Sesamoid Pain: Email Advice

Hi Dr. Blake, 

Thank you for providing so much information on your blog. It really is so kind of you to selflessly help so many people. I was hoping you could provide some thoughts on my current sesamoid issue. 

I started feeling pain in the ball of my left foot around the beginning of 2016. I didn't go to a podiatrist until December 2016, as I ignorantly thought the pain would eventually go away. The pain was always a dull ache. I continued to run, do plyometrics, and perform lunges and push ups during this time. 

The podiatrist in December 2016 took xrays (attached both right and left to this email) and determined I had a fracture. As the injury had been there for a long time, he said it probably was already partially healed so directed me to stop running for 6-8 weeks and put padding in my sneakers. I follow his direction but did not see any improvement.

2 Views left tibial sesamoid December 2016

 I continued with this non-impact activity and padding method until mid-april when I came across your blog and started wearing a boot with a dancers pad for three months. I iced twice a day and contrast bathed at night. I also was weight training and cycled on a stationary bike in a surgical shoe during this time.  The pain level was definitely within 0-2 so I thought it could be healing. After three months, I decided to try to get an MRI so I visited a doctor recommended by you, Dr. Dan Altchuler in Santa Monica. He took xrays (attached), thought potentially I could be feeling pain because my sesamoid was slightly pointed and suggested potentially performing a sesamoid planing to shave off the point. He was surprised that it didn't hurt me more when he was putting pressure on my foot and moving my toes in certain ways so he directed me to stop wearing the boot and padding. to see how it felt without anything. 

Recent Xray showing left tibial sesamoid irregularity July 2017

My foot definitely felt weaker from non-use and I had to force myself to put weight through the full foot, as I previously had inadvertently been putting weight on my outer foot. I didn't feel any pain while walking unless I went up on my tippy toes but I did feel a dull ache at the end of the day. I starting wearing padding again which has helped. I told Dr. Altchuler that I wanted to get an MRI, especially before any surgery. I have the CD and have taken a few images (the program doesn't have set images but instead I use a slider to change the image so I don't know if I'm using it correctly but I tried to screenshot images that appear most clear). I also just got the report today. I will try to scan tomorrow and sent it to you. I have an appointment with Dr. Altchuler tomorrow and will update you on what he thinks. 

MRI showing intense inflammation/bone edema in tibial sesamoid

I completely understand if you don't have time to review the attached images or the report I will send tomorrow, but I would greatly appreciate if you could share any thoughts you may have!!

Thank you so much!!

Dr Blake's comment: Thanks for sending me the views. Since I am not a surgeon, I am not sure about the planing procedure. The pain right now from the August MRI is the intense inflammation still present in the tibial sesamoid. It is trying to heal!!As you put weight down, that sesamoid pushes against the first metatarsal and gives pain. You have been in a boot long enough, but no Exogen. That could be a wonderful new chapter. You have to commit to a year of activity modification to continue the 0-2 level, 9 months of Exogen twice daily, icing and contrast bathes, orthotics with dancer's padding or just dancer's padding if the 0-2 pain level can be attained, repeat MRI in one year. You could get a CT scan to get a clearer view of the sesamoid for avascular necrosis, which could speed up the decision making. We need you to weight bear for mineralization, but not to crank up the pain. Hard, but doable. You were doing a great job on creating the healing environment. The bones can desensitize so doing surgery in the next year makes sense only if you are frustrated too much. No one would blame you, but I would just recommend taking the whole sesamoid out, and not risk not doing enough surgery. Again, I am not a surgeon. I am assuming you can do alot, and continue in a 0-2 pain level now, while adding the Exogen bone stimulator. With the hot MRI, you do not know if the sesamoid hurts because it is still partially fractured, or it is just very sensitive due to bone inflammation. I hope this makes sense. What are your thoughts and I will put them below?