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Tuesday, September 25, 2018

Sesamoid Injury: Email Advice

First off I wanted to extend my appreciation for your amazing blog showing so much 
dedication to helping patients heal. The most frustrating thing for me on my
 sesamoid journey has been feeling like I don't have the right team of doctors/resources
 to begin 
healing from such a complex injury. I am willing to do anything but need to feel I am 
moving in the right direction to stop obsessing and focus on healing. 
Dr. Blake's comment: Thanks for the compliment. I am probably trying to pay off sins 
of the past. 

I am a 22-year-old, active, healthy female who rarely spent any time on the couch
 until recently. I am a Veterinary Nurse who works 8-10 hour shifts on my feet 4 days a week. 

I began having sesamoid pain in my left foot in early May 2018 likely caused by 
hiking at a quick pace, uphill, for long distances. I stayed active and ignored it for
 about a month as it wasn't bothering me until I came home from a two week trip to 
Colorado during which I was more active than ever. After coming home I realized I 
had a serious issue as I couldn't walk up my driveway without pain or otherwise dorsiflex
my big toe without pain. I went online and self-diagnosed myself with "turf toe" and
 taped it accordingly. I wore this tape for two weeks but didn't take more than a few days 
off hiking as it wasn't bothering me much with the help of the tape. While the taping helped 
I kept having the feeling that padding under the area I now know contains the sesamoids
 would have been helpful. After the two weeks in the tape, I was discouraged by not 
having more progress and made an appointment with a local orthopedic/sports medicine 
clinic. I saw the PA at this clinic on July 17th, 2018 and had xrays done on foot. The PA 
looked at my xrays, watched me stand, and felt my foot a bit. She said I likely injured the
 area (no specific diagnosis or fracture) and aggravated it by not resting and made the
 healing process take longer (2+ months at this point). She also said I had pronating feet 
with high arches and needed to do arch strengthening exercises and rest. If I didn't improve
 in 4 more weeks I was told to come back. 

I was encouraged by a lack of fracture and overall it definitely felt better than when
 I initially injured it (likely due to changing my gait and overcompensating) so I still did
not stop exercising and in fact began doing more. From the time of that appointment until
3 weeks ago I continued hiking and began more intense yoga (more planking/lunging/balance)
and started a new running hobby. I wore old, worn out running shoes and did not work up
 to running properly at all. I mostly ran on asphalt and the same trail I was hiking on (hilly)
and did not notice much pain except for when lunging/planking/dorsiflexing the toe, or
 running over a rock in the sesamoid area. In general, the foot was always irritated when
I would think about it but not so much so that I pursued further treatment. 

On Sunday, Sept 2nd, 2018 I went on a run at a park on concrete for the first time 
and then came home to do housework for a few hours in my bare feet. I sat down 
after all this and realized I had a throbbing pain in my sesamoid area that did not 
improve with anti-inflammatories and knew I needed to address this once and for all.
 I began researching and decided upon sesamoiditis as my new self-diagnosis. 
I called the same orthopedic/sports medicine clinic and scheduled a follow-up 
appointment with the surgeon himself but they couldn't get me in until October 5th. 
I attempted some home treatments with varying success that made walking bearable.
 During this time I also started developing issues with my other foot (right foot). 
 Eager to get some real answers and a real treatment plan going with the help 
of a doctor I tried calling another clinic. 

Yesterday, Sept 24th, I went to see the podiatrist specialist. He took did more
 imaging (fluoroscopy) and examined my foot a bit. He diagnosed me with
sesamoiditis, saying that the tendon between the two sesamoids was stretched
 out and having trouble holding them in place. He also said there was a shaded
 area on the lateral sesamoid (the one I have issues with) and he wasn't sure if 
it was a stress fracture or not. He prescribed an air cam walking boot for the foot
 and told me to come back in 3 weeks. I was diagnosed with general metatarsalgia 
on the other foot from overcompensating (no imaging or palpation was done). I asked
 many questions regarding MRI, orthotics, physical therapy, why this happened/gait,
 etc. Basically, he was most concerned with getting me in the boot and addressing
 anything further after rechecking my progress in the boot. He said an MRI may be 
helpful but it wouldn't change his course of action so it is just an additional expense.
 After going home and taking this all in and reading further I had him order the MRI
anyway and will be having that on Friday, Sept 28th. I am still going to keep my 
appointment with the orthopedic surgeon on Oct 5th as well. 

