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Thursday, March 10, 2016

Sesamoid Injury with Possible Surgery:Email Advice

Hi Dr. Blake,

I just discovered your blog and wish I had found it when I first looked for information on sesamoiditis.  

Almost two years ago I slipped on wet pavement and fell.  My foot only hurt a little immediately after but by the next morning it was painful to walk.  However, I'm a  teacher it's so difficult to take a day off (especially last minute since it takes several hours to create good sub plans).  So I decided to see how it felt in a few days.  I wore tennis shoes most of the time and it started feeling better.  However, a few weeks later when it got worse, I ended up with an appointment at an urgent care clinic.  That doctor had x-rays taken and said it wasn't broken and gave me a "post-op" shoe which he told me to wear for two weeks.  After two weeks, it felt better but not healed.  I had planned to continue wearing the shoe but the sole cracked in half.  Since it was over the two weeks, I decided it should be fine.  I realize now I should have followed up with my regular doctor immediately, but I didn't until the pain was bad again.  She said to try the post-op shoe again since that worked before.  And the same thing happened (including the shoe breaking after a couple weeks).  At that point I made an appointment to see her and she contacted the podiatry department for my health plan who said that I needed custom orthotics for sesamoiditis.  They referred me to a doctor out of my health plan because none of the doctors within my health plan make them.  However, that doctor was on vacation for a month.  At that point I had been reading about sesamoiditis as a chronic injury.  So I asked to see a podiatrist within my health plan to confirm the diagnosis and get some suggestions for what to do in the next month.  That doctor just suggested over the counter shoe inserts and a sturdy shoe (which I was already wearing most of the time).  He also looked at my initial x-rays and said that there may be a fracture  but there was no way to get a better picture of that area to determine because if where it was, but that the treatment would be the same and I needed to get the custom orthotics when the other doctor was available.  (When I eventually met with the orthotics doctor, he said an MRI would tell and was surprised I was told that there was no way to tell if it was broken or not but also said that the treatment was the same so I didn't worry about it.  He also said that he thought I would be in more pain if it was broken--but I wasn't sure he knew how much pain I was in because every time he asked me to walk barefoot he expressed surprise that I was walking entirely on the side of that foot and not putting any pressure on the ball of my foot.)
So finally a couple months later (6months after the injury) I had the orthotics but no treatment plan was ever discussed other than "wear the orthotics."   And I wasn't sure who I was supposed to be asking since the one doctor was out of my health plan but the other one hadn't seemed very helpful.   So after a couple months when I was feeling better I figured even a broken bone was only 6-8weeks and started going barefoot in the house.  Of course the pain got worse and eventually I contacted the podiatrist within my health plan since follow-up visits with him would be covered by my insurance.  
He ordered a bunch of x-rays that he said showed that it was not broken.  He blamed me for stopping treatment early even though I had never been given a time frame for treatment and still had to ask him multiple times in that visit to get a straight answer on when he felt I could stop wearing the customer orthotics for everything except sleeping and showering.  (He finally said two weeks without pain and I could try without them.)  
He also gave me some stretching exercises to do and said that I was probably putting a lot of pressure on the ball of my foot when I walked and the stretches should help change the way I walked.  At that point he said surgery was a possibility but I should try stretching it and staying off of it for longer and that the stretching would help me have a better outcome if I did need surgery.  The problem was that several of the stretches required that I put my weight entirely on my right foot.  So the stretches were making it worse.  Thinking that he was the doctor so wouldn't have told me to do those if they weren't necessary, I kept trying to do them even though they hurt and some I could just never make myself do every day.  Finally, I went in to see him again and he said I should only be doing the ones that didn't hurt.  I was also about to go on a long-planned extended family vacation to an amusement park.  So I asked about precautions for the trip.  He gave me a boot that he suggested using.  My friend had also suggested asking about cortisone shots so he also gave me one of those (although I researched later and saw a lot of negatives on those and wish that I hadn't).  I ended up renting an electric scooter after a few hours using the boot because it hurt my legs and hips. 
I saw the podiatrist a few months later.  At that point I wasn't having pain during the day although it was often achy at night when I took my shoe off to go to bed.  He suggested icing it and also suggested I could try short walks in the house barefoot.  School was about to start again so I said that I would wait for a month to see how being on my feet more affected me.  Unfortunately, I made a poor choice to take my kids swimming just as school started.  I told myself I would be very careful and get out if I felt any pain.  But I didn't feel the pain until the next day.  I was embarrassed to admit to the podiatrist that I over-did it like that after insisting I was going to be extra cautious.  So I just went back to being very careful, icing it, etc and tried to heal it again.  I tried using the boot at school for a couple days but it felt worse when I did that so I went back to my regular shoes & orthotics.  It was slowly getting better.  But a few months after that we cleaned out our guest room so I was carrying stuff down the stairs to the garage and the next day it was very sore again.  It got a little better but was still a little sore at the end of the day.  Then last week I was walking and I stepped down and had a sudden sharp pain in the ball of my foot.  Since then it has been very painful even first thing in the morning.  
I've made an appointment to see the podiatrist again but I really think he's going to recommend surgery (which is another reason I haven't gone back to see him in several months).

I feel like I just told you my whole life story, but I know you've mentioned looking at the big picture on your blog.  You've also mentioned that you respond to comments that have a more general audience.  So I"ll sum and ask my question in a way that may be easier to respond to:

I am nearly 40 and have been dealing with sesamoiditis for almost two years.  It gets better but the pain returns if I try even a moderate level of activity (even when wearing custom orthotics).  I'm not very active.  I'm not a competitive/professional runner or dancer who needs to get back into shape.  I'm just a mom who wants to walk to the park and play with her kids again.  At this point, would I be better off just having surgery rather than continuing what seems like a losing battle to get my foot to heal?  
If you think there are measures I should still try to avoid surgery, then I have one other question.  My doctor has ordered x-rays but I see you recommend an MRI consistently.  Since my injury was almost 2yrs ago, would it be worth it to push for an MRI now or should I just go with what my doctor uses/expects.
Dr Blake's response: I am so sorry for your situation. You would have every right to have surgery due to the length of time you have been suffering. Surgery is every successful and you just want to make sure your surgeon has done these and knows the subtleties of the surgery and post op course. How much PT? What happens if the joint freezes up? How long in a removable boot afterwards? Etc, Etc. 
     That being said, surgery is done for a non-healing fracture, not sesamoiditis. This is why I would recommend an MRI to make sure everyone really knows why you hurt. I have seen situations where the original fracture had completely healed, but the metatarsal head developed arthritis, or a bursitis had developed, or excessive scarring. So, without an MRI to tell you that the only source of your pain is a non healing fracture, I could not at present recommend it. Also, non healing fractures can heal with 9 months of Exogen bone stimulation, rigid sole shoes, orthotics that do off weight the sesamoid, dancer's pads and spica taping, icing and contrast bathing, and making sure your bone density and Vitamin D levels are healthy. 
     So, step 1 MRI. Based on the MRI results, step 2 can be another smarter approach at conservative management if seems reasonable or surgical removal of the damaged bone. Keep me in the loop and I sure hope this helps you. Rich

Thanks for any help you can offer!

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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.