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Saturday, February 25, 2017

Sesamoid Fracture: Email Advice

Hey Dr. Blake,
Thank you for all the hard work you put into your blog. I injured my sesamoid bone three months ago and your blog is the only thing I've come across with any good information. With that said, I have some questions if you have the time and can help me out.

I am a runner, but take very good care of my feet. I have never had any pain or problems anywhere but my right knee (once, after a half marathon last May). In November, I was on a walking break during an easy run and felt a "crunch" in the ball of my right foot. It was followed by immediate pain and I knew I must've broke something. Went in to have it x-rayed that afternoon, nothing looked off. The doctor said this is normal with fractures and to return in 4 weeks if the pain was still present (didn't mention anything about a boot at this time, just told me to try and keep weight off of it). The tricky thing about the timing of this, though, was that this happened the Thursday before I was set to perform in a musical for the weekend. I worked for 3 months rehearsing and wasn't about to quit right before opening night. So, I danced on it for three days (icing it when I could), and started some serious time off right after the weekend was over. My doctor wasn't thrilled that I chose this, but said I should be fine just for a weekend. 4 weeks later, the pain was still there. I went back and they re-did the x ray, this time there was a fracture visible in the sesamoid bone towards the inside of my foot (I believe you call this the medial sesamoid). He put me in a walking boot and scheduled a follow-up for 6 weeks later. He asked me to limit weight bearing activities, but told me I could swim, stationary bike, or do other things that didn't require my body weight. This appointment was mid-December.

I got along okay for 6 weeks, but I really miss running. I swim 3 days a week and do Pilates once or twice a week, too. When I went in for my 6-week follow up last Monday, the x ray didn't show any improvement at all. I'm feeling very discouraged. He mentioned that I'm a candidate for surgery now that it's almost been 3 months since the initial injury, but I'm wary of that option. My questions for you are:

1.) To me, this seems like a very acute injury rather than a chronic stress fracture. My doctor keeps using the words "stress fracture," but should I be treating it differently if it was a sudden, trauma-induced injury?
Dr. Blake' comment: Both are treated the same at this point. Stress fractures you never see the fracture line, and acute fractures yes. A stress fracture never goes  "crunch". So, you have a potentially healing fracture of the tibial or medial sesamoid. The nature of the injury is suspicious of some underlying bone health issue (like Vitamin D Deficiency) so that needs to be checked out. Did you change to a less padded or stiffer shoe just before that could have increase the stress?
2.) What can I be doing to help this darn stubborn little guy heal? I read some of your advice in the sesamoid post "advice when not healing well" and I bought some hapad metatarsal pads and dancers pads for my shoes, but I'm wondering if I need further immobilization?
Dr. Blake's comment: Yes, it is typically get the bone health evaluated and treated if needed. Get the biomechanics secure with off loading in all things, even the removable boot. Spend 3 months in the boot, and if you have attained the 0-2 pain level, begin another 2 to 6 weeks weaning out of the boot with no increase in pain. This usually means experimentation even begins now with orthotic supports, dancer's padding, spica taping, shoe change (possibly Hoka One One). I love of course Exogen bone stim, so see if you can use that for 9 months. It is way too early to consider surgery.

3.) Have you seen runners be able to return to the sport after healing their injury? I'm not finding anything encouraging online and I'm supposed to run my first marathon this November. My training doesn't start until June, but I'm starting to think it's really unrealistic and it's getting me down.
Dr. Blake's comment: Yes, runners get back to running for sure. You should not have any deadlines on your calendar, because that we potentially have you rush through the rehab and take too many risks. Set goals to get better not participate in events right now. Goal #1: Get out of the removable boot in 5-6 weeks into an equally painless environment.
4.) Is it a bad sign to not see any healing in an x ray after 6 weeks? I've been so careful and the only time I haven't been in the boot is when I'm in the pool or the stationary bike at the gym, at home relaxing, or using my Birkenstocks to take my dog for a walk (I don't feel pain when wearing those shoes).
Dr. Blake's comment: X-rays can be 2 months behind showing the actual healing of the bone, so are poor indicators of bone healing at times (and this is one of them). I love MRIs to follow. You need a baseline, and 6 months from now, if you need another one, that comparison baseline can come in handy. Good luck and keep me in the loop. Rich
Again, thank you so much for doing what you do. And if you make it this far, thanks for reading!


  1. Hi Dr. Blake! I was hoping to email you a question about Sesamoid injuries but cant find your email address. What is the best way to reach out to you? Thank you for all of the work that you do ! Caroline

    1. Caroline, so sorry this is delayed. I have been in a mess trying to learn electronic medical records! Yuck! You can reach me at Rich

  2. Hi Dr. Blake,

    I have a quick question... I have been in a cam walker for about a month now and really feel as though my sesamoid fracture has improved. i am not really in any pain in the boot (level around a 1) and my gut is telling me that i am healing. The only pain i feel from time to time (when landing in a bad direction) is a "springy sensation" right under my big toe and the toe besides it.

    When do you think i can transition ? and how do i know for sure i am getting better?

    thank you so much!!!!!!

    1. (forgot to also mention that i have had this fracture for about 3 months now, i believe)


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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.