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Wednesday, January 24, 2018

Sesamoid Injury: Email Advice

I have been corresponding with this patient over injury to the sesamoids. Here are some of our recent conversations. 

     I reviewed the MRI which shows you have bone edema in both the tibial and fibular sesamoids, and also the joint, and also the soft tissue. It is one unhappy joint. For mineralization of the bones we need protected weight bearing with orthotics and dancer's pads. You need to be doing icing twice a day and contrasts once a day. You need to see if you can get the Exogen 4000 bone stim, like Harry Potter's broom!! You need some PT to de-inflame the joint, and help with the off-weighting. No surgery since more than one thing wrong and you can not be sure if it is the sesamoid and which one that is bothering you. A new MRI in 6 months to check progress is important. No NSAIDS or cortisone shots since they are bad for bone healing. No surgery should be needed, but it may take awhile for impact sports again. No guarantees, however. Have your overall bone health checked. Questions? Rich

The patient's response:  Wow, that is a lot of problems with my foot. Not good at all. Thank you so much for taking the time to review my MRI. As I suspected, my local doctor told me today that after reviewing my MRI, he wants to put me in a cast 4-6 weeks, preferably go on disability, he fears a possibility of Avascular Necrosis in the sesamoid bones. He even mentioned a steroid shot! Aggh. After the 6 weeks of casting, I should heal then begin retraining my foot to walk. If all fails he wants to remove the sesamoid bones. Aggh. What a way to start the new year. I wish you had a local office nearby. Lol. I asked if PT could help, he said it would just make inflammation worse. 

Dr. Blake's response:    Good luck my friend. See if you can push for a CT scan in 6 weeks to see the true shape of the bones. The MRI is vague sometimes when there is some much inflammation. The CT scan only shows the bones and many times shows things better then they seem. A CT scan is always good when the phrase "avascular necrosis" is being waved around. Please push also for Exogen bone stim. It is a commitment to 9 months of conservative care. Rich

     Hi Dr. Richard Blake, just an update. So today I got my cast put on. I took 2 months off work, and I'm doing my best to stay off my foot 100%. I'm using a knee scooter to get around the house and using crutches to move outside the house. I've been offloading all the weight of my right foot that now my left foot is aching near the same spot in the ball of the foot of my left foot what😥 a bummer. So I still want to get the device you recommend, Exogen 4000. But my doctor says it's to expensive and that it cost thousands of dollars and that my insurance won't cover it. He's right, my insurance won't cover it, so I'm still looking around. I found one on eBay used, does this look like the device? If it is I'm willing to buy it out of pocket. But my question is, could I use this with a cast on? Is this the one you recommend? 

     Doctor, from your personal and professional opinion, do you believe the 6 weeks of cast should fix my issues? I'm really scared of not being able to do any sport activities again like running and hiking. I just had my first daughter 6 months ago and I really want to be able to do sport activities with her. I'm afraid of the 50/50 possibilities my current doctor is giving me. He says there is a 50/50 chance the cast does not work and we need to do surgery. I asked him if he believes if this should work and he says according to all the literature, it's the best approach. I'm afraid he has no actual experience with this sesamoid issue. It's so hard to find a doctor that knows how to treat this. I feel like a guinea pig with my doctor. 

Sorry for my rant and for bothering you, but I'm at a lost right now. I truly do appreciate you taking your time to even read my emails.

Thank you,

Best regards,

Dr Blake's response: Any of the Exogen 4000 units should work. You are getting it to start a one year process of healing, with the 6 weeks of casting just the start. You should be at a 0-2 pain level and you then advance to a removable cast weight bearing for 2-4 more months still keeping the 0-2 levels. The bone stim should lay on the top of the big toe joint twice daily for 20 minutes so the cast would have to be opened up by the doc or you wait until the cast comes off. See all the advice in this blog on the treatment post-boot. Rich Good luck!!


  1. Sounds so much like my story. Email me and I will see if I can help you. Couple of things. Call the Exogen people directly. My insurance would not cover it and they let me get one for under 300 bucks. I was in a wheelchair this time last year. A combination of Doctor Blake’s advice and finally finding a great PT after going through 4 of them is what saved me. The orthopedic doctors were not helpful to me personally until I found one that worked closely with the PT.

    1. HiJohn...I am from India. Been through this injury ...wheel chair and all. Got out of it with Dr.Blake's advice and help through this blog.Is it okay if I email you-to learn some more on dealing with this?

  2. Btw I did not have surgery. The surgeon who knew the most about it said that would not be the thing to do in my particular case. I had stress fractures and AVN.

  3. Dr Blake,
    Could you please verify the position of bone stim for sesamoid fractures? I know, every case is different, and in this case (cast?) you say it should lay on the top of the big toe. I use the opposite side, just below my fibular sesamoid. It is less convenient, but I assumed it was better to get closer to the injury(pain). Thank you!


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.