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Friday, January 5, 2018

Sesamoid Pain: Email Advice

Dear Dr. Blake,

I am a runner who partially tore the medial band of his plantar fascia in March 2017. Started a run/walk comeback in Nov 2017 and developed some sesamoid pain around Thanksgiving. 

Traditional X-rays were ok about 20 days after onset of pain, but the improvement has plateaued after using dancer’s pad for last four weeks or so. Had an MRI on Jan 2, which showed sesamoiditis. Report is attached. However, everything I read in the literature suggests that MRI is not great at showing how far along the continuum of bone injury one is and there can be different treatment paths that are best for different degrees of the catch all “sesamoiditis”.
Dr. Blake's comment: First of all, the MRI report showed healing of the tear!!! Hooray!! It showed some wear and tear of the cartilage of the big toe joint (mild arthritis) and showed swelling, no sign of a break, in the fibular sesamoid. In my mind, you have to put sesamoid swelling in the category of a stress fracture to treat the worst case scenario. That sesamoid swelling, without a sign of any fracture lines, could be a stress fracture or bone bruise. Sesamoiditis just means there is inflammation at the sesamoid from any cause. The injury to the sesamoid area has gone deep enough to affect the bone. Therefore, the bone must be mechanically protected with off weight-bearing padding, and there must be enough decrease of big toe joint bend to create a healing environment: normally 0-2 pain levels. This is how you know how much or little to treat, what does it take to get to 0-2 pain? This does not change if you do not know if it is a stress fracture. Without evidence of a fracture line, an Exogen bone stimulator is usually not utilized or approved by insurance. I love that to strengthen the bone, even if just bruised. You may be able to get via the bone changes in the first metatarsal which you do not know if new or old. If it is a new cartilage injury, a bone stim would be wonderful, as you could be looking at microfracture surgery. It was injured because it is one of your personal weak spots, so why wouldn't you want it stronger. Contrast baths daily are crucial with bone edema to remove the swelling on a consistent basis. Helps prevent avascular necrosis, bone death from too much swelling cutting off normal circulation, along with a bone stimulator. Acupuncture would also be great if the practitioner knew how to get the blood flow greater in a small bone like this. 

I live in the Chapel Hill, NC area and have been to multiple podiatrists, who all gave me bad advice on how to deal with chronic plantar fasciitis I had leading up to the tear. I realized this after reading all the research papers on a plantar fascial injury. This is why I am reaching out to you as someone who seems to be up to speed. 
Dr. Blake's comment: I am getting older by the minute, so you do not realize how good that little compliment makes me feel. Thank you. 

Would you be willing to look at my images and recommend how I treat this? The MRI data are 144 megabytes, but we may be able to figure out a way to get the data to you.
Dr. Blake's comment: Sending a CD always works. But patients do use Dropbox for my google drive. My address is 900 Hyde Street, San Francisco, Ca, 94109. Good luck Rich

Thanks very much for your time and Happy New Year!

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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.