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Friday, January 11, 2019

Sesamoid Pain and Trying to Avoid Surgery: Email Advice

Dear Dr. Blake, 

I work in the US but my home is Brazil. 

I just came back from vacation in Brazil with disturbing news: the podiatrist there told me I need to get surgery on my right foot, as my two sesamoids in my right foot are compromised. One of them is split in the middle and the other one is worse, fragmented (see below). 

After looking for doctors over the Internet I came across your name and website. I have also noticed that you are able to treat patients with less invasive treatments, avoiding surgery. The prospect of a surgery is really difficult for me for different reasons: (i) my family does not reside in the US, so it would be difficult to recover and work at the same time; (ii) my work involves a lot of travelling; (iii) any invasive approach scares me.

If you believe there are any chances of curing my condition without surgery, I would like to talk to you. Could you please look at the CT scan results below? I would truly be grateful for any inputs and/or ideas you might have. 

After researching online I found that a vitamin D level exam and a bone density level exam should ideally have been carried. Neither of them were requested to me. 

Below please find the CT scan results (translated by myself from Portuguese). The exam was undertaken at Albert Einstein Hospital (considered the best hospital in the southern hemisphere)  
A study carried out using the fast spin-echo technique, in heavy multiplanar cuts in T1 and T2, pre and post-paramagnetic contrast, showed:

·         Attitude in hallux valgus.

·         Lateral sesamoid with fragmented appearance, with irregularities and bone sclerosis.

·         Medial hallux sesamoid with bipartite morphology with bone marrow edema suggestive of overload.

·         Other bone structures with normal spinal morphology and sign.

·         Minimal metatarsophalangeal joint effusion of the hallux.

·         Lack of significant joint effusion in the other joints.

·         Tendons without significant changes.

·         Fluid distention of the intermetatarsal bursae between the 2nd and 3rd spaces.

·         Obliteration of the plantar adipose cushion underlying the heads of the first, second and fifth metatarsals, indicating load points.

Thank you so much for your help and support. I truly appreciate it! 

Best regards,

Dr. Blake's comment: Thank you so very much for writing. As I write this, I know it must be late on the East Coast of the US. It probably does not matter at this point how you did this, but you have injured the sesamoids. Okay. Some doctors take them out after 3 months of treatment, and others like myself drag their feet delaying and hopefully preventing surgery. It is a whole spectrum. You really have to treat the injury as if you just got it. Depending on your insurance, an exogen bone stimulator distributed through Bioventus works well most of the time. This is a 9 month assignment to get the bone strong. Contrast bathes 4-7 nights a week will act like a deep flush to the tissue. Order Dr. Jill's dancer's pads to protect the sesamoids yourself, along with learning how to do spica taping, and cluffy wedges. Make sure your winter shoes are stiff to help immobilize the tissue as many hours a day as possible as you are trying to create a 0-2 pain level environment for healing. See my buddy Dr. Steve Pribut (link below) in DC for local hands on. Keep me in the loop. Good luck. Rich
I know there are some good articles supporting shockwave therapy as a noninvasive treatment for sesamoid problems, but it may be just too costly.

1 comment:

  1. If your insurance won't cover an Exogen, you can get an affordable, pre-owned unit with a full warranty from Best of luck in your healing journey!


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.