Total Pageviews



Tuesday, August 4, 2020

Sesamoid Fracture: Email Advice

Dear Dr. Blake,

I came across your blog when I was researching the internet for resources on sesamoid fractures.  There is not a ton of information out there and sometimes advice seems to be contradictory across different sources.  Your blog has been a blessing!  Thank you for sharing your advice on foot injuries.  I wonder if you could share some advice based on my experience...

About 2.5 years ago, so early 2018 I think, I started experiencing limited mobility in my right hallux and discomfort in the ball of my foot.  The great toe was stiff and I felt the need to pop it frequently.  Often my right arch and great toe would cramp up.  I didn't think much of it, so I just ignored it or tried to rub/roll/stretch my arch whenever this happened.  Then after a week or so of this, I was walking into work one day and could not put any weight on the ball of my right foot without severe pain.  So I immediately went to the podiatrist.  She took an X-ray, did not see any fracture, and diagnosed me with sesamoiditis.  They gave me a foam dancer (J-pad) for my foot and told me to wear that at all times.  I also took some naproxen for 10 days.  She said if the pain persists I could get steroid injections or have the bone surgically moved.  At that point, I had absolutely no idea what to ask the doctor and I just took her word for it.  I didn't want surgery or steroid injections, so I thought that the solution must be to just power through the pain since it was now tolerable with the pad in my shoes.  And it couldn't be that bad, right?  No one told me about any underlying issues that needed to be addressed, either...and no one recommended an MRI even though the X-ray didn't show a fracture.  At the time I didn't know that I should have asked for an MRI. 

Since then, I decreased (but didn't completely discontinue) running until one year ago.  I just ran much less frequently and for shorter distances (3 mi. or less).  Now it has been over a year since my last run.  I kept doing pretty intense weight-bearing workouts including lifting weights, squats with and without weights, using the elliptical, going on long walks, walking on the treadmill with an incline, etc.  All of these things were done with the pad in my shoe which helped relieve some of the pain but the low-level pain still persisted. 

Fast forward to early this year and I realized that I may have a problem since my foot pain has continued.  I went to a different podiatrist on March 5, 2020, and he took an X-ray that revealed a fracture shaped like an "x" in my fibular sesamoid (that's the one on the inside, right?).  Again, he encouraged me to wear a dancer pad, buy shoes with a stiff sole and rocker bottom and wide toe box, and stop doing activities that caused the pain.  He also advised taping my toe and getting an orthotic with a metatarsal extension.  And again, I had no idea what kind of questions to ask so I took that advice (sort of).  I stopped the hard workouts and started doing completely non-weight bearing workouts (thanks to Caroline Jordan fitness on youtube - chair cardio and floor barre).  However, I kept going on long walks even though this was pretty uncomfortable (I just wasn't willing to give it up!)  Then I realized that the long walks also needed to stop if this was going to ever improve.  My orthotics are STILL not delivered yet.  So finally after some more research I asked my podiatrist if it was time for a walking boot and he said yes.  So now I've been in a boot for a week and a half. 

For some additional background, I'm a 26 year-old female. I was an athlete in high-school and played softball and volleyball.  I have Osgood Schlatter's in my right knee and still have a protruding bump that is uncomfortable when I sit on my knees.  I have high arches, tight arches, and tight calves and hips (I never really made stretching or warming up and down a priority until just very recently).  In 2012, I began training for a half-marathon (probably running very poorly...never really taking much time to stretch or learn proper form).  In 2013 I ran a full marathon, and 2014 another half marathon.  Then I cut down on the distance running for a while.  I went on a 60 mile, 4.5 day hike on the Colorado trail in 2016 (hiking the majority of it in Chacos), and climbed the Manitou Incline in 2017.  In 2017-2018 I began running shorter distances on the treadmill but I pushed myself very hard, sometimes ran and walked on an incline, and didn't stretch well. 

I'm realizing now that I REALLY have not cared for my body very well or listened to my pain.  This fracture could have been an unidentified stress fracture back when I had the first x-ray 2.5 years ago and I didn't even know it!  I wanted to run and work out really hard because I thought that was "good for me," but in reality it was hurting me.  I also had no idea how to advocate for myself in this process.  I feel pretty helpless when it comes to this injury and I really want it to heal without surgery.  Do you have any advice?  Is this injury too old to heal properly?  I plan to stay in the walking boot for 8 weeks and continue safe non-weight bearing stretches and light non-weight bearing exercise.  I ice my foot once a day.  Is this a good approach or should I be doing something else?  I've been removing the boot at night but taping my foot and I sleep on my stomach so my toes are pointing down instead of up.  Even after wearing the boot, the ball of my foot still aches at the end of the day most days.  Should I be sleeping with the boot on and elevating my foot?  Should I use a bone stimulator?  Should I request an MRI or is that pointless since the X-ray picked up the fracture this time?  I'm a little curious if there has been any scar tissue forming that is also causing some neuroma in that area. What do you recommend post-walking boot?  I really want to find someone in town (Tulsa, OK) who will take a holistic approach to my body (probably a physical therapist?) to identify what may have led to this injury so that I can address those things and prevent re-injuring this in the future, but I don't know where to look or what to ask. 

Thank you again for being willing to answer questions and offer advice.  I look forward to hearing from you. 

Dr. Blake's comment: Thank you so very much for your email. I will try to help. Sesamoid fractures are difficult to both diagnosis on xray and follow any healing progress. So, I would advise an MRI, and if it documents a fracture, begin 9 months of bone stimulator treatment, followed by another MRI. The boot you are using now should be worn for 3 months, and not while sleeping, and then there is another 2-6 weeks of transitioning from boot to shoes (like Hoka One One and orthotics with dancer's pads). We have to have you create a 0-2 pain level for this next year, while the above is happening. It is in creating the 0-2 that you make orthotic adjustments, shoe adjustments, activity adjustments, tape, ice, contrast, PT, etc. Ask the podiatrist to take some photos for the best sesamoid views on the MRI and send to me and link that to this post so I can look back. I hope this helps. Also, make sure bone health is good with Vitamin D levels and good diet. You want 5 servings of food that has calcium (like diary or tomatoes per day). Rich 

No comments:

Post a Comment

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.