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Tuesday, June 27, 2017

Sesamoid Fracture: When One is Already Missing

Dr. Blake,

I'm a very fit and aggressive 65-year-old hiker and backpacker who left the Bay Area eleven years ago for a remote small town in New Mexico.

I have high arches and I pronate, and my left fibular sesamoid was diagnosed with a displaced stress fracture 27 years ago, and was excised dorsally. I was given no further recommendations or precautions at the time.

Pain in that area began recurring 15 years later. Since then, I've seen three different podiatrists, none of whom ordered radiology and none of whom diagnosed a sesamoid problem. No one has ever analyzed my gait. They all simply prescribed new orthotics, and now I have four sets of expensive prescription orthotics, only one of which provides reasonably good arch support.

The latest pain began three months ago. Our (only) local podiatrist likewise just recommended yet another set of orthotics, but it took over a month to get them, so I continued hiking with stiffer boots, adding a metatarsal pad to my best existing pair of orthotics, on my own initiative.

Within three weeks, the pain became acute and I had to stop hiking. I rested it for a couple weeks, but it got no better and began aching at night in bed. Then I iced it three times a day for another two weeks. The ache went away, and the pain (on loading) decreased, but only to a point, so I returned to the podiatrist and requested an x-ray. After reviewing it, he said the tibial sesamoid appears deformed and may be fractured. He said if it is, he will need to remove it and fuse the joint, likely resulting in permanent disability. He ordered a CT scan and left on a three-week vacation before the results arrived.
Dr Blake's comment: No, you first try save it with all the things in this blog, or out in the universe. 

As in the past, he didn't suggest any further precautions or limitations, but on my own initiative, I conscientiously keep the load off that joint. What little walking I need to do around the house, I use my best orthotics/met pad, take short steps, and walk on the outside and heel of the foot to keep pressure off the joint, and I also keep the foot flat to avoid extension of the big toe. For anything more strenuous, like driving my truck with clutch, I wear my heavy hunting boots with orthotics/met pad to distribute the load over the arch and outside of foot, continuing to avoid big toe movement. This way, I've been able to avoid all but intermittent light pressure on the sesamoid.
Dr Blake's comment: You are a better rehabilitation specialist than anyone you have seen. 

In the meantime, I've researched the condition online and find that time is of the essence in treating a fractured sesamoid without surgery. I'm already three months into this condition and I've read that four to six months is the window for preventing nonunion and potential avascular necrosis.
Dr Blake's comment: Sure, you want to catch them early, and you are doing good things. Try to create the 0-2 pain level environment for healing. I have seen them heal or not heal after 3 years undiagnosed, so there are so many factors like biomechanics, bone health, work, etc. 

My next appointment, to receive and discuss results of the CT scan, is July 6. I am EXTREMELY frustrated with how long this problem has been recurring, and how bad it's gotten, without adequate attention, diagnosis, and treatment. I'm concerned that my local doctor may only give me the option of debilitating surgery, and I've learned from previous experience that our local physical therapists have limited experience and limited availability, usually with a month-long waiting list.
Dr Blake's comment: See what he says. Bring in a copy of my blog post attached on treatment thoughts. 

I'm open to traveling anywhere, for example back to the Bay Area, for more aggressive treatment to keep the use of my foot. I've read about treatments like hyaluronic acid injections, platelet-rich plasma injections, rejoining a fracture with wire or screws, arthroscopic debridement, shock wave therapy, bone stimulator, biomechanical analysis, gait analysis, spica taping - none of which seem to be available here. Here, I haven't even been given a walking boot to keep the load off the sesamoid.
Dr Blake's comment: I do not do the PRP or surgery, but can establish in 2 weeks a good program. I would want to make the appointments if you can come in on a Monday and leave the 12 days later. I would have you see our surgeon, me several times, our physical therapist, and bone stim guy, to name a few. 

Do you think I should be patient and wait for a local diagnosis on July 6, or should I be looking into outside options ASAP?
Dr Blake's comment: You can mail the CT Scan to Dr Rich Blake 900 Hyde Street, San Francisco, Ca, 94109. Definitely have a long discussion after reading my post above with the podiatrist. 

And regarding outside options, it seems that sesamoid conditions are often difficult to treat. Should I really be looking for a medical team with deep experience in sesamoids, or do you think any general podiatry practice would be sufficient?
Dr Blake's comment: You just need a good rehab person, who can take the information, protect your foot, give it time to heal. You need an MRI 6 months after the first to check its progress, and another 6 months later. Anyone can do this, but they have to want to do it. Good luck my friend. 
Thanks for your consideration!

Dr. Blake,

This is the patient you replied to on your blog on June 27 - the 65-year-old hiker in a small town in New Mexico whose fibular sesamoid was removed a long time ago and is now having problems with the remaining bone.

I've put in a request for my CT scan to be sent to your office. They say it will go out this week. My local podiatrist says that all he can tell from the CT scan is that my remaining tibial sesamoid is arthritically deformed and enlarged, and the only treatment he can offer is surgical removal. He agrees that I might have better options in a big city, and I'm skeptical about arthritis and the need for surgery, since this problem became acute rather suddenly after years without symptoms.

Therefore, I'd like to initiate the intensive two-week round of appointments with you and your team that you mentioned in your response: "I would want to make the appointments if you can come in on a Monday and leave the 12 days later. I would have you see our surgeon, me several times, our physical therapist, and bone stim guy, to name a few."

How should we proceed? Would you like to wait until the CT scan arrives so you can review it first and decide on a plan?

Dr Blake's comment: Yes, let me see the CT Scan. I will put some of the best images on this post. Our surgeon is gone from July 24th to August 14th. I am here except several days in Sept. When we you thinking of coming, after 8/14 is best. Rich


  1. I will plan to visit whenever your team is ready...

  2. I should add that I have two other long-standing conditions that are biomechanically interrelated and need to be considered as context for the left foot problem. I have three compromised lumbar disks that have been triggering lower back pain intermittently for 17 years and make it hard to do maintenance on any lower-body problems. And I had a slightly deformed right hip joint that became painful a decade ago and was finally surgically corrected via resurfacing surgery two years ago. Due to the hip condition, I had long-standing muscle contracture in the TFL and piriformis, and probably some adhesion at the surgical scar, which were not addressed by PT post-surgery, so I'm still experiencing intermittent hip pain and working to restore full range of motion in that area.

  3. I have the same thing. I made a YouTube video series of my journey. Except for me, it all happened within 6 months. Osteoporosis at 33years old. Tubular sesamoidectomy followed by tibial ses fracture. Put on forteo, sent to physical therapy after being in a boot for 12 weeks. In my case, the fracture of the tibial stopped hurting and the pain left is mostly in the tendons from the original fib. Removal. Stretches and massage helps. All of this has left me with bad opposite knee problems. You are not alone in this misery.


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.