Recent Sesamoid Fracture: Email Advice

Greetings Dr. Blake,

First off, your blog is amazing! I learned more here about treating my tibial sesamoid fracture than I have any other sources combined together. My question is primarily regarding getting the proper treatment and when it's time to seek a 2nd opinion. I fractured my tibial sesamoid back in January of this year. I'm not one to rush to the doctor, so I waited 5 weeks from when the pain started to get treatment. The DPM I went to took X-rays that clearly showed an acute fracture of the tibial sesamoid resulting in a bipartite sesamoid. He said that the bones may never unify, however most cases heal with a fibrous union between the fractured pieces. He put me in a cam boot and sent me on my way with instructions to come back in 6 weeks. He also said to ice 3 times daily and take ibuprofen for pain.  I’m on week  5.  At week 3 I had really bad heel pain due to the boot and added a gel insole. That greatly helped the heel pain. Once that calmed down, I realized that I still had light pressure on my sesamoids. I did a sesamoid accommodation myself and that’s help alleviate the pressure on the sesamoids while wearing the boot.

Dr Blake's comment: Bravo!!!!!!!

Since the boot is almost impossible to sleep in, I was sleeping barefoot and was waking up in a lot of pain. I had a muscle spasm that jerked my big toe one night and was in a lot of pain after that. I dug more into your blog and learned to spica tape. That’s allowed me to sleep and shower much better.  I only walk outside the boot for just a few steps on the side of my foot to get to the bathroom that’s right outside my bedroom. I can do that pain free for the most part. Do toe jerks and things like that re-break the bone if fibrous tissue is trying to grow?

Dr Blake's comment: No, you could not generate enough force to re-break the bone or the fibrosis junction.

How easy is it to re-fracture and set back the healing?

Dr Blake's comment: It is very hard to re-break after about 6 weeks in the cam walker, when most of the consolidation occurs. However, after 6 weeks, there is the worry about avascularization of the bone with boney fragmentation. That is why I push when possible for daily contrast bathing, Exogen Bone Stimulators, pain free environments (0-2 pain level), weight bearing to tolerance, good diet with calcium and Vit D3, and icing when aggravated, for about 6 months. 

I am taking calcium and vitamin D3.

My 6 week appointment is next week. I don’t know if he’ll want to keep me in the boot another 6 weeks for a total of 3 months in the boot, or if he’ll try to wean me out of the boot. I’ll need help getting a good insert for my shoes with a sesamoid cutout for that to be the case. Should he be doing this with me in the office?

Dr Blake's comment: I am so impressed by your knowledge and questions. Orthotics can be done by a doctor, physical therapist, pedorthist, running shoe store. Ask your doctor where to get the right insert that off weights the sesamoid appropriately. It is crucial to begin a successful wean out of the boot, and can take several weeks to make, and several visits to adjust. 

What if he recommends custom orthotics? I hear about as much bad about custom orthotics as I do good. Seeing as I feel he didn’t give me the type of useful information I’ve found through your blog to really allow me to be mostly pain free there’s a question of trust which is making me leary of going through the time and expense of getting custom orthotics and they not working due to his office just not seeing many of these cases. I don't want to be rude and question him, but I want to be sure I'm getting the treatment I need.

Dr Blake's comment: Time is never enough in a medical office, it is one of the personal reasons I started my blog for my patients, because I do not have enough time either to talk about everything. So, if he did not discuss everything, it was because the Immobilization phase is a relatively simple phase without the need to go over everything. Custom orthotics are my life, I see the unbelievable changes they can make in someone's life, but I sure do not understand everything about them. The secret to every part of your rehabilitation is in execution of the subtleties. Any doctor is good with some things, and okay or poor with others. Medicine is too complex. I have no idea about your doc, but I would not be worried at this stage. Just ask good questions, without putting a wall between the two of you. He may need to send you to a place that really specializes in orthotics, or for any aspect of the treatment. Does this sort of make sense?

How do I know for sure that if he tells me to wean out of the boot that it’s really time? I still have pain and swelling. In normal healing how long is dealing with a lot of swelling normal?

Dr Blake's comment: Golden Rule of Foot: Keep the Pain Level between 0-2 and you will know you are maintaining a Healing Environment. So, Listen to your Body. And swelling can be part of the overall healing for the next year, and you should continue to work with it with icing and contrasts bathing, while paying attention to the pain level utmost. 

No MRI was done initially. I have a $3000 deductible, so we’re being a bit conservative before really getting into high-cost items like MRI scans and bone stimulators. Having said that, I want to get this healed.  Can you help me with some indicators of judging healing progress as well as what my DPM should be doing at this stage that might let me know if he’s on the right track or if it’s time to seek a 2nd opinion?  What if he does X-rays and the bones are further apart? Does that mean the fibrous tissue will never grow to unify the fracture and that surgery is the only option? If I was your patient, what would you recommend be done? When's it time to start a bone stimulator? Most insurances wants to wait 3 months from what I'm hearing.

Dr Blake's comment: The following is my protocol if I was to take over your treatment right now:

• Not rely on x-rays at all, they are visually way behind the healing, and usually cloud the judgement rushing patients into surgery. But, not a reason to give up on a doc if this is what they are used to relying on.
• Ask the patient to self pay for an Forefoot MRI without contrast at some imaging center (typically $500 or so). It may be a crucial baseline in 3-6 months down the line. 
• Keep the patient in the cam walker for 3 total months (initial plan), and actively design inserts with dancer's pads and some arch support to off weight the sesamoid. It can be that by 8 weeks with the right off weighting insert, the weaning process can begin early.
• Request 2 times daily ice pack 10-15 minutes, and evening contrast bathing to control inflammation and flush out bone swelling.
• Make sure diet, calcium, Vit D3 are good. Consider Vit D3 blood test. 
• Make sure patient is getting core, cardio, and lower extremity strength and flexibility work close to daily.
• See if you can self pay for Exogen. If not, it is a judgement for the patient to wait and get another x ray 3 months from the first x ray documenting the delay healing for the insurance company. 
• Have the patient learn how to spica tape (takes a few times to get good at it)
• Look at their shoes and perhaps replace (how is the padding, flexibility, heel height, etc). It is at least good for the patients to look at Hoka One One, New Balance 928, carbon graphite plates from Otto Beck, etc.

Thanks for your time, I sincerely hope you can help guide me with an opinion of how to proceed.