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Monday, August 12, 2019

Sesamoid AVN: Email Advice

Thank you for the email and song! And thank you for the blog. I know you aren't really accepting new messages currently but I'm emailing you my issue more for myself to track my thinking than in expectation of feedback. I didn't have a clue what a sesamoid was until a month ago and now I've read every scrap of info on your blog page on it! Mostly I'm just terrified of not being able to be the active person that is my whole life.

Background: 37 y/o male - 5'11, 190lbs, extremely active athlete - activities include swimming, biking, running, soccer, surfing, snowboarding, hiking, backpacking. 2 small kids at home that I'm very active with.

** February 2019 felt mild pain and stiffening of the big toe in left foot for a few days - thought it might be related to gout due to previously being diagnosed with hyperuricemia and having family history. Tried tart cherry extract and turmeric supplement - gave bad stomach issues so stopped.

**Feb 21st - contact GP as pain has increased. Started on 100mg Allopurinol and 3 x 800mg ibuprofen daily. Acute pain subsided by early March and was able to resume normal activities, stiffness in toe remained.

**Mid March injured plantar fascia acutely playing soccer - worried about chronic plantar fascitis as pain did not subside for over a month - pain in heel continued through early May and dominated foot concerns.

**Early May - saw sports med doc for the heel and mentioned toe pain. Doc thought toe was arthritis based rather than gout due to minor joint narrowing on X-ray. Heel pain cleared up for the most part within a month with self-care and basic PT exercises.

**Early June - pain in toe worsens again (bad flare?) got referral to podiatrist. 

**Mid June - podiatrist diagnoses early osteoarthritis in 1st MTP toe joint from x-ray of left foot and sesamoiditis causing pain in ball of foot from pressing into sesamoid bones with his thumb. Notes bipartite tibial sesamoid from x-ray images. 
3 weeks of one a day Meloxicam (NSAID) and dancers pads to be worn in shoes. While on Meloxicam the pain is greatly diminished and am able to complete normal activities. Still feel the dull pain/stiffness in ball of foot though. During the time I was on Meloxicam I was able to play soccer with relatively little discomfort and went on a short backpacking trip with some minor discomfort in the sesamoid area. Biking and walking with the dancers pads (Dr Jills) was fine with minor stiffness feeling in sesamoid area. Discomfort never completely went away.

**Mid July - After a week of being off NSAIDs the sesamoid area flared up badly again. Tender to touch, difficult to walk on without pain. Favoring outside of foot and hobbling. Right big toe area has some minor stiffness also. I can't figure out if I'm freaking out unnecessarily. I haven't played soccer or done anything seriously aggressive on the foot and have continued to wear the dancers pads - I have however been barefoot a lot.

Current treatment plan:
Ice 3 x a day
Figuring out dancer pad/ inserts and shoes to ease pain while walking
Contrast baths every other day
Try to keep off toe and avoid pain (keep 0-2)
Follow up podiatrist appt July 29 - request MRI to rule out fracture vs bipartite and visualize inflammation; discuss steroid shot options (next step according to DPM).

Other things in my head:
What's the situation with surgery? When would that be considered? Who would do this?

NSAIDs seem to help - does this indicate an underlying inflammation issue - any other way to get that under control? Long term use of NSAIDs problematic?

Concern about injection? What kind of injection? How long to stay inactive? Need a plan for returning to exercise.. PT person to work with? Need to be able to do vigorous exercise - surfing in bare feet, skiing, snowboarding etc. Can give up soccer and running in favor of biking and swimming as a compromise but REALLY DON"T WANT TO GIVE UP BOARD SPORTS

Custom orthotics? Worth doing that versus trying to figure out what's needed on my own with customizing dancer pads and superfeet supports etc?

Spica taping? Helpful?

Toe spacers? Wider shoes?

Sesamoids out of alignment? Rolfing? Re-aligning sesamoid bones?

If you made it through the whole email then thank you!!! Even if you don't have time to reply. As I work through this issue I'll leave a comment on one of your blogs to let people know what helped and how I got through this.

