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Sunday, October 9, 2016

Recovery from Sesamoid Avascular Necrosis:Can he avoid surgery?

Hi Rich

I hope fall's arrival is treating you and your family well.  I noticed that on a video or two you are wearing cornell gear.  I graduated from cornell in 1984 and my daughter graduated with both her BA and MS. 
Dr Blake's comment: What a wonderful school!! I actually went to Cal Berkeley, but my oldest son Steve went to Cornell. He loved it, and really blossomed as a young man.  

wanted to give you and update.  It has been 6.5 months since my injury and Since labor day, I have resumed partial weight bearing, after 12 weeks NWB (bc of avascular necrosis).  Have had PT since july and ongoing.  Progress has been slow, prob 75 to 80% weight bearing, but can't seem to do more than that without getting pain beyond (0-2) and getting some swelling on the big toe joint.  Feel stalled for past 2 weeks.  Still in walking boot 80% of the time and using crutches to control weight bearing 100 percent  of time.
Dr Blake's comment: Of course, the daily routine of pain level is fine. You can not push it. You should be bone stimulator daily, ice pack twice daily, contrast bathing in evening, massage 2 minutes 3 times a day with the palm of your hand, 1500 mg calcium, 400 units or more Vit D, 1/2 inch adhesive felt in boot as dancer's padding off weight, and a soft orthotic with 1/2 to 1 size larger shoe in the wings. 

  Since injury, I Have seen 2 ortho foot and ankle MD's who counsel patience and slow rehab, and the diagnosing podiatrist (Ivan Herstik, MD, do you know him?  affiliated with NY School do Pediatric Medicine, says he has done over 100 of  these  with many good outcomes ) who feels I have maxed out on conservative measures and recommends surgery.  He feels risk of arthritis and other factors could limit my mobility in the  future even more if I do not get the medial sesamoid excised as I am only 54.
Dr Blake's comment: No, I don't. I would see one of the podiatrists in New York for their opinion that I know: Dr Karen Langone, Dr David Davidson, Dr Robert Conenello, and Dr Joseph D'Amico. Arthritis can be watched for as joint limitation and plantar changes of the first metatarsal. With all the followup MRIs, typically every 6 months, it is hard to imagine missing the development of arthritis. It is still with you in the discussion of "preventative surgery" and I do not have a great feel of those 2 words used together. 

I am going to get custom orthotics from a well regarded pedorhist next week or so. I may also try aqua therapy at Burke Rehab.  Still getting once a week acupuncture and exogen (5-10 min 3-5 times a week, cannot tolerate more as it sometimes causes more swelling and pain if I do too much) and contrast foot bathing 1-2 times a day.   My thinking is that if I cannot walk with minimal assistance (cane) and keep pain level manageable by Thanksgiving (only 6 weeks away), then I will likely get surgery.  My QOL has been low to nonexistent since april.  thanks goodness I have supportive family to help.

Any advice or reflections would be helpful
Dr Blake's comment: I try to tell the patients I am treating to give me a year. If their quality of life is still too hampered, and usually we have now 2-3 MRIs by then which do not show enough improvement, then surgery is needed. But, it is rare to have the surgery, but only 1 out of 20 get significant AVN. If you haven't gotten, please get a CT Scan in the next month, because it is the best test for AVN and for arthritis. The protocol for sesamoids that alot of docs use is 3-4 months to heal, and if not, remove. I have many patients that healed fine in that time, and some taking several years. Vital to the surgery is the manufacture of good off weight bearing orthotics for the year post op. It is also vital to the avoidance of surgery. 

By the way, for my Left foot sesamoiditis, I am finding zero drop or low drop sneakers helpful.  Altra shoes in particular.  Tried Hoka Bondi but the early stage rocker design was too much (although super max cushion ) and seemed to aggravate the sesamoiditis , maybe because toe was curved toward in that early stage rocker design?  they recommended constant 2 which has later stage rocker and is a more stable cushioned shoe, but I will wait to try until I see how I am doing over ext 1.5 months
Dr Blake's comment: I love the Hokas for sesamoids, and typically the Hokas with orthotic with dancer's pads with spica taping can work. But not for everyone, and the subtle differences in Hokas can make a difference for sure. Good luck and thank you for your kind words. 

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  1. I was just diagnosed with sesamoid AVN after 3 months of pain and corticosteroid pills for pain and inflammation management with little to no success. Prior to this MRI, doc was thinking cortisone injection. Is there no immediate pain relief option now?

    1. AVN is classically approach with surgery to remove the dead bone. I have had some good help with 3 months of below knee removable boot, Exogen bone stimulator and daily contrast bathing as a deep flush to the bone. This is just the start of a 1-2 year process in trying to save the bone, but a start. Hopefully you local doctor can help you. Also, make sure you have Vit D levels testing and bone density screening. Rich


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.