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Friday, February 15, 2019

Sesamoid Pain with Fragmentation: Email advice

Hi Dr. Blake,

I came across your website when researching sesamoids. Apologies in advanced for the long email but i hope you can read through it and provide me some guidance.

I have been dealing with my sesamoiditis since May of 2018. It started with improper Cycling equipment (tight shoes, wrong cleat positions and wedges/shims). The pain came and i removed the wedges, got proper shoes and proper cleat fit and continued cycling for the most part pain free just inflammation of the toe and pain during walking or bending of the toe.

After sometime i went to the first of 2 doctors and we did the dancers pad and a small sandal/boot for 2 weeks with dancers pad without cycling, i then convinced him i wanted to bike because of the carbon shoe in cycling and high arch support insole, cycling would not be an issue. He agreed and i was back on the bike training as usual, -  i do it competitively so its around 2 hours a day almost every day and longer on weekends (4-5 hours). Also some gym workouts usually focusing on leg strength. It didn't get any better and we tried an injection of cortisone on the foot and continued as is, cycling almost daily and using the dancers pads.
Dr. Blake's comment: There must be a better way to train so you can have more recovery time for your body, even when you are not injured. Without recovery time in sports, you always run the risk of tissue fatigue and resulting injury. It is a fine line. Do you have a cycling coach? What is his philosophy?

I got an x-ray and an MRI and all it showed at the time was inflammation no fractures. After some time i decided to see a new doctor recommended by a friend who put me on Hokas and  an Atrex orthotic for my work shoes (office job). He also got me a more serious walking boot (one you would get for fractures) up to the knee and i got completely off the bike for about a month due to an accident, during this time i only wore this boot and did some aggressive Epson salt baths and daily icing.
Dr. Blake's comment: Hopefully this is the start of your healing!!

Going back to the doctor, we did an Xray and it showed again the sesamoid bones were good no fractures but there was still swelling, so he took me off the boot gave me a lot of confidence that cycling was not an issue and to continue cycling at full strength and use orthotics and good shoes when I was not on the bike so i did. The inflammation never went away but i was pain free on the bike so i continued cycling and wearing the shoes as advised and attempted some nighttime walks on the Hokas.
Dr. Blake's comment: For those who do not know Hokas, they have a roll in the forefoot so you do not have to bend the metatarsals. There are various types of Hokas, and some have the roll in a good place for an injury, but some do not. Some experimentation with various Hokas may be needed. Typically, I would also allow you to cycle if you are keeping the pain between 0-2, and really work hard on protecting the sesamoid area and controlling the inflammation. Were you pain free, or at least 0-2 in the boot, that is the goal?

A couple of weeks ago after a day of walking at Universal Studios park my feet were in some serious pain, i also started cycling in dirt/off road about a month ago which caused more stress and i would feel it more on the bottom of the foot. 
Due to the higher than normal pain during universal i went back to the doctor where the xray showed now a fragmentation of the inner sesamoid. And this is where i am at now.
Dr. Blake's comment: Wow, that is very disappointing. I am surprised nothing showed on previous xrays. When you said the MRI did not show sesamoid fracture, but did show swelling, was any of that swelling in the sesamoid (a possible sign of a stress fracture)?

At this point i am dealing with some neck/lower back issues and i am off the bike again while i figure out that situation. So again i can get off cycling and let the foot relax heal a bit but its not looking good for me. I am now considering surgery due to this new development of the fracture. The doctor described is no blood flow in the area causing it to fragment. From your experience since my main focus is cycling and on the bike i don't really have pain should i continue trying conservative treatments while returning to bike competitively.
Dr. Blake's comment: I have never found that if you are damaging something you have no pain, unless you have masked the pain with pain killers or cortisone shots. Definitely stay away from cortisone injections. Next time you see the doc ask them to show you the MRI images that show that most swelling so you can email me. Also take a photo of every x-ray image, first to now, and email so I can appreciate the progression. My gut level is cycle, boot rest of the time in creating 0-2 pain level, Exogen bone stimulator for 9 months, contrast bathing every night for circulation, and acupuncture for circulation if you can get it. Also get Vitamin D levels, and if you are low, bone density.
What is your experience mainly around cycling and this injury, if i were a runner things would be different but how much damage am i causing by cycling on it and at this point with the fracture of the bone and the lack of blood flow causing it to fragment am i doing or have i already done permanent damage down there? I know without imaging it will be hard for you to assist me but any insight you can provide will be helpful.

Thank you so much
Dr. Blake's comment: You are welcome. All was okay in your story until the fragmentation. If insurance is okay, get a CT scan of your foot which shows the bone so much better. Again, cycling should be fine if you can keep the pain level between 0-2, and you do not have any increase in pain afterwards. Hope this helps some.

And then the patient responded with an Important Decision!!

Thank you so much for taking the time to write back to me and for your recommendation. This injury is frustrating to say the least, it's beaten me and I have decided on surgery to remove the lateral sesamoid. Surgery is scheduled for March, hope to have a successful surgery and recovery.

And my response!!

Good luck! If you want to write in 6 months about your surgery experience, it will help many patients! Remember after one sesamoid is removed, you always have to protect the other one. Rich

1 comment:

  1. In cases where a bone stimulator is indicated but insurance won't cover it or the patient does not want to wait 3 months to begin, the can affordably rent or purchase an Exogen system with a warranty from


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.