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Thursday, April 20, 2017

Discussion on Avascular Necrosis of the Sesamoids: Email Advice

Hi Dr. Blake,

I hope all is well ! I read over your blog and focused on the AVN posts, which were helpful.

About a year ago, I started noticing a dull pain in the ball of my left foot, but nothing unbearable. This must have been from walking around in a bad pair of shoes for a week. The dull pain did not at any point between April 2016-December 2016 get any worse.

 I did however decide to go see a podiatrist in December to see what was going on. He put me on two different anti-inflammatories separate times and took x-rays (normal results). In January, after not having felt an improvement, he ordered an MRI. This is when we discovered that I have AVN of the fibular sesamoid. He put me in a post-op shoe for a few weeks, which did not help at all. In fact, it made the pain worse. I decided to get another opinion so I went to see another podiatrist who gave me a cam walker to wear for 6 weeks. She also suggested a bone stim. I wore the boot every day, but felt pain when I was walking in it.
Dr Blake's comment: Both the shoe and  walker typically stop you from bending the big toe joint but put extra pressure on the toe. So you need some form of dancer's padding to float the sesamoids even in these contraptions. Definitely if someone mentions AVN, because of the high risk of surgery if the bone stim not work, you have to use the bone stim for 9 months. 

 After 5 weeks, I realized that it was also aggravating the problem and starting hurting other parts of my foot (assuming this is because it forces you to walk in an unnatural way). I switched to sneakers with Hapad dancer’s pads and have been wearing them for the last two weeks. I found a third podiatrist who recommended orthotics. I just received my custom orthotics today and after putting them in, I feel a bit of pain when I walk in them (the same amount as when I wear the dancer’s pads). Not sure what to think of this...I also ordered an exogen bone stim, which will arrive tomorrow. Following the doctor’s suggestions, I will be using the stimulator once a day for 20 minutes for 3-5 months. 
Dr Blake's comment: This is a hard call. You have pain from 3 sources: mechanical (being off weighted by the hapad and/or orthotic, inflammatory (do the twice daily 10 minute ice pack, and once daily contrast bathes), and neurological hyper-sensitivity (try Neuro-Eze, pain free massage). Everything needs to be perfected. Look at each component since a littel change in anything can potentially make a big difference. Can you tolerate a bit more arch? How about a little more dancer's padding. If you are not immobilizing, perhaps a hike and bike shoes for several hours per day to rest the area better. Sometimes just go anti-inflammatory program, or consistently wearing spica taping. 

I am very worried that the pain is only going to get worse with the orthotics. If I feel pain when I walk in the orthotics, does this mean that it will not subside? My last hope is the exogen. I really am trying to avoid surgery at all cost because I have heard awful stories. Unless the pain gets unbearable, I do not even want to consider it. 
Dr Blake's comment: The real reason not to do sesamoid surgery initially is that in the long run it can effect the joint, and the lower leg biomechanics. We try to leave in what was originally there. But, it is a very successful surgery, and not too difficult to heal from. So, when a few of my patients need it from time to time, I do feel I let them down alittle, but I am happy they can gain relief. Whatever they have learned before surgery, in trying to prevent surgery, they can use post operatively to protect the joint. You would need to find a surgeon skilled at this surgery with good results, expectation to get back to full pre-injury activity, with a little sesamoid protection of the other one. 

Do you have any recommendations as to what I can do? Nothing seems to be working and it’s starting to put me down. I used to love running, but I haven’t been on a run in 2 months because I am worried I will worsen the situation.  Even before I started wearing all these shoe-alternatives, I would go on runs a few times a week and the pain was stable. I am so confused!!! I feel as though I should never have gone to see a podiatrist and ignored the problem because now the pain is worse. Are there any exercises I can do that will help?
Dr Blake's comment: You have to give this time. One year from now until you are feeling very fit is not uncommon. Avoiding the bend of the joint for the next 6 months is a start with the hike and bike shoes, spica taping, carbon graphite inserts, or just stiff shoes and orthotics. Just try to create a consistent 0-2 pain level in what you do. Bike, swim, and elliptical without lifting your heels are common exercises. Keep your foot strong with metatarsal doming, single leg balancing, inversion and eversion resistance bands, and FHL strengthening with theraband as long you only work the plantar flexion range. A physical therapist should be able to give you a good program, but protect the sesamoid also. Definitely this should include 9 months of the bone stimulation twice daily, and icing twice per day, and contrasts at least 5 evening a week for a deep flush of the stagnant blood flow trapped in the sesamoid. 

