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Sunday, July 24, 2016

Sesamoid Fracture: Email Advice

Hi Dr. Blake, 

Thank you so much for all the information you share on your blog and YouTube channel. I have learned so much over the last week or so while trying to get some relief from my foot pain. I was wondering, is it ever possible to heal a sesamoid fracture without wearing the boot? 

A little over a week ago, I started experiencing intense pain in my foot (I know now that this was from a fibular sesamoid fracture that happened gradually). I couldn't walk on it, could barely stand to touch it, and it woke me up two nights in a row with an aching/throbbing/burning/sharp pain. During the day, the pain was slightly less intense, but my foot was swollen, purplish, and hot. Prior to this, I would sometimes get pain and minor swelling in that area and the side of my foot just below the base of the big toe after running, plyometrics, wearing flip-flops a lot, even some yoga, etc, but rest would take care of it. This cycle went on for about a year. 

After trying to treat the new, more intense pain myself with rest, ice (which made it feel worse), and elevation for a couple of days, I made an appointment with a podiatrist, but the earliest they could see me was several days away (my fault for calling on a Thursday). Since I had to wait so long to see the doctor and none of my shoes were comfortable anymore, I researched a bit on what type might take the pressure off of the painful area and offer good support. I ended up purchasing a pair of Birkenstock Gizehs with a normal, not soft, footbed. My heel sinks low into the shoe, the sole is extremely stiff, and it has support for my high arches like I've never had before. I stopped going barefoot at all and kept those on my feet Friday-Monday. The swelling was almost non-existent and the pain was completely gone by Saturday morning, but I kept my appointment with the podiatrist. He found the fracture in the x-ray, put me in a rocker-bottom boot, and said to come back in six weeks. I've been in the boot for about a day now but I feel like it's slightly increasing the pain (dull throbbing in that area and my big toe joint) and the feeling of inflammation on the side of my toe, and maybe even putting more pressure in that area at times. 
Dr Blake's comment: I am sorry for your dilemma. Even though I prefer the removable walking boots, you can heal a stress fracture to the sesamoid without one. My office handout reflects that as well. You basically have to listen to your body, and create a 0-2 pain level consistently for a 3 month period. The Gizeh is not listed as a stiff sole, but I will take your word from it. Removable boots have to be modified in probably 50% of the situations with dancer's padding, etc, to make comfortable. Plus you need an EvenUp for the other side. Several of the problems not wearing the boot are 1) John Q Public does not know you are injured, and 2) you forget you are in the 3 month period of no pushing off, or it can rebreak.

How is it possible for my foot *not* to hurt if I have a fracture? I took my last Aleve on Friday night. And based on the relief I felt from wearing the Birkenstocks vs the discomfort of the boot, would it be possible to wear those instead of the boot and still heal?
Dr Blake's comment: Sesamoids initially hurt mechanically due to the injury, and then the inflammation comes in causing its own pain. When you were woken up for two nights, you probably had a combination of inflammatory pain and neuropathic pain (the pain produced by the pain itself and your body making the area hypersensitive to protect itself. So, you seem to have addressed the neuropathic pain, and stiff shoes helping with the mechanical pain. Keep icing 10-15 minutes twice per day, and contrast bathing in the evening for the inflammatory pain. 

What is your running shoe recommendation for someone with a very high arch, narrow feet, and a history of a sesamoid fracture? What about cross trainers?
Dr Blake's comment: The high arch feet seem to do better with Brooks Ghost or New Balance 928 with narrow width selections. The 928 has a rocker forefoot. For cross trainers, I like the New Balance 608. I sure hope this all helps. Good luck. Rich

Thank you so much for any advice you can offer.

Sesamoid Fractures:

By Richard L Blake, DPM

The top 10 initial treatments for sesamoid fractures are:

  1. Exogen bone stimulator for 6 to 9 months
  2. Removable boot or a stiff soled shoe like Hike and Bike for 3 months to create a consistent pain free (0-2 pain level) healing environment.
  3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths twice on non-work days.
  4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.
  5. Learn how to use 1/8th inch adhesive felt from Moore Medical to make dancer’s pads for the boot and for post-boot action.
  6. Learn how to spica tape for post boot action
  7. When you are not wearing the boot, avoid barefoot.
  8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!
  9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.
  10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

So, what do we know about sesamoid injuries that may help? Here are my top 20 plus pointers when teaching about sesamoid fractures.

  1. They rarely do not heal.
  2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
  3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
  4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
  5. Follow up MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.

6.            The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis (self pay MRIs of this area are $500 in the San Francisco Bay Area).
7.            Since we are dealing with bone, we must look at diet, Vit D3 levels, calcium/zinc/magnesium, and bone density.

8.            Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Restrengthening, and Return to Activity.
9.            When the patient is in the Immobilization phase, the treatment visits should be thinking about (and acting on) the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, cardio.
10.         Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase).
11.         One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.
12.         As treatment starts,the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc) that maintains 0-2 pain level.
13.         The initial goal is to create this pain free environment for 3 months by whatever means it takes.
14.         Non weight bearing (via crutches or RollaBouts) always increases swelling, so some protected weight bearing is crucial. Every step pushes fluid out of your foot.
15.         The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed.
16.         If you are basing treatment on x-rays alone, you may be way off base.
17.         Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques. Go to YouTube and type drblakeshealingsole Self Mobilization.
18.         Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist. Keep the joint/foot flexible and strong.
19.         Patients with sesamoid injuries are prone for setbacks so do not get discouraged.
20.         If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months wait to document delayed healing, some not. Self pay for Exogen Bone Stimulator is around $500.

The patient's response:

Thank you so much for all of this wonderful information and for taking the time to type out such a thorough response. I'm especially interested in the mobilization info and eager to watch the videos you mentioned because I was worried about a bit of stiffness in my big toe joint (it's not bad, but I'm glad to know there's something I can do for it). The Gizehs I bought have the classic footbed, so that may have contributed to the stiffness of the shoe. I'm not sure if that makes a difference since this was my first pair, but noticed there were two versions. They're a bit more flexible now than they were when I got them, but they still feel good.  

Thank you again. I really appreciate your advice. You have been such a huge help and I am so grateful!

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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.