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Friday, February 20, 2015

Sesamoid Injuries: Questions

This is my answers to a student studying the treatment of sesamoid fractures with my comments in red. 

Thank you so much! Below are some questions:
1. Which method would you recommend for the rehabilitation of the sesamoid bone in the foot? 
     I prefer to treatment conservatively with a removable boot for awhile, then orthotics that can off weight the area. The only other method would be surgery, which may be unnecessary, and I think the last resort. Lack of response to treatment, coupled with MRIs showing bone fragmentation will sway me towards surgery. Any treatment done, if surgery is eventually needed, will help greatly in the rehabilitation (like designing a good off weighting orthotic device). 
2. Why this method? 
     My personality which is conservative, and seeing patients still having bothers after surgery sometimes, knowing that surgery is not always the perfect fix. Any treatment should get the patient to no disability, and conservative treatment can do that the majority of time. 
3. Which method would you say is the worst? Why?
     Neither, because both have their pros and cons. The surgical treatment for a broken sesamoid is technically easy, and gets patients back on the road quicker than stubborn cases of conservative treatment. The con of surgery is that you are potentially removing a vital bone, and surgical complications can lead to some permanent problem. Conservative treatment avoids bone removal (leaving your anatomy intact) and avoids surgical complications. However, conservative therapy may take up to 2 years to complete (generally 6-9 months is normal), which would be difficult in a highly functional athlete, with no complete guarantee that it will not, in the end, require surgery. 
4. What is the most common way of injuring the sesamoid bone in the foot? 
     From the impact of sports
5. Have you ever heard of someone getting arthritis in their big toe from a certain treatment?
     The sesamoid is bottom part of the big toe joint. If the bone is fractured and irregular is can start arthritis forming on the under surface of the first metatarsal. When I x-ray and MRI or CT, I am always checking for signs of that. 
6. If you had to put your patient in orthotic devices, would it be a Morton's extension or a Dancer's pad (apologies if my terminology is off, while researching I realized some doctor's use different names)?
      The six basic designs for sesamoid injuries, which can be used in some combination, or with all of them are:
  1.  Enough arch support or varus wedging to shift the weight back into the arch and over to the 2nd and 3rd metatarsals as you move through your foot.
  2. Metatarsal arch support to shift weight laterally (towards the outside of the foot).
  3. Dancer's pads (aka Reverse Mortons) to shift the weight laterally as the weight goes onto the metatarsals at pushoff.
  4. Cushioning under the first metatarsal head
  5. Minimal heel lift not to shift too much weight forward
  6. Stiff forefoot area to minimize bend if needed (at least a design that does not encourage excessive big toe joint motion).  
7. What sort of side-effects could occur if one was to perform surgery to remove the bone(s)?
     I find that the crucial question is why did the patient get this in the first place. If the surgery does not correct that, and most of the time it can not, then removing the sesamoid puts the other at more risk. Losing one sesamoid is not the perfect scenario, but you are still highly functional. If you lost both sesamoids, you have not protection for the first metatarsal head. Removing the medial sesamoid does make you more at risk for bunions, but if you start wearing toe separators and yoga toes, and start doing abductor hallucis strengthening, you can minimize that. Typically when you injure something, there is an obvious cause, and several still important less obvious causes. After surgery, you have to know what the causes were and prevent them in the future. I find this area is addressed the best while the doctors are trying to avoid surgery in the first place, learning why it happened helps with designing treatments. Only some of the causes are: poor running or walking styles, poor shoe selection, inadequate fat pad, high arches, plantar prominent first metatarsals, training techniques, improper cleat placements, poor bone health, transient Vit D or Calcium inadequate intake, over pronation, stiff foot that does not adapt to ground, etc. I am sure I have left out quite a few. 
8. It was brought to my attention that some people are born with their sesamoid already in two pieces, do they experience the same problems of someone who has broken their sesamoid experiences?
     Yes, even when the sesamoids are congenitally in two or more pieces, they can still fracture or bruise these small bones. I feel having the bone in multiple pieces greatly confuses the diagnosis. It is too easy to say they are congenitally that way, so they must not be injured. These separated pieces can develop fractures, but they are even more prone to sprains between the bones. These sprains are impossible to fully diagnose, and seem to cause lingering pain more than from a fracture. So, when I see the bone in more than one piece, and the pain matches a stress fracture level, I am more worried that they are going to have a difficult time healing (at least quickly). I sure hope all these answers help you and other reading. Dr Rich Blake

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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.