I live in NYC and am still trying to find the right podiatrist. Do you have anyone in mind?
Dr Blake's comment: Contact any of these 3 pods to get a name of someone good near you: David Davidson, Robert Connenello, and Karen Langone. 

I would appreciate any suggestions you can give me because I have been feeling hopeless.

Thank you for taking the time to read this.


Below is the report for my MRI that I got done in January:

Study Result


History: 23-year-old female with left forefoot pain for 4 months. Evaluate for sesamoid injury.

MRI of the left foot

Technique: Routine multiplanar imaging of the left forefoot was performed on a 1.5T MR scanner according to standard protocol.

Comparison: None available.


A skin marker has been placed along the plantar-medial aspect of the forefoot at the level of the tibial hallux sesamoid.

There is a homogeneous low signal of the fibular hallux sesamoid on T1-weighted and fluid-sensitive sequences, likely reflecting sclerosis, which can be seen in the setting of avascular necrosis. The tibial hallux sesamoid appears within normal limits.

There is no evidence of acute fracture. The joint spaces and alignment are maintained. The articular surfaces are intact. There is no significant joint effusion.

The visualized extensor/flexor tendons and ligaments are intact.

There is no Morton's neuroma. There is mild first webspace intermetatarsal bursitis.

There is no abnormal signal in the musculature to suggest atrophy or denervation.

The subcutaneous tissues are unremarkable.


Findings compatible with avascular necrosis of the fibular hallux sesamoid.


  1. Dr. Blake-
    I first had some issue mid August 2016.  I believe Barre class started the issue.  I have high arches.  I am 57 and have ran since I was 39 and never seasmoid issue.  X-Ray was done and it appeared to have a small fracture.  I wore a boot for about 3 weeks and that was causing more issues.  Quit running for Sept.  Started back in October.  Went back to the doctor and he gave me a small amount of cortisone.  It helped.  I also started wearing arch supports in my shoes.  Frustrated I went to a different podiatrist and she did and x-ray and she said it looked like maybe a fracture that was healing.  I told her I wanted an MRI.  Attached is the result of the MRI.  She also ordered a bone stimulator for me in late February.  I have been using it 2-3 times a day still.  She suggested I go back to my original doctor.  He looked at the MRI and the first x-ray and last one.  Gave me another cortisone shot- small amount.  It is 6 weeks later and I feel it some, but can run and OK.  He told me go ahead and do what I have been doing.  It is into pieces or anything.  He said sometimes they stay like they are.  He said if it got bad then he would do surgery, but would rather not. Recovery time takes a while he said.  So now I use the Exogen, wear my Hoka's to run in with arch supports and a dancer's pad under.

    What are your thoughts?  Do they stay the same?  If they completely die do they have to be removed?  As it is now I am not in great pain.  It is noticeable sometimes, but I can bend the toes and do not have major pain.  Maybe a 2 scale at times.  Just scared I am going to do something bad.  The doctor I have is excellent and I trust him, but wanted to ask you. I have the MRI paperwork and do not know how to attach and send the paper. The impression states - Edematous change medial and lateral seasmoids. The lateral seasmoid is slightly sclerotic. Residual fatty marrow is present. Avascular necrosis is not demonstrated. Plantar plate and seasamophalangeal ligaments and the flexor and extensor tendons of the great toe are preserved.

    Bobbie Hickman

    1. Bobbie, I am sorry I am behind in my responses. Everything sounds okay now. If you are keeping it at 0-2 pain, it can heal. Do not put the cart before the horse. One month at a time. If you are using Exogen, continue for 9 months no matter how it feels. Experiment with dancer's padding in everything, Cluffy wedges, spica taping, etc. See what makes it feel better. Set no new goals for 1 year. Keep a healthy diet, and get a Vit D blood level, and perhaps a bone density. Try to send me the MRI via google drive sharing. See my email above. Consider a new MRI in one year, 6 months minimum. Avoid long acting cortisone completely even in a small amount. Keep me in the loop. 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.