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Saturday, December 29, 2018

Sesamoid Injury with possible AVN: Email Advice

Dear Richard,
As so many others I found your blog and I agree that it is one of the most valuable sources about sesamoid problems. Thank you so much for providing it! You are truly one passionate doctor. As many others I am suffering from sesamoid pain and I would be very thankful if you find the time to answer to my message.

The entire black sesamoid (black is normal for this image) is seemingly demineralized and has this white shape

  • 45 year old athletic man, working as a professional mountain bike guide in the summer (not riding with cleats!). Office job in winter time.
  • First subtle pain at the ball of the foot started around 1.5 years ago when wearing fancy shoes in the city. Plus some pain on the side of the big toe joint, mostly when pressing on it.
  • First saw a doctor in October 2017 (which is 14 months prior to this dictation). X Rays were done, showed no arthritis in the big toe joint. Doc said it is an inflammation in the joint plus the tendon of the lateral sesamoid. Prescribed Arcoxia pain killers for one week, rest and orthotic insoles with stiff extension + gait analysis. Approx. 4 weeks later I started carefully with cross country skiing again, I cannot remember major pain so I continued sports with only very little discomfort. Dr. Blake's comment: So, this was the beginning of it bothering you, but it was manageable. 
  • August 2018 aggravation of pain on the side of the big toe joint and at the ball of the foot when biking and walking. Difficult to walk normally. I began to walk on the side of the foot not trying to bend the big toe. Dr. Blake's comment: I am assuming it was fine, or at least slight between November 17 and August 18. 
  • End of September new appointment at doctor, ordered MRI. Diagnosis = the lateral sesamoid has problems with the blood supply. New orthotics and rest prescribed.
  • November 2018: went to 2nd doc. He looked at the MRI and said the lateral sesamoid is „mushy“, dead and damaged (AVN). Very pessimistic, also about surgery. Started shock wave therapy with this doc on Nov 22nd cause I found good case reports about it. Also send MRI to a friend/radiologist who said there is bone marrow edema but no fracture and only maybe AVN and I should try shock waves. Dr. Blake's comment: Yes, conservative management is fine at this stage. I am not qualified to assess shock wave for this however. My read today would be CT scan ASAP to see if you truly have AVN, then Exogen bone stimulator, and contrasts and acupuncture to get the bone healthy over the next year. Weight bearing is crucial for mineralization. Assessment of Vitamin D levels to make sure you are not deficient. Even bone density especially if the Vitamin D is low or low normal. Experiment with Hoka One One shoes, off weighting orthotics, biking shoes with embedded cleats, all in attempt to have you do as much weight bearing while keeping the pain level between 0-2. 
I am attaching some photos of the MRI. If helpful I am happy to send you the full pictures via wetransfer/dropbox etc. What is your opinion about the condition of the lateral sesamoid? AVN? Fragmented? Or just edema and still in one piece? Dr. Blake's comment: Please send me a disc of the MRI and CT scan when done at 900 Hyde Street, San Francisco, CA, 94109. 
My plan of action is following:
  1. Continue shock wave therapy (6 more sessions 3 radial and 3 focussed, then rest and give the bone time to revitalize)
  2. Wear insoles at all times in stiff soled shoes (longer walks 5 mins+ in heavy mountain boots). Will try dancer´s pads. I read your advise not to be barefoot at all, however I have no pain standing barefoot on my foot? It is even more comfortable than in shoes. Dr. Blake's comment: With general rules, you have to see what applies to you. Listen to Your Body and how to attain the 0-2 pain levels. Sound like Barefoot for you is just fine. 
  3. Contrast baths daily Dr. Blake's comment: Very important to flush out that bone edema. Try twice on weekends. 
  4. Vitamin D + 750mg calcium daily
  5. Taping the big toe joint so the joint is stabilized when longer walks are required.
  6. Massage the area. Passive stretching of the big toe helps, but I read not to bend the big toe at all? Can I bend it passively? Dr. Blake's comment: This is one of those that has to do only with pain levels. Typically you restrict the toe motion while exercising to limit the pain, and you keep it loose when you are at rest. 
  7. Thinking about hyperbaric oxygen therapy. Have you any experience with it? Dr. Blake's comment: If you find an article supporting its use in AVN, I will run it by the doctors here that run our HBO program. 
  8. Make a control MRI in 3-4 month (6-7 month after first one). If no progress to be seen consulting foot surgeons about surgery options. I have heard very contradicting opinions about the surgery. People who are totally happy and returned to sport activities and others who had even more pain. What is your experience? I am afraid about losing my profession and outdoor life. Dr. Blake's comment: The few patients I treat with sesamoid surgery typically are happy with the procedure, so I do not feel bad about recommending it if it comes to that. The failures are from bad luck, bad surgery, inadequate evaluation of what is causing the pain, etc. The inflammation in your MRI is excessive and will distort the viewing of the bone and the decision making. I would get a CT scan now, start Exogen, contrasts, pain free activities, perhaps acupuncture, get another MRI in 6 months, and probably another CT scan in 12 months. Some of my patients cycle with the weight on the pedal not the ball. See the posts on how to design weight bearing floats for the big toe joint so you can do yoga, Tai Chi, stretches, etc without irritating the sesamoid. 
Is there anything else you can recommend me? I read you are recommending the bone stimulator, does it make sense in my case? Bioventus Exogen seems to be available here in Germany.
Richard thank you so much for your time and hopefully short answer. Of course you can publish this message on your blog.
Now I wish you a merry Christmas and hope you will spend it with your family and friends and that you are having a good time!
Best wishes from Germany,
Dr. Blake's comment: Good luck to you my friend!! I hope this helps you. 


  1. Hi. Did this patient have successful results with shockwave therapy? I started shockwave therapy 2 weeks ago. I have AVN and fragmentation of the fibular sesamoid. So far, it seems to help with inflammation in the area. Thanks!

    1. Hello. Unfortunately the shock wave therapy did not solve my problem (AVN and fragmentation of the fibular sesamoid). I am following all therapies suggested by Dr. Blake (bone stim, orthotics, contrast baths, Vitamin D etc.) and there has been some progress but it still hurts.

  2. Hi, I'd love an update on this patient! How are you doing now?
    I have AVN of my fibular sesamoid and have been recommended shockwave therapy. Thanks!

  3. Hi I am the original patient. After treating the sesamoid extensivley for more than a year now, it looks much better on the images. The bone is better mineralized and the bone has consilidated. There is just one fragment near the joint surface that has not been incorporated. Bone marrow edema still visible. I still have pain, but it is much better. I am ok in daily life and can do 2-3 hour hikes in stiff shoes and orthotics. I will now slowly try to start with sports again (cycling etc) and see how I am doing. If it is not ok in 6 month I will take the final decision to remove the bone or live with some handicap.

    1. thanks a lot! would love to get an update in 6 months, if you have the occasion :) I am dealing with sesamoid AVN myself, in fact Dr Blake just posted my case on his blog yesterday. We can share learnings!


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.