Injury to Fibular Sesamoid in Rock Climber: Email Advice

Hi Dr. Blake!

I've been reading your blog and thought I'd try and see if you respond to my questions. I'm desperate for answers and I've seen 2 DPMs and 1 Ortho surgeon with foot/ankle specialization. Each of their prognoses is different and so is their proposed treatment. I'm going to get one more opinion from an ortho too but if you have any insights, I'd love to hear them.  I'm a 34 yo female construction manager, rock climber, dancer (ballet growing up, lots of Latin dancing in heels as an adult). I hate running so I'm not as concerned about losing my ability to compete in triathlons.

Summary of the condition:

1. initial injury occurred in rock climbing in late March 2018. There was no impact, but I was standing in a precarious position for over 45 mins standing over a chasm and didn't have much room to move. My weight was mostly evenly distributed between my feet but my toes were hyper-extended and all the weight was on the balls of my feet. I was in instant pain in my left foot that felt like a hit a pressure point. My foot became instantly numb and remained that way for the rest of my 6 hours climb and hike down the mountain. the feeling in my foot came back the next day but my toes stayed numb for 6 weeks. I did not go to the doctor because I had no idea I could have broken a bone by just standing on my foot. It's common for climbers to complain about toes going numb so I just rested for a few weeks and didn't think much of it.  (Dr. Blake's comment: The numbness is either from compressing a nerve for too long as you describe or from the intense swelling internally from a fracture or sprain, that pulls pressure on the local nerves. Or, a combination of course). 
2. Fast forward 3-4 months to July 2018 (I've been continuing to run, lunge, climb, and wear high heels to work all day).  I should also say that I drive a standard transmission vehicle with a stiff clutch and sit in traffic constantly for work. By the end of July, my left MTP joint would be swollen, most of the pain was on the side of my MTP joint, not on the ball of my foot. Eventually, I started having numbness in my toes again and finally went to a podiatrist. (Dr. Blake's comment: I am assuming the numbness went away and these months were not painful, and you did not have to limp.)
3. Aug 3, 2018, I was diagnosed with a lateral sesamoid fracture. I wore a boot and unna wrap for 4 weeks while my DPM was taking x-rays every 2 weeks telling me it was healing. 
4. By Aug 28, 2018, my pain was increasing not decreasing and the ball of my right foot is now hurting because of me trying to offload the left foot. The DPM Xrays both feet, says the left fracture is still healing and the right foot shows no signs of fracture. The DPM put me in the iWalk crutch and ordered an MRI of both feet since I was still having pain. 
5. I've had J pads in the boot on the left foot and orthotics also with a J pad on my right foot because I was starting to have pain in that foot now. (Dr. Blake's comment: I am sure this is Dr. Jill's Gel Dancer's Pads or something similar).
6. After the MRI I saw an orthopedic surgeon (who recently operated on my mom's foot with success) and a leading podiatrist in the state. Both of these doctors agreed that the Xrays showed NO signs of healing and that the original DPM was wrong. MRI indicates no sign of healing and is inconclusive as to whether or not it's a bipartite sesamoid or a nonunion fracture.  There are signs of AVN and edema. (Dr. Blake's comment: Yuck!!)
7. Here's where I'm confused:
   1. Ortho surgeon says he doesn't know if it's a fracture or bipartite but it doesn't matter because it's not healing and shows no sign after almost 6 months (the last 1.5 was immobilized). he says surgery is inevitable but he'll wait as long as I want. He gave me a cortisone shot and suggested within a week I transition to regular hiking shoes until I'm ready for surgery. he doesn't want me to stay in a boot that will cause muscle atrophy and all other sorts of problems while I decide on surgery. My question is, is 1.5 months enough time in a boot to be sure it won't heal. and if it's not a fracture, is there another cure than surgery? (Dr. Blake's comment: Sorry this is confusing. These time frames do not apply to sesamoids or a lot of other injuries. The wait with sesamoids can be a one year process, and sometimes more.)
   2. DPM #2 says it's fixable with 6 months in a boot and exogen bone growth stimulator. Do I really wait 6 months in a boot with an expensive contraption waiting for the bone to heal (what if it IS bipartite?). Will the exogen doing anything for bipartite sesamoid? (Dr. Blake's comment: I agree sort with the DPM #2. I will look at the images you sent below to comment on the bipartite aspect).
8. I have an active lifestyle but more importantly, I have to walk at work a lot. I can't afford to waste 6 months in a boot for a bone to heal that isn't even broken.  I also can't afford to have sesamoiditis in my right foot as a result of offloading for multiple months on the other foot. What do you recommend? (Dr. Blake's comment: Work can force people's hands at having the surgery, since the prolonged rehabilitation may not work for them. That is one of the huge reasons patients will have some foot surgery.)

