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Thursday, September 15, 2016

Sesamoid Recovery: Email Advice

Hello Dr.Blake 

Thank you so much for your reply,I had been waiting for it!

Just to briefly update you ......After I last wrote to you on 22nd August, I increased my activity a bit .I also began to cycle for about 10 - 15 minutes,(taking care not to use the left forefoot for peddling).Hardly have I done that for 5 days and the pain level has really gone up.Sometimes I feel pain in the whole foot and at other times its the forefoot ,including all the toes and the arch .
Feeling quite dismayed at this set back since prior to this I was enjoying a pain free period for a number of weeks.

I am worried that I might have re injured the sesamoid again.Is it so?
Dr Blake's comment: The way you did this you probably only stretched the nerves that run through the arch into the sesamoid. It would be hard to hurt the sesamoid since the weight was not on it. 

As for orthotics,I do have soft insoles, wondering if I need a pair of moulded ones? Right now I'm using silicon gel cushioning and foam for padding the area.
Dr Blake's comment: That is really up to the orthotic designer capabilities. The goals are to off weight the sesamoid with arch support (that you can feel) and dancer's padding. The higher the arch, the more the insert should be full length to distribute the weight better. 

The Darco Orthowedge, which is a front foot off loader is available ,everytime I've tried it even for a few minutes it has been uncomfortable. Maybe I need to wear it longer to get used to it.
Dr Blake's comment: I have never found that comfortable for patients. You can use Anklizer removable boot with a dancer's padding applied.

Peg assist insoles are available here , do you think those will be helpful?
Dr Blake's comment: Okay to make a dancer's pad arrangement.

Is it better to off load the forefoot or to keep it cushioned? 
Dr Blake's comment: Initially we think about major off loading, but need to transition to a little off weight bearing and a little cushion. For the two years following the sesamoid injury, err on more off weight bearing, but we have to gradually have the sesamoids bear some weight. Typically the patients are more protective then they need be. 

I have not yet tried taping since the spica tape is unavailable here, is there another way to go about it?At night I tie my foot with a bandage, which has so far been helpful but not with this recent episode of pain.
Dr Blake's comment: Spica taping is only the technique. You could technically spica tape with scotch tape if your skin tolerated it. 

During the past four months I've taken ultra sound therapy thrice for 8 days each time,it did help.Would you advise another session of that again?The physiotherapist I went to told me it could adversely affect the region if repeatedly done.
Dr Blake's comment: I only recommend Exogen ultrasound once daily. And, regular ultrasound is contraindicated for fractures. Hope this helps.Rich

Waiting for your advice to my queries.

Thanks and regards 


  1. Dear Dr.Blake Thankyou so much for the insights ,really appreciate your taking out the time to answer my queries.So the pain is due to strech ed nerves...It still hasn't gone ....Any anti inflammatory drugs(I'm diabetic) or compression bandage required,does the foot need rest/off loading or I can walk about a bit?Please let me know how to control this episode of pain and the precautions I need to take.
    Thanks once again.

  2. Stationary biking also flared my sesamoid up. Everytime
    I start to get it under control I have a set back. Knee push-ups, crunches and seated upper body weight training seem to be the only safe exercises I can do. I've been taking tumeric capsules (supposed to help with inflammation.) I also found a good tape at the drug store. Im not sure of the brand but it's tan soft and a bit stretchy. Hope you and I both get through this nightmare soon.

    1. Hi Sadie...I am using turmeric too,stirring it in my tea and also making a paste with mustard oil, turmeric and a plant called cisuss quadrangularis (known to heal fractures)and apply it to the foot before tying it up with a bandage at night.Though I was pain free for a number of days ,this time the pain is just not settling down .What did you do when you had such a flare up and how long did it last?What kind of shoes/orthotics do you wear?
      At home I wear crocs with sponge padding that I have cut out and silicon cushion under the sesmoid.Are you also cushioning the area or off-loading it completely?
      Good luck for a speedy recovery.

    2. Thank you I will look into the herbs. My injury happened in June so unfortunately I am still in a boot off loading with a Dr. Jills dancer pad. Rarely is the pain only 0-2 but when I have flare up RICE and time is the only thing that helps. Usually in a few days to a week it starts to feel better. I've found sleeping with my foot elevated has helped the most with inflammation. I am leaning towards the Hokas when I'm finally out of the boot. I purchased crocs for the house also to protect my other foot from barefoot and for when my foot recovers. The tape i mentioned before is Nexcare.

    3. Hi Sadie ...hope you're better.I got the dancer's pad they are quite good.A friend of mine is returning from the USA this week and can get me a boot...since there is a large variety online I'm not sure which one to buy for my injury( broken lateral sesamoid of the left foot) which one are you using?

