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Saturday, April 16, 2016

Sesamoid Fracture: Email Advice

Dear Dr. Blake

Thank you for all your efforts that you put into this blog - tremendously helpful for people like me that are suffering from a sesamoid fracture.
Here a side view using CT scanning showing the broken tibial sesamoid with different bone densities acoss the fracture

This bottom view of the tibial sesamoid using CT Scanning shows that it was bipartite before the injury due to the rounded nature of the fragments across the fracture site. 

My sesamoid fracture happened around 4 months ago (stepping too hard on that bone on a hard surface) and I broke it twice again since (after week 5 then after week 12 due to too much pressure). Before the latest trauma I was walking almost normally again (therapy was no sports, little weight on the sesamoid, carbon sole, taping big toe, gradually increasing weight, no crutches or cast).
Now, the fracture seems not to be healing again and is terribly sensitive. I use crutches since the last trauma (due to awful tenderness on palpation on the fracture; four weeks now) and an orthoic similar to the one you describe (insole with soft pad under the broken bone with weigh support on the arch and 2-4 metatarsal; stiff sole with rocker bottom). However, the third trauma resultied in a new stinging pain that goes up to the knee on a light touch on the sesamoid and I cannot take benefit of the orthoic so far.

You can see the tremendous reaction of the body to this injury which looks like gout, and gout could be layered on top of the sesamoid injury. This could also suggest RSD which is an over-reaction of the nervous system leading to vaso constriction and vaso dilatation episodes (vaso motor insufficiency). 

Received diagnosis so far (X-ray week 3: bipartite sesamoid, bone bruise; MRI week 7: fracture or stress fracture of medial sesamoid; CT week 12: sesamoid fracture, with bone bridge after some healing). I enclose a few CT and of course would be happy for any specific advice you have to get the healing process started again (I read most for the relevant entries in the blog). As I have a family I am completely stuck and I am desperately looking for a way forward!

My specific questons:
- Where I am not sure on your advice on the blog is, if during the initial period following the trauma you recomment total immobilisation with NWB for some time or if is advisable to put some weight on the foot (e.g. with using crutches) also at an early stage to the extent pain remains 0-2?
Dr Blake's comment: I would definitely see if you get great pain reduction with an Anklizer type removable boot with your orthotics inside to off weight. We always want as much weight as possible as long as you can keep the pain within 0-2. I would discuss with your doc about the redness and the possibility of gout flare or RSD flare. Both would influence what is done next. 

- Would you also recommend some very light physiotherapy at an early stage to increase blood circulation (e.g. moving the big toe lightly, soft massage on the inflammated area) or to leave it completely?
Dr Blake's comment: You are going to need to find a good PT that understand this, so starting now is great and being proactive. Just to avoid the development of nerve hypersensitivity you want to massage the area 3 times a day with NeuroEze, Biofreeze, or another cream/gel recommended by your doc. Nonpainful massage is wonderful and desensitizing and moving swelling. 

- Is it in your experience now rather likely, that after two repeated traumas it is much less likely to heal (pseudoarthrosis) and therefore it would make sense to look into surgery rather sooner than later?
Dr Blake's comment: Yes, and no. Repeated traumas can cause worsening of the fracture, but it is probably just making it longer to heal. Since you have passed the 3 month level, you should really get an Exogen bone stimulator for a 6 month rental. It will reduce the chance of non healing for sure. 

- Any idea how to bring the inflammation down?
Dr Blake's comment: Massage, not continuing to irritate, see if contrast bathes help, but start with one minute of warm water (100 degrees) moving your toe up and down, then 4 minutes of cold tap water (no ice), alternating for 15 minutes total. If that helps you can slowly add more time to the warm, and less time to the cold. Hope all this helps you some. Rich

Best regards


  1. I have had severe pain for over a year now, it was suggested to me it could be a sesamoid injury. Subsequently, a facture was found in my great toe, which actually wasn't causing me pain, I've since been diagnosed with RSD and am developing plantar fibrosis, but the pain, discoloration still stems mainly from the sesamoid area. How do I suggest further investigation into this?

    1. Hello, I am so sorry for your injury. If you can get an MRI on the foot, that should tell you if the bone is broken. The RSD component needs to be treated with creating a pain free environment, warm soaks if tolerated, sympathetic block if you qualify (at least meds to decrease the pain hypersensitivity like gabapentin), etc. I hope this helps some. 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.