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Monday, May 17, 2021

Sesamoid Fracture: Dr. Blake's Office Handout for Patients

In my office, I have developed many handouts to give to patients for many topics. Since I treat so many Sesamoid Fractures, I thought I would share this one. Rich 

Sesamoid Fractures


The top 10 initial treatments for sesamoid fractures are: 

  1. Exogen bone stimulator for 6 to 9 months

  2. Removable boot or a stiff soled shoe like Bike Shoes with Embedded Cleats for 3 months to create a consistent pain free (0-2 pain level) healing environment.

  3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths twice on non-work days.

  4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.

  5. Learn how to use 1/8th inch adhesive felt from Moore Medical to make dancer’s pads for the boot and for post-boot action.

  6. Learn how to spica tape for post boot action

  7. When you are not wearing the boot, avoid barefoot.

  8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!

  9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.

  10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

So, what do we know about sesamoid injuries that may help? Here are my top 20 plus pointers when teaching about sesamoid fractures.

  1. They almost always heal.

  2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).

  3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.

  4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.

  5. Follow up MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.

6.               The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis (self pay MRIs of this area are $750 (2021) in the San Francisco Bay Area).

7.               Since we are dealing with bone, we must look at diet, Vitamin D3 levels, calcium/zinc/magnesium, and bone density.

8.               Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Re-Strengthening, and Return to Activity.

9.               When the patient is in the Immobilization phase, the treatment visits should be thinking about (and acting on) the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, cardio.

10.           Oftentimes treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase).

11.           One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.

12.           As treatment starts, the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc) that maintains 0-2 pain level.

13.           The initial goal is to create this pain free environment for 3 months by whatever means it takes.

14.           Non weight bearing (via crutches or scooters to off weight one leg) always increases swelling, so some protected weight bearing is crucial. Every step pushes fluid out of your foot.

15.           The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed.

16.           If you are basing treatment on x-rays alone, you may be way off base.

17.           Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques. Go to YouTube and type drblakeshealingsole Self Mobilization.

18.           Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist. Keep the joint/foot flexible and strong.

19.           Patients with sesamoid injuries are prone for setbacks so do not get discouraged.

20.           If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months wait to document delayed healing, some not. Self pay for Exogen Bone Stimulator is around $750.

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