Thanks again,

MY Response: Thanks for the email. Yes, life is too hectic for me until December, so I am giving the blog a rest. I did read the history. You need to get an MRI, and I would be happy to look at when you do. If your insurance will not get, they are typically $600 in the Bay Area. You want the MRI magnet around 2.0 Tesla or higher. Stay non impact for the next 6 months, or at least until the snow starts falling. Swimming, biking, elliptical if you have the padding in your shoes okay to off weight the sesamoids. You can just treat this as a fracture with 3 months in a removable boot with dancer's pads. The boot needs to drive the pain consistently to 0-2 for 3 months, and then it is 2-3 months to wean back into normal shoes. Bike shoes with embedded cleats or Hoka One One shoes can help the gradual transition. Masking pain with NSAIDs or cortisone is not smart. You have to feel the pain. No shots please. See if you can get an Exogen 4000 unit on ebay relatively cheap. 2 times daily with the bone stim for 20 minutes. Hope this helps some. Rich

The Patient's Response:

Thank you Dr. Blake - I've just re-read all of the blogs on your site pertaining to sesamoid AVN. I've requested copies of my MRI and X-rays which I'll mail to you this week at the following address. Is this correct?
Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109 

I've convinced my Podiatrist that we should do bone stimulation so he is ordering the equipment for me. I'm not sure what his exact plan is but he is talking about a period of non-weight bearing and immobilization of the foot. Just wanted to check in with you regarding that as I've read in some of your posts the importance of continuing to exercise and be weight bearing with no pain (0-2). 
1. Is a cast or boot for a period of time a good idea for this treatment?
2. I have already established low/no-pain environment over the last few weeks with modified activities and have continued to exercise with dancers pads/arch supports/ spica taping etc. to ensure pain level (0-2). Is this enough?
3. I continue to walk barefoot in my house carefully and this has not caused me any pain - is this ok?
4. Other things I should be thinking about - calcium and vit D supplements? Dry needling? Contrast baths?

Thank you again for your time. I'll absolutely make the $50 donation to your blog as I've found the information there and your email advice invaluable during this time.


Thanks again for the donation. It means alot, and means I can do this type of service more. I have a big project to complete by December 1st so I want to make sure everything is answered for you. The address above is correct. I love the boot and you can float the sesamoid way off the ground for no weight bearing with dancer's padding and metatarsal bars (all podiatrists to my knowledge understand this stuff). Way off the ground for non weight bearing is only 1-2 mm with the weight on the metatarsal and big toe. I prefer some protected weight bearing as long as the patient swears the pain is 0-2 since I think it helps strengthen the bone. Since you are at 0-2, stay there for the next 2 months with little change other than slowly increasing distances. Adding stationary bike is great for cardio. Barefoot is fine with no pain, but that goes bother every health care provider. See how you feel in some Oofos sandals with Dr. Jill's Gel Dancer's pads. AVN is treated with bone stimulation, contrast bathing, making sure bone health is great, and protected 0-2 weight bearing. The Big 4. Good luck my friend. Rich

1 comment:

  1. For anyone that might read through this with similar problems - I am the patient in this email correspondence. As I write this comment I'm 6-months further along - it's Jan 2020. I'll update again in another few months. I spent about 6-weeks non weight bearing on my left foot and then another couple of weeks after that in one of those big boots you can walk in. I spent 3-months through to November contrast bathing every night and I've been using an Exogen bone stimulator on my left foot every night for the last 5 months. After the boot I transitioned into New Balance Fresh Foam More shoes with some home made orthotics to off-weight the sesamoids.

    For whatever reason over the summer my right "good" foot also became painful in that big toe region and I freaked out and ended up getting that MRI'd as well. It continues to be sore in that same sesamoid big toe joint area but the MRI showed up pretty benign. I've continued to exercise throughout although being pretty conservative with my activities. I haven't tried pushing it too hard yet but I'm curious to see how my feet handle more aggressive activities.

    My current status is a pretty much constant low level discomfort and stiffness feeling in both feet in that sesamoid/big toe joint area when I'm walking. It ebbs and flows a little bit but I haven't had severe flare-ups at all in the last 6-months. I've done a little walking bare foot, played with my kids fine, swim regularly even pushing off walls, bike rides, done a couple of short hikes, and worn dress shoes for work on occasion. It's not perfect and I haven't done any running or played soccer at all - the background level of things doesn't really feel much different to when I was diagnosed with these issues 6-months ago - but it was really the flare-ups and not being able to walk without hobbling that was the most debilitating. 

    I'm not willing to take any more aggressive steps like surgery at this point. Especially considering my right foot acted up as well and there's not really any way to pinpoint exactly what the problem is with that. I was taking a lot of anti-inflammatory meds to be able to function before I got formally diagnosed with this issue last summer. I'm not taking any now and so I at least feel like I'm establishing a good background level of functionality. It's concerning to me that the background level of pain and discomfort hasn't really improved or changed at all in the last 6-months but at the same time I'm working on finding the balance with how highly I can function activity-wise. My next step is to get some custom orthotics and further define what kinds of footwear can help me diversify into increased and more aggressive activities. 


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.