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Monday, January 7, 2019

Sesamoid Fracture: Email Advice

Dr. Blake,

Happy Holidays! Thank you so much for all the time you’ve put into this blog! I’ve read through many posts regarding sesamoid injuries, and there's more info here than anywhere else.
My 15 year old daughter fractured her sesamoid and her podiatrist hasn't known what to do, so I was wondering if you could help her out.

This is what she said:
In october, I felt a pop in my foot during cross country practice, and ended up in a lot of pain. I ran one final 5k a few days after, and went to homecoming in heels that night. Horrible idea. My foot was bruised and my pain level was about an 8 (10 being the most painful).

I went to the podiatrist, who said I just had sesamoiditis and could run again in a week. I took an entire month off just to be safe, and when I went back to the podiatrist because I was still in pain, he said it turns out that I had a fracture. I wasn't given a boot to immobilize it.

A few weeks later I felt another painful pop in my foot, went back to the podiatrist, asked for a boot, and here I am. I’ve been wearing the boot to immobilize my foot for the past 2 weeks and my pain level is at a 0, but it is very visibly swollen. I've been icing 3x a day and am going to start contrast baths as you recommended. I bought calcium supplements and am taking vitamins as well.
Dr. Blake's comment: So you are now starting about 3 months of immobilization with 10 weeks to go. Now until Feb 15th, the boot should be your friend in creating a consistent 0-2 pain level. The icing twice a day, and the contrast baths each evening are important. Gentle massaging the area with your palms 2-3 minutes three times a day with arnica, mineral ice, hand lotion, just to desensitize the area. Make sure you bike a lot of leg strength. Unfortunately 30 minutes of running is equivalent to 2 hours of biking outdoors, but probably one hour on a stationary bike.
     This part is the easy part. Soon, the podiatrist must make a good pair of custom orthotics to protect the sesamoid. These should be ready for you at 8 weeks into the immobilization, the earliest time to start transitioning into orthotics and athletic shoes. It is imperative you keep the pain level to 0-2 during this whole process. Sometimes, as you wean from the boot, you need to wear Hoka One One shoes or Bike Shoes with embedded cleats.
     Remember also to have your Vitamin D level tested as this is a frequent cause of stress fractures. If the normal range is 30-80, I want my athletes around 55. Also, a good healthy diet is crucial to get the building blocks for fracture healing.

I am just wondering if there's anything i'm missing. Also, how would I get an exogen bone stimulator? I assume I would need a prescription. I can also send you my MRI if you would like to see it. The radiologist confirmed that I have a fracture.
Dr. Blake's comment: Yes, you can send it to Dr. Rich Blake 900 Hyde Street, San Francisco, California, 94109. The podiatrist or your pediatrician can start the Rx process for the bone stim from Bioventus called Exogen. Hope all this helps. Rich
Here's the MRI report:

Technique: Routine MRI images of the right foot
A marker has been placed beneath the medial forefoot and great toe to indicate the site of clinical concern. There is confluent marrow edema within the medial sesamoid bone indicating a nondisplaced vertical fracture or stress fracture and edema in the underlying soft tissues. The lateral sesamoid bone of the the great toe appears normal. No metatarsal stress fracture or suspicious lesion is identified. Normal signal is present within the muscles. No Morton's neuroma or ganglion cyst is evident. The flexor and extensor tendons are intact. There is no plantar plate tear.
1. Nondisplaced fracture or stress fracture of the medial sesamoid bone of the great toe and edema in the plantar soft tissues.

Again, thank you so much for the blog!

Happy Holidays!!


The patient's mom sent me the MRIs for review. Here is my response:

 I had a chance to look at the MRIs. So, clearly there is a nondisplaced stable fracture of the medial (also called tibial) sesamoid which needs some protection going forward. You can protect it in different ways as you blend the Immobilization phase into the Return to Activity. The protection can come from Dr. Jill's dancer's pads, cluffy wedges, spica taping, custom orthotics, and removable boots. The boot is to prevent her from stirring it up and some of the patients only use while walking great distances (probably 4 hours a day to rest the tissue and trying to decide which 4 hours are the most meaningful. With return to sports, you have to see if sometimes she can wear an orthotic, say in her conditioning, and sometimes Dr. Jill's padding with cluffy wedges with or without spica taping. If patients feel good, they first stop taping. I would experiment as you place her on a 6 week return to full activity program. Each week she adds more and more stressful ball of the foot activities until she is at full speed and full activity at 6 weeks. It is the push off of most concern, so speak to the coach and see how this can be arranged.
     The difference between the 2 MRIs are minimal, which is to be expected. After the first MRI, I wait 6 months to repeat and go solely on the patients feel, and if they have to limp at all (a big no no!) It is usually a mistake to remove the sesamoid protection for the next several years. Part of me saying that is because I do not know her foot mechanics (some patients have 3-4 reasons that their sesamoids can be stressed) and part of that because I know sesamoid padding will not inhibit her ability to perform at the highest level.
     Contrast bathing remains the best home treatment to flush out the sesamoid of swelling that can cut off the circulation. Try to average 3-4 nights per week, and simple ice pack after workouts. Hope all this helps. Continue to listen to the pain, even if she is competing again. 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.