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Sunday, April 19, 2015

Sesamoid Injury: Email Advice

Dear Dr. Blake,

     Firstly thank you for all of your support you give to this issue. When researching my condition I have found your website to be of great value. Mostly because I can relate to much to all of the other people dealing with such a tough issue.

     I was diagnosed with sesamoiditis about 8 months ago. I have tried every treatment I know of besides acupuncture, which I am putting my hopes in now as I have an appointment tuesday.

     I have a
bipartite sesamoid in my right foot. I had a hot spot in the bone scan followed by a CAT scan. Two doctors have agreed that from the scan that there is no fracture.
Dr Blake's comment: I always treat a positive bone scan as a stress fracture, since you have the treat the most serious problem, and CT scans and x-rays will not show the fracture itself (even when the bone is broken). 

    I have been in a boot for two months, tried rigorous icing and heat daily, anti-inflammatories (which I am not off for being on too long, plus they didn’t seem to do anything), dancer pads - minimal help, off the shelf and custom orthotics - little help there. Two cortisone shots - the second one worked for about 7 weeks. Then slowly back to square one.
Dr Blake's comment: The thing with orthotics and dancer's pads is that they have to shift the weight to the middle of your foot and off the sesamoid. If not, get them adjusted. Cortisone is to be shied away from because of the possibility that this is a stress fracture and cortisone can slow down the healing process. 

    I was a sub 3 hour marathoner and used to run ultra marathons and climb mountains for fun, so being stuck swimming laps is often a tough pill to swallow. Besides swimming and low impact activities and the once every two months a short run just keep sane- no long walks, no hiking, no mountaineering, very few casual runs. My podiatrist has stated that he is not convinced surgery is worth it yet and it may just heal.
Dr Blake's comment: I am glad your podiatrist is sane. At some point, get an MRI to see how much bone edema still exists in the sesamoid. If positive, then you also should be on a bone stimulator. It is great you are cross training and trying to create a pain free environment. 

    When discussing the idea he has brought up a partial sesamoidectomy stating that with my bipartite the offending bone is slightly smaller, so he should be able to take out half, hopefully leaving me with full function. He also stated under the preface “if you’re game” It would be an experiment, but trying a bone graft to join the two parts, but he wasn’t sure if this had been done or where he would take the bone from to graft it - does this sound feasible? Has anyone else done this?
Dr Blake's comment: If 6 months from now, only one of the two sesamoid pieces remained hot on MRI and you were still struggling, I would entertain a partial sesamoidectomy, but only then. Never heard about bone grafts across the fracture site. 

    I am also seeking a third opinion outside of the clinic which I go to. Is there a sesamoid specialist in the greater pacific northwest who has experience in this issue? It seems very difficult to find a podiatrist who has a great deal with sesamoid issues not that I don’t think they are out there, its just how to find them.
Dr Blake's comment: I typically recommend Dr Richard Bouche in the Seattle area, he is very smart and deals with athletes all the time. 

 My last question is the current surgeon I have been seeing has performed 50 or so sesamoidectomies, I have no idea if this is an adequate amount of experience? Is 50 a lot or a little...
Dr Blake's comment: After 3 or so you have good adequate experience, after that it helps fine tune the thought process on when to operate, and what to do post operatively. I hope this helps. 
If you’ve read this far, thank you for your time, any advice you can offer would be greatly appreciated. I would give anything to have my life back.

Thank you,

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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.