Email Advice: 9 months after Sesamoid Injury and AVN diagnosis

Hi Dr. Blake,

Thank you so much for your blog posts over the years on sesamoid pain! They have helped me greatly in my diagnosis with sesamoid AVN.

I'm 19 years old and was diagnosed July 2022, though my pain started February 2022. My affected leg was immobilized in a CAM boot for ~10 weeks before I transitioned to orthotics. I still experience pain occasionally while walking.

I'm wondering if you could provide some insight on some patterns of pain I've noticed:
1) My sesamoid tends to hurt when I walk after sitting or lying down for long periods of time. After I've walked for a while, the pain disappears.

Dr. Blake's comment: This is called post static dyskinesia, meaning pain after rest. The tissue either tightens from swelling that collects during the rest period, or some neural tension that develops while the tissue is immobile (nerves like motion). Both of these causes hurt at the beginning of activity and then disappear as the nerves relax or the swelling dissipates. Either way, it is consider good pain in that 0-2 pain range. You should try to warm it up before you begin to walk like foot massage, big towel range of motion with your muscles doing the motion. Patients will do both by placing a towel next to their bed. When they wait up, they lassoe the toes and pull gently up and down with the towel, or massage the area like you are drying your foot after a shower motion. Remember, total healing (meaning when your body will stop trying to heal everything) typically takes 2 years with these sesamoid injuries. So, recognizing when it is good pain is crucial. 

2) I used to go on 30-minute bike rides. When I finished the rides and started walking, I felt virtually no pain in my sesamoid.

In both cases, I suspect 1) walking for some period of time and 2) biking increases blood flow to my foot and therefore sesamoid, which temporarily alleviates my pain. Is this the likely explanation? If so, I'm wondering why this relief is only temporary (the pain returns after extended periods of inactivity), and if not, I wonder what alternative explanations could be. I am especially curious about the physiology behind temporarily increased blood flow and temporary sesamoid AVN relief, if there is a relationship between the two at all.

Dr. Blake's comment: Increased blood flow with activity, contrast bathing, after icing when the area warms back up, acupuncture, massage, warmth, all play a role at daily increasing your chances to save a bone that underwent AVN (avascular necrosis). As some may not know, the sesamoid normal blood flow is tiny, and alittle swelling in the bone can cause compression to the bone vessels temporarily shutting them off. No one knows why AVN occurs in one person and not another, but daily use of Exogen bone stimulator and contrast bathes are my go to treatments to make sure that bone gets more normalized blood flow. Temporary is fine and short lived, but it is the utilization of temporary methods of increasing blood flow daily for 9 to 12 months that will produce the best chance for the bone to get healthy, really healthy again.

     The other main component to a healthy bone is weight bearing more and more each month. You will be fine if you live in that 0-2 pain level, or the good pain levels since we also need to gradually re-mineralize the bone. Good luck and I hope this answers your concerns. 

Thank you very much for taking the time to read -- I appreciate your help!

Happy New Year and All the best,