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Tuesday, December 26, 2017

Sesamoid Dilemma: Already Down One!!

Hi Dr Blake

Trying to keep this short, but it isn’t going to end up short.   I’ve been through years of sesamoid pain (fibular, originally).  Now I’m facing the loss of both sesamoids in my left foot.  Catch your attention?  Thought it might… btw, love your blog. 

Fibular removed June 2016, no instruction is given on after-care, and a few months in after being told to walk normally my supposedly healthy (medial, the inner one) fractured.
Dr Blake's comment: One of the reasons I try to get my sesamoid patients to try everything before surgery is that at least they have a system in place after surgery to avoid just this. I am so sorry!! When you break a major bone like this, you also want to make sure your bone health is great. 

Xrays before showed intact medial.  So it definitely broke after the surgery. 

Looking back on the MRI I had done way back before surgery, there were signs of marrow edema in the medial that I was never informed about.  I suspect that hasn’t helped things.  Frankly, if I had known that I probably wouldn’t have had the fibular removed. 
Dr Blake's comment: So, I am dying to know what was done pre-surgery for the first fracture. How was it treated? Was bone health overall accounted for? What about the biomechanics of your foot? Some patients have such a high degree of pronation or a high degree of lowness of the first metatarsal (plantarflexed first ray or metatarsal) that they are just set up for this problem. The more analysis of the situation more surgery, in the process of trying to avoid surgery, the more chance of hopefully avoiding this scenario. 

So here I am, with heavily customized orthotics (from another Dr), which include a metatarsal pad and Morton's extension.  Bouts in a boot haven’t healed things, so I got another MRI done.
Dr Blake's comment: So, Morton's extension tries to limit the big toe motion, but puts pressure on it. A dancer's pad also called a Reverse Morton's, attempts to float the metatarsal head/sesamoid, at least taking significant pressure off. Have you experimented with both to see what is better?

I’d like for you to see it.  The gist is they “can’t rule out AVN” and there is prominent bone marrow edema.  They also mention edema in the base of the proximal phalange which may be degenerative.
Dr Blake's comment: I would be happy to look. The mailing address is Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109

The dr basically tells me it is up to me on how to proceed.  He seems to think to remove it will help the pain, which is substantial.  He seems smart, but hard to talk to a bit.   I have no clue how I got AVN. 
Dr Blake's comment: AVN, or avascular necrosis, means the bone has been so swollen for so long that the bone circulation has been compromised. Only a CT scan can really make that call in my mind. If the bone fragments from avascular necrosis the recommendation is to remove it. If the bone just gets sclerotic (denser, harder), I have seen these reversed with Exogen bone stims for 9 months and daily contrast bathing. Acupuncture can be a great idea also. 

Have you run into anyone having both sesamoids removed?  I understand the weakening after having one removed, as I can feel it, but honestly you really still have the strength to push off.  But I can for example, still stand on my toes (though it hurts like crazy).  Getting down in the catcher position (I used to be a catcher as a boy/young man), that is nearly impossible though.  Pulling weeds in the yard, impossible.  Running, getting in shape… you know where I’m going here.
Dr Blake's comment: I have attached only one other email correspondence I had with someone, but no idea what is going on. Without the sesamoids, even one, you lose strength in push off, and probably like a hip replacement you can run, but should avoid things that stress it too much. Golf okay, sprinting not, etc. These are long-term preventative, and I am not sure if any that studied patients having both sesamoids removed. My patients that have one sesamoid removed should be in orthotics, or at least some form of dancer's pad, forever. And, they are usually so smart about their feet, you don't have to remind them.

I am really curious how much different it would feel to walk without any sesamoids.  I’ve read that it might be like “walking on a pebble” and that sounds awful.  Then again, the pain is pretty dang bad.  I am envisioning that it would be like crawling with no knees maybe…. And that my metatarsal would essentially drop and it would mess up my gait and probably my knee.
Dr Blake's comment: I think you live with orthotics to protect your feet and you will do fine. It can take some work of a good orthotics person, and they typically start before surgery to make you more comfortable, and then 3 months after surgery when you are really walking again. 

To make matters worse, after the 2nd fracture was discovered I was sent for a bone density scan by the first doctor who removed the sesamoid, and subsequently told I have osteoporosis and extremely low Vitamin D.  I’m 34yo MALE.  They put me on Forteo which they said might help the fracture, but it hasn’t.  I also have my Vit D back up now after being on 10k units/day for over a year.
Dr Blake's comment: Wow, so do not be in any rush to remove this bone. Get it protected. Get your bone health better. Can take 4-6 years to see a much healthier picture. But, more important than your sesamoid, reversing osteoporosis at your age will be life changing as you get older like me. You want your body to have great bones in your 70s and 80s. 

Here are the MRI’s… mind giving me your thoughts on how out of luck I am?  I’m super depressed about it.  We just had a baby and I can already barely keep up with her….

These are the full scanned medical records, but I want to share them with you (I don’t mind pics of them on the blog either but please safeguard sensitive info).  I think you have to run the application to view them.  The links are on my one drive account that is why they have all the gibberish in them, but I can tell you they are legit/safe.
Dr Blake's comment: Please send them to me on a CD if you can. Better for me. 

One more question.  What is the word on implants for sesamoids?  Any talk in the medical community about folks trying to do this? Dr Blake's comment: No, sorry

The patient then had a followup to my questions.

Thank you.  Means a lot to me, I hope it helps others more than anything to get people thinking (more than I did) before they jump into surgery.  If I’d found your blog before I had my first surgery, I know I wouldn’t have had it done.  Patience is truly the name of the game. 

By the way, you asked me about the care I had before the surgery.  It was comminuted and non-acute by the time I realized it needed to be looked at.  I was walking through the pain for at least a year before I looked for a doc.   At that point, he told me it was too late to do much but cortisone shots and a stiff leather orthotic.  I went through the most excruciating 1st cortisone shot.  I can’t describe to you the pain, but it was the worst I’ve ever felt in my life.  The rest of the shots didn’t hurt at all, oddly.  After about 6 months in this orthotic, which had no Mortons/reverse Mortons or dancers pad, I couldn’t take it anymore and asked for the surgery, which he was very willing to perform (said he had done many). 

The surgery took some pain away, particularly pain I had laying in bed (the sheets over my upward toes used to ache, and that went away).  He told me to keep walking after a week on crutches in my leather orthotic and eventually, it would get better.

A few weeks later, the other one broke.   He x rayed it, saw it, stared at me dumbfounded, told me to get a bone scan from my primary care doc, and sent me home with a boot.  (that was my last time seeing him).  Primary care ordered a scan, found the osteo, and the rest is history.  Since then, flare-ups in the sesamoid are regular.  Now that you explained that my current orthotic likely puts more pressure on it, that definitely makes sense.  I might call them to see if it can be adjusted.  I do have a bump insert in the middle, that lifts my metatarsal up though.

Just seeing your reply gives me hope that folks like me aren’t forgotten in the universe.  For a small bone, the sesamoid is life impacting.


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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.