  3. I’m so glad to have come across your blog. I have emailed you but I'm not sure it went through.

    I am a 21-year-old female with a history of pain and injuries in my right leg. For 5+ years I’ve experienced pain in various parts of my right leg. My primary pain is currently in my right foot, and I have been diagnosed with a stress fracture of the lateral hallux sesamoid (see MRI report summary from 06/27/2016). In May 2014, after severe foot pain that prevented me from walking, I was diagnosed with a stress fracture in the 2nd metatarsal bone in my foot. From May-August of 2014 I spent in a boot and refrained from weight-bearing physical activity. In Sept 2014 I attempted to begin to run again, trying change my running form, shifting from heel strike to toe strike, and after experiencing pain, I was then diagnosed with a stress fracture in my 3rd metatarsal.

    At this point, I gave up on returning to running. I embraced all forms of non-weight-bearing exercise, such as Pilates, yoga, core strength workouts, and swimming. I did not run at all from late 2014-to the present. In March of 2016, even with limited weight- bearing exercise I was experiencing significant pain in the ball of my foot. By May, the pain was too much to even walk comfortably. (I believe it may have been this way for a while and I was altering my gait so as to not put pressure on the ball of my foot/sesamoids.) In June, I had an MRI, which revealed edema. Here is the radiology report:

    1. Imaging findings likely representative of stress change within the lateral hallux sesamoid with suggestion of cortical disruption. Osteonecrosis could have a similar imaging appearance. Correlation with plain radiograph to evaluate degree of sclerosis and/or fracture line may be helpful.
    2. Additional edema like signal within the medial aspect of the first metatarsal head is nonspecific but may also be related to stress change. No discrete fracture line is identified.

    My orthopedic doctor (in Charlottesville, VA) believes I have a sesamoid stress fracture. He prescribed a pneumatic walking aircast boot (weight bearing) with crutches for 8 weeks. I got a dexa bone density scan as well, with normal results.

    After 8 weeks on crutches and the boot with a significant amount of pain, I went to see a foot & ankle specialist in at University of Virginia. He looked at my MRI, and said that AVN was occurring and I needed to have the bone excised. Knowing the risks of surgery, I sought out a second opinion in Baltimore, MD. After 10 weeks on boot and crutches, he said I did not need crutches. He immediately requested that I get my Vitamin D, calcium, and thyroid tested as well as a general physical. Everything was normal, but my vitamin D levels came back as 40, which he said was on the low range of normal. He has me on Vitamin D supplements for 2-3 weeks, and says if I don’t see some improvement then I should consider surgery.

    At this point, I was on crutches/boot for 10 weeks, and boot only for another 2 weeks (3 months total of immobilization). I am still in the same level of pain as when I first started immobilizing. The pain is intense and debilitating.

    A few specific questions:

    Is the boot the best healing device for me right now? Are there any alternatives?

    What can I do to alleviate the pain? You say on your blog a level of 0-2 is necessary to begin healing. I am wondering how to reach this level.

    Is it worth using an Exogen bone stimulator since it has been 3 months?

    Should I be spica taping?

    Should I continue taking Vitamin D? And calcium? Any other supplements?

    Should I get any more imaging done to see what is going on? I have not had imaging since an MRI in late June.

    What exercises and stretches do you recommend to keep up strength and flexibility while I am in the boot?

    Should I be getting fit for an orthotic? I have very high arches.

    Many, many thanks in advance,
    Nell Ackerman

  4. Your story is similar to mine. I finally saw the Dr in June after a few months of pain. I've been in the boot doing very little weight bearing since. I've been super committed to my healing but making no progress. Pain and swelling are worse then before I starting treating it. I've been following all of Dr Blakes suggestions since both Drs I've seen so far don't seem to know anything about this injury. Luckily they've not talked surgery yet rather just tell me it needs more time and send me on my way. I'm considering getting a 3rd opinion. I hope you get some relief soon I know what you're going through. I never imagined I'd be dealing with something like the at such a young age. It's so hard not being to do anything.

  5. Hi, a friend of mine is returning from the USA this week,she can get a boot for me!I need your suggestions to know which is the right kind of boot/camwalker for my injury (broken lateral sesamoid of the left foot).There is a lot of variety online and I'm not sure which one is appropriate for me.

  6. I just wanted to drop by and say thank you for your great tips and posts! It really helped my mother and my grandfather with reducing the pain after having an injury. Thanks a lot!

  7. be careful, guys and if ytou ever need instant essays you can write to me or my collegaues


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.