Additional Questions:

1. No one has commented on the right foot having a bipartite sesamoid or not. It was not specifically mentioned in the radiologist's interpretation but when I look at the Xray it looks possibly bipartite to me. I've been researching this a lot and I've seen that 90% of bipartite sesamoids are bilateral and occur on both feet. Can you see from my Xrays if both my right and left foot of bipartite lateral sesamoids? 
2. Should I be considering selling my car? From what I read about surgery, it'll be a long time until I could press the clutch with my left foot again. Maybe I should buy an automatic transmission. (Dr. Blake's comment: Whether you end up in surgery or not, switching from manual to automatic makes sense right now. Can you rent one for a week to convince yourself?)
3. I'm worried that if I get a sesamoidectomy that my fibular sesamoid will fracture too. Should I worry about that? (Dr. Blake's comment: This is at the root of why we try to avoid the first surgery if possible. It is a rare occurrence because people are so protective of their remaining sesamoid. But, with rock climbing positions, who knows? Make sure your Vit D is at 55 with low normal at 32 or so, halfway on the normal scale. You would not want transient Vit D deficiency to cause a fracture.)
4.  I don't know who to believe the orthopedic surgeon or the podiatrist? How do you choose? (Dr. Blake's comment: First of all removing the sesamoid is technically simple, but the decision to do the surgery is not at all. Also, who is going to provide you will the best post-op course, orthotics, taping, etc? )
5. How long is too long to wear this boot? (Dr. Blake's comment: My golden rule of thumb is 3 months with the bone stimulator for 9 months total. The transition from boot to shoe can be tricky with the need for orthotics, perhaps rocker shoes like Hoka One One, taping, padding, bike shoes with stiff soles, etc.)

I've attached my L and R foot Xray from 8/28/18 and summary of the MRI interpretations, in case you have time to look at these. (Dr. Blake's comment: Please send me a disc of the MRIs to Dr. Rich Blake, 900 Hyde Street, San Francisco, Cal, 94109. Please email me at rlb756@gmail.com when you think I got it. I want to see how inflamed the sesamoids are). 

Thank  you in advance for your time!

Jaime

This does look like a lateral or fibular sesamoid stress fracture with irregularities where the junction between pieces area. Bipartite usually look more symmetrical and rounded borders. To me, it is the incredibly long first toe and metatarsal that makes this prone to injury. Yes, removal of the one sesamoid could set up problems for the other.

Here the lateral sesamoid looks more like it is bipartite, which shows you have the bone overlap from the first x-ray distorted things. If it is bipartite and began to hurt with prolonged hyperextension, I wonder if you have a turf toe situation. Has anyone mentioned that?

I read this as mild injury to a bipartite sesamoid junction leading to a mild reaction of the tissues. Maybe once I see the views the mild level will look more like moderate. The biomechanics of Turf Toe, where you hold the toe on the ground, and you stress various things, like the bipartite junction to cause injury or one of the muscles or ligaments (not noted) makes sense here. If you switch to turf toe protocols, it may make more sense then sesamoid fracture protocol. The treatment can be some the same and some different. Create that 0-2 pain level consistently.

More obvious bipartite. A CT scan should be ordered for your left. Again, the long first metatarsal and toe (called Egyptian Foot in ballet)  which takes more stress than normal. 

 Again more bipartite looking with the two parts of the sesamoid with smooth borders and unequal in dimensions

Sesamoids look different on MRIs. They are wrapped up in ligaments and tendons, and unless they are abnormal (as in your left side) they look normal. Your workups have been good. Until I see your films, 3 months in the boot, with an EvenUp on the other shoe to keep the weight normal. If it is Turf Toe, spica taping is key, and probably advancing gradually to bike shoes with embedded cleats. 

https://youtu.be/l_4HESXCG40

1. Should I cut back on my glass of wine or a beer most evenings? No, unless it causes you to stumble.LOL

Sesamoid Injury: Email Advice

Hi, Dr. Blake, 

My 12 year old daughter plays year-round soccer at a very highly competitive level. In early June after coming back from a tournament weekend, she complained of her foot being sore and not able to bend/flex her big toe very well. After asking her more questions, we find out that her foot had been slightly sore when she pushed in on the ball of her foot with her fingers for a couple months. However, now it was sore to walk and her flexion was limited. 

We took her to a podiatrist. MRI revealed inflammation and a bipartite sesamoid. He said it didn't appear fractured because of the clean lines. She was in a walking boot for 4 weeks with no pain. Then, she started wearing her custom orthotics in all shoes. We kept her out of soccer and pretty much all other running activity for another 2-3 weeks. She had little to no pain. We then slowly started her back into soccer wearing her orthotics in her cleats. She would only playing at 50 percent effort/time for a couple weeks and slowly increasing that keeping her discomfort level below a 3. After each practice and game she did an ice foot bath. We also were spica taping her foot all day at school and at practice in the evening and games. All the while she was doing foot strengthening and stretching exercises. A couple of weeks ago she was able to go at 100% effort with very low discomfort. We continued to ice bath after each practice and game, but because of the little amount of discomfort, we discontinued taping. Last week she mentioned it was getting a little sore with pressure again and this weekend at the end of her game she was in a higher level of pain than she had been in several weeks. 

Ugh! Will this ever go away and will she be able to be back playing regularly at her level of soccer? She's only 12 and the podiatrist doesn't do cortisone on children her age, which is fine. And, I don't want to resort to surgery. 

We are struggling with really knowing what her pain level is because she has a hard time determining when she has the "ok" kind of pain and when it's "time to pull back kind of pain". Her podiatrist told us/her that a low level discomfort is normal. 

Please help this mom who jumps to the conclusion that her child will never play soccer normally again! 

Dr Blake's comment:

     First of all, you are to be commended for the great and thoughtful course of action. Unfortunately, there can be many bumps along the way and you need to use the same common sense with each one of them. Children do have a hard time in general distinquishing good and bad pain, so typically parents must team with the coaches to pull the child when limping. I have found that bipartite sesamoids can fracture, but this does not sound like a fracture due to her good early return to soccer. This years advice though would be 100% spica taping while playing, removing any cleat under the sesamoid, making sure the orthotics have good arch support and great dancer's pads, and icing twice daily during the season. If you ever get an xray, please take some photos. Hope this helps some. Rich