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Monday, December 12, 2016

Sesamoid Pain and Need of Night Protection

Hi Dr Blake,

I'm hoping you may have some advice for me.

It appears that i have a lateral sesamoid fracture and according to the MRI possible Avascular Necrosis (the bone round with a central fracture was showing black).  I don't have the images with me at this time, however the sesamoid still appears whole with a fracture line showing down the centre (my podiatrist described it as fragmented?).  He also questioned whether my pain was coming from the avascular necrosis or whether it was A. a disruption of the fibrous connection between the fragmented sesamoid or B. from a tear in the flexor tendon and joint ligament.
Dr Blake's comment: That is alot of possible causes of pain, all plausible, but typically the the treatment right now is the same. As the soreness goes down, they can test the flexor better, and see if it is torn. You can typically tell if it is a complete tear, but the subtle partial tears are tricky. Fractures should coming from impact, where tears for a fall or more stressful non-weight bearing activities. 

At first my dr. thought he would need to put me in a walking boot, however now the swelling has gone i seem to be able to walk ok (usually with pain under a 2) in my sneakers that have been altered (with a dancers pad and arch support) so he has left me in those for a week and asked me to check back in with him to see how i'm going.  I did ask about bone stimulation and hot and cold baths at my appointment (as i'm quite desperate , as we all are, to get my foot well again), but he said at this stage it's probably not necessary just yet.  We went with sneakers over moon boot because last week the pain was not bad at all.
Dr Blake's comment: It is all about timing, although with the threat of avn you definitely should push for a 9 month course of bone stim. The Exogen is  a mere 20 minutes a day. Contrast bathing is also a no-brainer, since you have to keep the swelling lighting up the bone flushed out on a daily basis.

So far i do have confidence in my podiatrist, however i thought i'd get your opinion on a couple of things as i've been reading up on your blog and so far have found the info on sesamoids quite informative and interesting.

What i would like to know is (without seeing the mri), would you normally see how it goes before jumping into using bone stimulation and hot and cold baths or would you prescribe them straight away in order to get on top of the avascular necrosis? 
Dr Blake's comment: Answered above. Great question.

Also, though walking is fine most of the time I seem to keep re-injuring my big toe/sesamoid (to where i can't bear to walk the next day) - not from walking, but from sleeping!  I seem to catapult myself from side to side all night using my injured foot and am waking 3 or 4 times in pain. It seems i do this once a week and the next day i literally can't walk at all from the pain.  I even tried out the moon boot with my altered orthotic (i have one on hand) and it was just as painful as the sneaker only more annoying.  I did this to myself again on Saturday night and by sunday afternoon i was at a level 9 in pain.  This morning (monday) it was still painful and i limped a bit, but now as it's the afternoon i seem to be back to about a 3 (though my whole toe bone still feels tender). Have you come across this before?  Is there any type of protection - support or taping that you could suggest i wear at night on my injured foot to minimise any damage i may do unconsciously?  I generally try to sleep with a wooly sock on my injured foot as a subconscious reminder and elevate it on a pillow, but it doesn't always work.  My feeling is that without these episodes of re-injury during sleep, i would be doing quite well pain wise and probably be on the road to recovery.
Dr Blake's comment: I would definitely recommend a ulcer guard for sleeping. This should protect you. The 2 links below can be bought or shown to the podiatrist for consultation and correct sizing. He or she may have another ulcer protector that they like. 

Just for a bit of general info: 
- It's been 2 weeks since i first realised i had the fracture after experiencing enough pain to go to a podiatrist. The podiatrist thinks my injury is older than 2 weeks (i think i can trace it back to a year ago when i sprained my foot/ankle and the GP i saw didn't think i needed an xray so i just waited til it felt a bit better then continued on - though i was hobbling around for the first 2 months of the year and it in general has been pretty delicate since - mainly just burning in my arches and ball of foot when jumping or exercising and me being very cautious about rolling it outwards).  
- This time when i injured it, it happened the very day i returned to doing some jumping exercises after i'd taken 2 months off (self imposed) from jumping due to what i thought was turf toe - brought on from my catapulting myself from my mattress in the middle of the night).
- I have seen my naturopath and gotten all the right supplements to help both bone growth and circulation and will be returning to some swimming and light (non weight bearing exercises) this week.
The only problem to sort now seems to be the nightly gymnastics that are hindering any recovery attempts.

Sorry for the long email for only 2 actual questions!

Any help is appreciated.


p.s. i'm 35 and my past history is gymnastics (though that was 20 years ago so i'm sure it's not a fracture from that far back, though who knows - i've injured this exact foot/leg many times over the years).
Dr Blake's comment: I hope the above was helpful. Let me know if I can help more. Happy Holidays!! 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.