Sesamoid Fracture: Email Advice

Dear Dr. Blake,

I came across your blog and since sesamoid injuries are so tricky, I thought I would reach out to you. It looks like you have been in the field for awhile and hopefully, you can give me the best course of action.

I was diagnosed with a medial sesamoid fracture on my right foot 7 months ago, about two months after running 1/2 marathon. I’ve been a runner all my life and have done a number of races. Im aware not to overdue things and had a running schedule designed by my PT to do a mix of runs and cross training so I was surprised to have sustained a stress fracture. I’m 39years old. 

I went into a boot for 5 weeks, and then slowly weaned out of the boot for a few more weeks. I was still having pain with walking, so  got another scan that showed delayed union, some healing but not fully healed. I went back into the boot for 3-4 weeks, and then has been walking in sneakers with orthotics. I was doing great until 2 weeks ago when the pain came back. An MRI showed edema, persistent fracture, a cystic intraosseus cyst  (which was on prior imaging as well), chondral loss, and partial ligamental tear of MCL. Full results below.

I saw a surgeon who has had good results with sesamoidectomies although I’ve heard that surgery could lead to further complications. I also have hallux valgus on my right greater than my left foot. Does surgery sound reasonable at this stage? If so, what should that entail, removal of the sesamoid only? Or would you recommend more immobilization? Drain the cyst? Steroid injections? I am desperate and would really appreciate any thoughts you have. I can send photos of MRI if that is helpful. I also had CT done back in Nov. Thank you so, so much.

IMPRESSION:

1. Undisplaced fracture of the medial sesamoid bone with persistent

diffuse bone marrow oedema appears similar to the previous study.

Fracture line is still visible on MRI but the degree of fracture

healing would be best assessed by CT if clinically indicated.

2. Cystic intraosseous lesion within the medial first metatarsal head

likely represents an intraosseous ganglion cyst related to the

proximal medial collateral ligament origin. This has decreased in

size due to bony ingrowth proximally but there is persistent

moderate bone marrow oedema within the medial head of the first

metatarsal similar to the previous study.

3. Persistent increased T2 signal and thickening of the proximal

fibres of the medial collateral ligament likely due to a partial

tear.

4. Unchanged full-thickness chondral loss first metatarsal-medial

sesamoid articulation.

5. Full-thickness chondral loss medial aspect of the first metatarsal

head at the first MTP joint.

Dr. Blake's comment:  thanks for reaching out. You had quite the injury involving at least 3 structures. If you can send me the images, I can get a better read than the report alone or some random images. My mailing address is Dr. Rich Blake, 900 Hyde Street, San Francisco, California, 94109. There is never a charge for this service, just part of running this blog. What I would recommend if this was me to rest the toe bend this next year. I know that sound alot, and of course you have to evaluate things monthly. You have alot to try to heal, and I think you should give yourself the time to try to heal. You abnormally loaded the big toe joint at some point injuring the medial sesamoid, first metatarsal head, and medial collateral ligament. If surgery was to be done, they would remove the medial sesamoid, perform microfracture surgery on the first met head, and sew up the medial collateral ligament. You would be off your foot for months on crutches and scooters, and this would be bad for the ligament should needs motion. And you would still need the shoe, orthotic, dancer's pads, spica taping, etc to protect the joint for a year post surgery. 

     So, my suggestion, start using Exogen 5000 bone stimulator twice daily, get into some bike shoes with the embedded cleats or other stiff soled shoes, learn to spica tape, and design dancer's padding. Massage with oils or gels the area twice daily to de-sensitize. Do icing for 5 minutes twice daily and contrast bathing for deep bone flush each evening. All of this work is within the blog at various parts. The spica taping is actually very helpful when the ligaments are involved. 

     As the year goes on, you may be on the fast side of healing, and the restriction of shoes can be lessened. Make sure you have good bone health by getting a Vitamin D blood test, and a bone density scan. There has been many surprises on these. Hope this helps. Rich