Sesamoid Fractures:
By Richard L Blake, DPM
The top 10 initial
treatments for sesamoid fractures are:
- Exogen (ultrasound based) bone stimulator for 6 to
9 months
- Removable boot for 3 months to
create a consistent pain free (0-2 pain level) healing environment with EvenUp over other shoe for balancing. This can be substituted by a bike shoe with embedded cleats for both feet.
- Ice pack twice daily and
contrast baths each evening for anti-inflammatory and deep bone flushing.
Do the contrast baths daily and twice on non-work days.
- During the initial 3 months of
immobilization, have orthotic devices developed that off weight the
sesamoids.
- Learn how to use 1/8th inch
adhesive felt to make dancer’s pads for the boot and
for post-boot action (patients also love the Dr. Jill's Gel Dancer's Pads that stick to the foot or shoe)
- Learn how to spica tape for
post boot action
- When you are not wearing the
boot, avoid barefoot (house slippers like Oofos protect and cushion well).
- Do cardio, core and foot and
ankle strengthening the minute you hurt the bone, and on a daily basis.
Keep Strong and Keep Fit!!
- 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.
- 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/bike shoe period can take
anywhere from 2 to 6 weeks and no added soreness is allowed.
In my Book Secrets to Keep Moving, I review the 20 top general rules for sesamoids.
https://store.bookbaby.com/book/secrets-to-keep-moving-a-guide-from-a-podiatrist
- They rarely do not heal.
- 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).
- Healing, and feeling better, is
based on many factors that are unknown when the patient first presents.
- MRIs and CT Scans are common
imaging techniques that can really elucidate the problem, and sometimes
change the direction of the treatment.
- Follow up MRIs, when needed to check healing, are often
done between 5-6 months after the first baseline MRI. Always look at the first MRI as probably just your initial 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
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, and cardio.
10.
Often times 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 Roll aBouts) always increases swelling (which can be a big source of pain), 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. No exercise should hurt however.
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 an option
Thank you for this helpful summary!
ReplyDeleteThank you Dr. Blake. If there is osteonecrosis of the lateral hallux sesamoid (or any part of either sesamoid bone for that matter), then is the bone stimulator and this list of general rules a moot point, since there is bone tissue death? Or is it possible to still see a full recovery despite osteonecrosis?
ReplyDeleteIf the bone has begun to fragment, break apart, then surgery to the usual recommendation. But, without that, osteonecrosis can be treated with contrast bathing, bone stimulators, probably stem cells, counseling on present bone health, great diet, no smoking, etc. Good luck. Rich
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