I am willing to do anything but I am getting discouraged that I do not have the right
medical team or diagnosis to begin this healing journey properly. I am hoping after
hearing my story and hopefully reviewing my MRI very soon that you will be able
to help me develop a treatment plan that can aid my current doctors in treating me. 

My main questions are:
- Would you definitely suggest I have the MRI as the treatment plan should be
 different if I have sesamoiditis vs. a sesamoid fracture? 
Dr. Blake's comment: Yes, this injury is 4 months old now and the MRI is the most 
subtle at looking for bone injury. Plus, if it is a fracture, you may need a comparison 
MRI 6 months from now, so might as well get that first one. I love PAs, but they do 
not have the foot training of podiatrists and a lot of orthopedic surgeons. The podiatrist
 in my mind has made the right decision to put you in the cast. If there is a break,
 typically 3 months in the boot is needed, and a bone stimulator as soon as 
insurance allows. 

- If I will be in the boot what physical therapy/exercise would you suggest to
begin to regain the strength I have already lost and likely will lose? Do you have
 any tips for finding a physical therapist who is familiar with this condition? 
Dr. Blake's comment: Most physical therapy places have PTs that like feet. You start
 there by calling and find out who deals with the rehab of foot fractures the best.
 Don't accept "we all do." The restrengthening of the foot and leg will be directed 
by the therapist. You need to protect your sesamoid by not putting full weight on it 
with various exercises. The exercises include single leg balancing, heel raises,
achilles stretches, metatarsal doming, posterior tibial and peroneus longus theraband work. 

- How can I decide if the boot is properly placed to help the fracture (should it be one)?
I can definitely feel the area when wearing the boot and I would still say it is in the 0-2
range of pain but I can't tell if I should dancer pad the sesamoid or not? And if I do pad it,
how can I make sure the padding is right other than by feeling/trail and error? 
Dr. Blake's comment: You can place a shoe insert into the boot, then use lipstick to mark
 the sore area, put the foot in the boot and tighten and walk down the hallway a few times.
 When you take the insert out of the boot, it should be obvious what area to protect
 with the dancer's padding. 

- How should I address the developing issues in my other foot if I am not sure it is the
sesamoids? I'm not sure what to have the doctor evaluate if the pain is just general
tightness and soreness. Also, I'm not sure how/if I could have developed sesamoid issues
 in the other foot if I'm not doing any impact exercising?
Dr. Blake's comment: Most likely strain from placing too much pressure on the other side.
 Some sort of OTC arch support or arch wrap may help. You should be doing daily contrast 
baths for the sesamoid and you can do both feet together. Make sure they evaluate 
everything. Please have your Vit D blood level drawn, because having low Vit D 
can make you start breaking things. 
- I see you have lots of suggestions about healing a sesamoid fracture but if it is
just a tendonitis issue what do you suggest for treating this? 
Dr. Blake's comment: Thus the MRI, since you have to make sure it is not a 
broken sesamoid. The tendinitis is treating with spica taping, icing, some physical
 therapy, metatarsal doming, and FHL theraband strengthening. Some of this will not
 be good with a sesamoid fracture. 

- Do you have any suggestions for doctors in North Carolina who you know have had experience/success with this issue?
Dr. Blake's comment: I am only acquaintance with Dr. Milch in Asheville, and Dr. 
J Barry Johnson in Winston Salem

I'd be happy to wait to get full answers to the questions after having my MRI and 
hopefully having you evaluate it. I am just looking for some encouragement that I
 am moving in the right direction and some advice from someone who is experienced 
with this condition. Dr. Blake's comment: Happy to review. Good luck. It can be a 
long road, but usually successful. The long part of it can drive people crazy, but not
 crazier than me I promise. Create your 0-2 pain level, and do not do anything that
 threatens that as you work through the rehab process. Rich

Thank you so much for your time and dedication to this issue.

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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.