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Sunday, September 20, 2020

Sesamoid Injury: Email Advice

Good afternoon Dr. Blake,

I hope this email finds you and yours well. Your foot and ankle injury blog and videos have been a great resource for me as I have been dealing with a sesamoid fracture/injury since late Feb/Early March. 

Essentially, I'm not sure how I fractured my sesamoid, but I didn't have a great podiatrist at the beginning of the injury, which, coupled with the quarantine (I'm in NYC), essentially means that I lost 3 months of proper treatment right away. I had x-rays and MRI with this doctor, but everything was taken very lightly. I was told it was maybe fractured, then just an itis, with no clear plan of how to get it to heal. I had to wait til June to get an MRI (now I know I should have had one right at the beginning.) It was all downplayed a lot and I even had to ask for a boot but with no instruction of how long to wear, when to wear, include dancer's padding etc. I stayed in the boot on and off for March/April but with no dancers padding and only outside. Inside I used slippers but was sometimes barefoot. Then in May/June (what is time anymore!?) I went to an orthopedic surgeon who saw me for 15 minutes and told me to get custom insoles, which I did get and now have for sneakers. I still knew something was wrong because I still had pain walking in the sneakers and did not feel comfortable putting all the weight through the ball of my foot and it just wasn't getting better. Fast forward to July, after getting more x-rays and a CT scan with a different podiatrist, he confirmed a fracture diagnosis, put me back in the boot and now I'm using a bone stimulator. I've been in the boot since July 29th and have been using the bone stimulator since August 17. Sometimes I use it twice a day. I've attached my MRI and CT scans below (if you'd prefer access to the portal to view all the images, I can certainly provide that).
Dr. Blake's comment: So sorry for the delay, but it did not sound like you made it worse, and it is sounds like good progress now!

As I've read from so many people who have this particular injury, it is incredibly frustrating, with little understanding of it, and very prone to setbacks. Right now, I'm wondering what else I can do besides the contrast baths, taping etc. I have gone to PT but haven't gone as much since I am back in the boot and am trying not to travel extra to the city. Plus I do a lot of leg strengthening at home. Should I be refraining from walking as little as possible and pretend as if this fracture happened yesterday and not in March? 
Dr. Blake's comment: Create the 0-2 level, walking within at framework actually is better for the muscle strength, bone demineralization, sanity!! There is no guarantee of complete healing for many reasons, but 3 straight months of immobilization in the walking boot, and then another 3 months of keeping the pain between 0-2 as you wean out seems vital to alot of these injuries. Unfortunately, the initial trial of boot does not count. 

I really want it to heal, yet I feel that this is going to be another 3 months, at least. It's so sensitive and a tiny little thing seems like it causes a flare up. My legs/feet and left foot just feel off/bad from being in the boot and even up on the left foot for so long, on and off this year, and I'm honestly afraid I'm not going to remember how to be in sneakers or how to eventually transition back into wearing them.
Dr. Blake's comment: It is not a waiting game since there are some many things to do now to prepare for the weaning out of the boot period. You need to make sure that your orthotic devices and dancer's padding off weight the area (so some visits with good shoes to the podiatrist office to make sure all is well is important). You want to have perfected spica taping, and have some stiff dress shoes for the holidays so you can place in Dr. Jill's Gel Padding as protection. PT is less important now since you are back in the Immobilization Phase, but without irritating the sesamoid, you need to keep strong, flexible, and with infrequent flare ups (but they will occur even in the best situations). 

I do ride my bike sometimes (walk down the stairs in the boot, switch to sneakers with insole etc-it's a process!) but sometimes even if my steps add up to 1 mile each day, that seems to aggravate my foot. It's all very frustrating :) I really want this to fully heal as it's been many months now. If you have any additional insight on my particular case, I would be so grateful! 
Dr Blake's comment: The 4 common areas you need to deal with are: protection (just discussed with boot, orthotics with dancer's padding, dancer's padding alone, cluffy wedges, spica taping, stiff shoes, or rocker shoes like Allegria dress, or Hoka One One type), inflammation (ice and contrast bathing very important, NSAIDs and cortisone shots can slow bone healing, and PT when needed), nerve sensitivity (pain free massage 3 times daily, big toe joint gentle range of motion with your muscle strength only, occasional topical or oral nerve stabilization meds), and bone health (eating habits, low vitamin D, smoking, etc). 

Thank you so very much.

My Best,
Dr. Blake's comment: So, now to the images you so kindly sent. A question I have was there a fall or accident before your symptoms developed since they have a diagnosis of medial sesamoid chronic ligament sprain? Also, any sesamoid injury which is definitely bipartite we need to know if you have a possible turf toe injury also. This is where the ligament is sprained, and the joint can become looser, and possibly require surgery. I assume since you did not mention anything, the doctors have ruled it out, but ask them about it and also if they have done bilateral Lachman tests for joint stability. The sprain can also just cause excessive scar tissue that gets in the way. 
Possible AVN in definite bi-partite. You can fracture the junction between the 2 pieces and the treatment may be the same. 

Here less AVN looking with bone marrow. Bipartite pieces are different sizes

Here T2 MRI clearly shows no AVN!!

Turf Toe Possible Raised when Ligament Sprained

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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.