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Tuesday, March 20, 2018

Tibial Sesamoid Fracture: Email Advice

Hi Dr. Blake,

I have been reading your blog and was hoping to get your advice on a tibial sesamoid fracture I have been dealing with.

I am a 27-year old female living in Japan (from bay area originally).
I am currently trying to decide if I need to return to the U.S. for treatment.
Please see a brief history below.

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May 2017: Pain began
October 2017: Pain was so unbearable I could barely walk. Diagnosed with a tibial sesamoid stress fracture, and poor biomechanics (forefoot varus/overpronation/flat feet).
Feb 2018: Still stress fracture. In fact, it seems the fissure/crack has progressed more than October! Swelling still present.

Since October I stopped all exercise, offloaded the fractured region using custom orthotics, and tried taping the sesamoid area. I tried physical therapy also.
The past few weeks the situation worsened so I have been working from home and barely leaving the house. 

The most recent doctor said it may take another 6 months to heal and to keep offloading and continue physical therapy. If not, the next step would be a cortisone shot, and ultimately surgery.
However, even with my extremely sedentary efforts, the bone is not fusing together.

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Sorry for the lengthiness!
Podiatry (not recognized as a discipline here) and foot orthopedics, in general, are so far behind in Japan, it has been difficult to get help.

Do you have any advice on the above/alternative treatment options?
I could send my MRI/X-ray data if needed.

Thanks!

Dr. Blake's comment: 
     We will have to have a running dialog which I will keep as part of this post. Any imaging you can send would be great. Try and use WeTransfer since that site seems to work. Even a photo of the most current xrays would help for now. 
      Any investigation into sesamoid healing should involve bone density screen and Vit D, so see if you can get that over there. 
      One of the tried and true methods of healing anything is an attempt to create a 0-2 pain level. Most need a removable boot to stop the bend of the toe. At times you have to use 1/4 inch adhesive felt to off weight the sesamoid inside the boot. Or, at least, use the orthotic inside the boot. What does it take now to achieve that goal is crucial to find out? 
     There is always three types of pain that we deal with after this long from the start: the mechanical pain of the break itself, inflammatory pain from the healing process, and neuropathic pain from the hypersensitivity or protection of our bodies to avoid pain. So, your daily treatment should involve mechanical floating of the sesamoid probably around 1/4 off the ground, anti-inflammatory with ice and contrast bathing, and nerve desensitization with pain-free massage, Neuro-Eze topical gel or something similar. 
     I hope this gets us started. I am sorry for your problem. Rich

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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.