Bi-Partite Sesamoid versus Fractured Sesamoid? Email Discussion

Hi Dr. Blake,

  I am a 34 yr old active male.  About a month ago I stepped on some glass that had to be removed from my foot.  Flash forward three weeks and I had to get more glass removed by my podiatrist due to pain.  This caused me to favor the ball of my foot under my big toe to avoid the glass that was stuck in my pad under the pinky toe.  I started to notice soreness and tenderness a few weeks after limping on the ball of my foot.  Once the glass was fully removed my stride returned to normal and I began to return to normal exercises, hiking, dog walks and lifting weights.  After a hike 2 weeks ago I was stomping my boots on the ground to get mud off and felt a sharp twinge in the bottom of my foot under my big toe.  The pain quickly subsided on the ride home and I didn't think anything of it until a week later when I noticed some bruising on the outside of my big toe.  Around that time I was having pain in the sesamoid area when walking.  The area became more bruised and swollen over the next few days.  I began RICE, which did help.  I also put myself in a walking boot since I had one from a previous stress fracture on the opposite foot.  Today I had my appointment with a podiatrist and he seems to think my foot is inflamed/swollen from limping on it for a month putting extra pressure on the sesamoid region.  However, my one x-ray reveals a gap in my sesamoid bone.  The doctor thinks it could be a bipartite sesamoid bone or a possible fracture.  He didn't seem too concerned with it being a fracture but said it's possible.  He recommended a walking boot for 3 weeks with an orthotic insert to support.  I have a follow up in three weeks.  My question for you is does it seem like a fracture on that sesamoid or is it a bipartite or a combo (x-rays attached)?  I was hoping for a more concrete answer then maybe or maybe not.  So far pain and swelling with the boot has gone down, still some slight bruising.  I have an appointment with another podiatrist next week, should I ask for x-rays on the other foot to see if I have bipartites in both feet or possibly an MRI?  I've read a lot online and would like to be as proactive as possible with this injury.  Thanks for your time! 

 Dr. Blake’s comment: From my prospective, having seen fractures through bi-partite and tri-partite sesamoids routinely, it would be a dis-service not to get an MRI for a definitive answer. Until then, stay in the boot if it is helping. If you could not get an MRI, these are such problems, that I recommend treating for 3 months in a boot as if you were 100% sure it was broken.  We want to get the pain level to 0-2 quickly for healing. Hopefully, you just bruised the tissue, but even then a month in the boot may be needed. Rich 

Bi-Partite vs Fracture in the Sesamoid Bones

Hey, I came across your site yesterday while doing some research. I have been dealing with some pain on the side of my left big toe joint since December of last year. I initially went to a local orthopedic where they x-ray both feet and they said I have bipartite sesamoid on both feet. They didn't really have any answers as to why I am experiencing pain though. I am able to run fine but and the pain is more of an annoyance than a debilitating pain. I can run for 3 hours or even do hike/runs for 6 hours and the pain doesn't get any worse. I would say the pain level is between 4-6.

Dr. Blake's comment: To most of my patients, pain levels over 2 and they are going to the doctor, and over 5 they are not running at all. 

Just walking around the pain is at a 1-2.

I recently went to a podiatrist foot and ankle specialist and he immediately said I in fact have a fractured sesamoid on my left but the right is a bipartite sesamoid.

Dr. Blake's comment: Only an MRI is conclusive, but to me they both look bi- and tri-partite with smooth borders. Sesamoids that are in multiple pieces congenitally can get irritated, even the junction between the bone fragments sprained or fractured. If you are not getting an MRI, you have to go by the amount of swelling, the level of pain, and use comparison xrays 3 months apart or so that will show a change. A broken bone will change and the xrays after 3 months will show that difference. Month to month changes will be less definitive. Unfortunately, when I have a decision between fracture and bipartite, and I can not get a definitive MRI, I treat it as a fracture with a cam walker for 3 months and I definitely do not allow my patients to go over pain level 2. 

He said I could try some custom orthotics or have surgery to remove it and that would fix the issue. Attached are images of the x-rays.

Dr. Blake's comment: To do surgery on a probable in your case non-fractured sesamoid is pretty absurd. So, custom orthotics (which should be only one of 10 things you are doing for your sesamoid to drive the pain now and let this heal: removable boot, hoka one one rocker shoes, spica taping, dancer's padding, cluffy wedges, activity modification, icing, contrast bathing, bone stimulator, and some PT to get their advice). 

If I get the surgery will I be able to run again? I am a competitive trail and ultra runner and I also race mountain bikes.

Dr. Blake's comment: Typically, unless you are the 1 in 10 that gets some complication, or has other unknown factors at play, you can run again, but the sesamoid bone will have to always be protected. Always. And this is why patients fight getting the right diagnosis and right treatment no matter how long it takes. Good luck Rich 

thanks