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Wednesday, August 17, 2016

Sesamoid Fracture: Email Advice

Dear Dr. Blake,
Good morning!
  I noticed your impressive blog, and would like to firstly say thank you for taking the time to help people with their concerns and questions.
  If you have a few minutes, I was wondering if you could please provide your opinion.  I was going to a Podiatrist, since February. I have been experiencing pain in my sesamoid.  He said it was sesamoiditis.  I mentioned a possible MRI, but he said that it was not necessary; hence I told him it was feeling better.  I decided to go to an orthopedic surgeon; for a second opinion.  He also did not notice a possible fracture.  Hence, both only looked at x-rays.  Then, I decided to go to a second opinion Podiatrist. He had me have an MRI, and it was discovered, that I have a nondisplaced transverse fracture fibular hallux sesamoid. Since u have a great deal of experience with this, could you please answer a few of my questions:
1.) Is it possible, that because of the longevity of not having any intervention, that it may not heal?
Dr Blake's comment: There are so many factors involved with sesamoids not healing, that it is hard to count them. Yes, delayed diagnosis can be one of them, but I have seen them heal fine after a year of misdiagnosis. So, you have to take that positive approach that you will heal just fine, once you start the 3 months of immobilization required. I would definitely do everything right from this point on, for example, wear a removable boot vs a stiff soled shoe. 
2,) what is the role of reduced blood supply, in this area, and how does it contribute to not healing well?
Dr Blake's comment: Supposedly the sesamoids do not have great blood flow, so the swelling from the injury causes too much pressure on the little capillaries and they can not push enough blood and nutrients in for healing. This is why I love contrast bathing for this deep bone swelling to daily flush out the excessive swelling. 
3.) I have an air cast. If I release some of the air in it, and it helps me better control my right foot movements, is it okay to drive?  I am referring to only an 8 minute drive to and from work?
Dr Blake's comment: In California, you can not drive with a removable boot, which I think is a great law. It is impossible to react to driving situations that arise with one of those. It is better to wear a stiff soled shoe with a dancer's pad. 
4.) would driving, on this right foot, which is the fractured one, with the boot, deter healing, or is it more an issue of driving safety? Safety!!
5.) could I drive, without the boot, for about ten minutes, and then put the boot back on? For sure, see my comment above. 
6.) if this doesn't heal, can I just deal with it, as a chronic problem?  The strange thing is that when I start to jog, run on treadmill, and get started with any activity, the pain tends to completely go away.
Dr Blake's comment: You want it to heal and not lead to degenerative changes in the joint. Many patient's running style does not put much stress on the sesamoids, you may be lucky. This will serve you well when you start running again. Good luck, Rich
Thank you in advance!

Dr. Blake,
Thanks again!  I just read your responses to my multitude of questions.  I appreciate all of your time.  I am not too blog savvy, so I am not sure if there is a way to respond directly to the answers in which you posted on the blog.  
A few more questions:
1.) I was wondering what is meant by a stiff soled shoe?  Is that a sneaker?
Dr Blake's comment: That can be rocker based athletic shoes like the New Balance 928 or Hoka One One shoe line.   Stiff shoes like some hiking boots or Hike and Bike shoes (made by Shimano or Pearl Izumi for example).You can definitely rotate as long as the 0-2 pain level is being maintained. 
2.) I went for a third opinion a few days ago.  The Podiatrist thinks I may also have a fracture on the top of my big toe.  The reason being is because I told him, that aside from the bottom of my foot hurting; which was never really too bad, a very different type of pain was coming from my big toe.  At rest, in bed, in the middle of the night, I would experience a deep pain, in my big toe, which felt like the pain would then jump across the other toes, within a straight line pattern.  When I subtly mentioned this complaint, since March, to the other Podiatrists, they would not think anything of it.   The questions I now have are:
a.) does an X-ray trump an MRI to assess a fracture? Sometimes it is seen better in a xray and sometimes the opposite is true.

b.) can my boot simultaneously also heal my big toe along with the Sesamoid? Hopefully
c.) does taping the toe, whatever this means, help? Spica taping can limit toe motion, and used alot in the return to activity phase of your rehabilitation. You are presently in the Immobilization/Anti-inflammatory Phase. 
3.) Is there a special xray to best assess the sesamoid bones?  This most recent Podiatrist, explained to me that, there is an angle in which this xray should be taken? Plantar Axial view
4.) The new Podiatrist said that he doesn't feel any scar tissue in the areas upon palpation. He stated that this is a good sign.  Do you still suggest contrast baths, and what exactly do you mean by a contrast bath? Yes

5.) Can I go swimming with two fractures, or will this disturb the healing process? No fins, and no pushing off the walls. The hardest part is getting in and out of the pool. 
6.) I think I may know how I developed this injury.  I was carrying a heavy tool station, up the stairs. It was just myself doing this.  I believe I was caught in an angle, going up the stairs, so  I ended up having the tool station rest on my foot.  I had no other choice.  Also, I would do stupid things, such as trying to snap a thick tree branch, by placing it under my foot, and pulling it upwards; and the same thing would be done to break down cardboard boxes for recycling.  I am also a heavy walker, on hard wood floors, and usually don't walk heal to toe.  As you can see, it could have been a combination of everything.
Thanks for listening!!!!! You are welcome!!

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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.