Good luck. Rich

Thank you so very much. It is difficult finding a doctor who specializes in this injury that accept workers comp. Your blog gave me much relief. I look forward to hearing from you. Again, thank you so much. 

Fondly, Martha

1 comment:

  1. Hi Dr. Blake!

    Thank you so much for your blog. I am currently sitting here reading though so much information - I wish so bad I lived near you so that I could come and see you.

    I recently moved to NYC (about 8 months ago) and have broken my right foot sesamoid - the one on the outer part of foot. I have been in a boot for nearly 3 months. I am not sure how I broke it. I guess I had a stress fracture for quite awhile ( I had pain on and off for about a year) and one day was doing yoga and that was it - I couldn't walk anymore.
    I'm not sure if it was the downward dog that put all of the pressure on the balls of my feet or what - either way that was it.

    I went to the foot doctor closest to me- which was a disaster. Immediately wanting to do surgery. I changed doctors and have unfortunately found myself 3 months in with no answers and a doctor that has frustrated me to no end.

    My first X-rays showed I had a break. After 6 weeks in the boot - my 2nd X-rays showed its healing but I need another 6 weeks. The doctor set me up with someone to get orthotics. They took foam prints of my feet and mailed me custom orthotics which basically are just arch supports with a heel...and the arch doesn't even match up to the arches in my feet.

    I am super frustrated. I am getting no information on when I will get out of the boot, the orthotics don't seem to fit, and now my other foot is having pretty bad pain directly under the big toe (it feel like the joint). I literally don't have a good foot to stand on. My insurance also declined a bone stimulator.

    I work for a living on my feet. I am a freelance artist/stylist. If I can't be on my feet- I can't work.

    Do you have any recommendations of doctors in NYC? I am at a loss on how to find a good one.
    Also, any other suggestions on healing are welcome. Thank you so much for taking the time to read this.

    Julie K


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.