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Saturday, April 16, 2016

Possible Sesamoid AVN: Email Advice

Dear Dr. Blake,

First of all, thanks so much for the invaluable website. Your knowledge - and the experiences shared on the website - have provided me with so much support and education whilst I've battled through the
sesamoid minefield!

Here are my details:
  • Active 27 year old;
  • Pain in the area of my right lateral sesamoid for about 5 weeks;
  • Before the pain started I ran about 5 miles 3 times a week;
  • I think a spin class, in which I had to wear tight fitting cycle shoes and pedal right over the sesamoid area, triggered my pain, but from MRI images my doctor thinks it has been fractured for years.
For the first week or so the pain was intense. So intense I could walk only on the outer edge of my foot.  So intense it kept me awake at night and even the pressure of the bed sheet hurt!

After the first week the pain got much better - I started wearing a gel dancer's pad and think that helped to take off the pressure from the area.

Since then, the pain is always there, but it's minor. I can walk "normally" and the pain is a 2 or 3. It's just really annoying. Occasionally it gets worse and is more like a 4 or 5; doesn't seem to be any rhyme or reason to this - it can get worse even when I've been lazing around all day and haven't been on my feet much.

I'm too scared to run - it feels like I'm living my life on a tight-rope right now and that one bad move will put the pain right back up and undo any healing I've helped promote. Does that make any sense? I'd give anything to put back on my running shoes and go for a run - I don't think it would cause pain during the run but I'm terrified of making it worse.

My doctor thinks my lateral sesamoid is AVN and said the MRI shows "signs of degenerative change" around the area. 

His view is that I should try custom orthotics (they'll cost me nearly $1000) and then if it's still causing me pain in 3 months, surgery is the only option and is "risky" with "potential side effects". I get the impression he thinks I should just "live with this". Apparently I should avoid getting a shot because it could make it worse?

I'd be so grateful for your thoughts: does this look like AVN to you (MRI pic attached)? Apparently he thinks it is AVN because the lateral sesamoid is "black"? If it is AVN, can the sesamoid recover from this? If not, when it "dies" completely could it become symptomless?

An article I read by you online suggests a CT could help to diagnose AVN and that an Exogen bone stimulator could help; what is your thought on this? Your article actually resonated with me so much because it sounds like my exact situation, I couldn't believe what I was reading because I feel exactly the same as this patient:

Best wishes and thanks again for the great website,
Dr Blake's response: Thanks for your kind words and patience with my response. I am sorry I could not put the image on my blog, but it had your name in the corner. However, it looks like a normal healing fracture of the sesamoid, the black on that view is the bone swelling. On the images that show normal bone black, the sesamoid will look white. The initial healing of a fractured sesamoid is 3 months, and I do not like my patients to push off during that time. They typically wear an Anklizer type removable boot, with a insert with a dancer's pad. You can go out and buy OTC inserts that provide cushion at the front of your foot and some arch support. You can buy 1/8th adhesive felt from to use for your dancer's padding. You can use the 

powerstep insole above to attach the dancers pad and even apply more arch. If the area under the sesamoid is still too hard, you can sand down the buld in half. Work on the swelling in the tissue with twice daily 10 minute ice packs, and evening contrast bathing. Before you get out of the boot, get your CT scan and look for the sign of AVN called fragmentation. I have had patients become asymptomatic with AVN, but it takes a year to know where it is heading. You typically qualify for an Exogen bone stimulator at 3 months post initial MRI or xray if the ordering physician repeats the test and documents delayed healing. The 4th and 5th months are the months that you begin to wean out of the boot into normal shoes. You have to be maintaining 0-2 pain levels and this rule dictates what you need (what does it take to keep the 0-2 pain level): carbon insoles, custom orthotics, rocker shoes, spica taping, etc etc. Hope this all helps and makes sense. Rich

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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.