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Saturday, January 23, 2021

Sesamoid Fracture Removal Post-Op Email Advice

Comment from my You Tube channel: drblakeshealingsole

I went 6 months on a fractured sesamoid without knowing it because it was misdiagnosed at urgent care. I then went a year trying the non-invasive treatments (post op shoe, full cam walker, bone stimulator and custom orthotics) before having the sesamoid excised. Now I’m about 2 months post op and I have reduced mobility in my big toe and numbness around the scar and the inside of my big toe near the web. Is this something I’ll have to learn to live with or can I do some specific exercise to gain more mobility and feeling?

Dr. Blake’s comment: I am not a surgeon, but have followed these problems over the years. Post operative healing to me goes in 4 time phases: 
  1. First 3 months (Important to measure range of motion and get PT)
  2. Next 6 months (3-9 month period post-op) Time where range of motion gains 1-3 degrees per month if that)
  3. Next 3 months (9-12 month period post-op) Typically major gains in range of motion 
  4. 2nd Year post op (5-10 degrees increase in range of motion can be gained)
     First of all right after surgery that tissue cut has to heal. This healing between the skin and fat layer, fat layer to fascia, joint ligaments, and joint itself gets to work by the inflammatory reaction of the body to trauma and fluid and scar tissue are the major players. Adding to the complexity of healing comes the bell shaped curve of how individual patients respond: some swell a lot and some not at all, some scar a lot and some not at all. And sesamoids have their own biomechanics that can make matters worse post op like:
  • Pronation of the foot that is not being controlled with the pre-operative orthotic devices
  • The presence of a plantar flexed first metatarsal that needs more dancer’s padding then average (see this all the time in high arched feet for example)
  • The presence of very tight achilles and hamstrings that cause more forefoot pressure and should be stretched out
     So, what is the take home with all of this? You are too early in the course to make any conclusions. The reduced mobility is very typically due to both the scarring and swelling. The numbness is probably from the internal swelling pushing on the nerve, but if it was the lateral sesamoid removed, there could be some irritation to that nerve in between the first and second spaces. In general, that symptom resolves, but at times, it deserves some specific treatment. 
     To me, you should improve every month. February for example should be better than January and so forth. Since you have had your stitches out (for those who may not know), you have to work on swelling 3-4 times a day with medications, icing, and contrast bathing. Hopefully, you are in PT, and they are working on the joint range of motion. Have them review my video on Self Mobilization of Hallux Limitus and see if it appropriate. If it is, do it 3 times a day to begin to get the range of motion back. 
     I find that the range of motion (which should be measured monthly) of dorsiflexion naturally increases as you walk with limping more and more, and then run. In fact, sometimes my patients are stuck until they can run. You can also experiment with 1/8 inch padding under the big toe itself to encourage range of motion. 
     This is a perfect time for you to work on the inflammation, range of motion, strength of the foot, protection you get from orthotic devices, etc. I hope this points you in the right direction. Rich 

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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.