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,

Healing from Sesamoid Injury: Email Advice

Hi Dr Blake ,

Your blog and email advice helped me tremendously in the last few years dealing with severe sesamoid problems (AVN and sesamoid displacement). It's been a long road, but having followed your protocol I am able to do most things today and avoid surgery.

I am getting back into tennis (after 3 years without playing!!) and so far have been playing in Hokas to protect my sesamoid. However, Hokas are not particularly recommended for tennis - I believe they don't provide good stability for lateral movements and are a bit high so increase the risk of rolling an ankle. Do you have a recommendation for a good tennis shoe that could still provide cushioning to the sesamoid?

Many thanks and happy holiday season,

Dr Blake's comment: 

     I am so happy that your sesamoid issue is resolving. But it is motivational for others who develop AVN and/or some sesamoid fracture displacement. My quick answer is wear good ankle braces for your tennis. I love the ASO brace. It is my go-to. My second answer would be a slow gradual introduction to well padded tennis shoes with your orthotic devices, and perhaps added dancer's pads on top of the orthotic while playing only (Dr Jill's gel dancer's padding), and spica taping and cluffy wedge to your foot. Limit your initial introductory time to 30 minutes, and ice after. Let me know after you have done 5 workouts. Good luck. Rich 

Sesamoid AVN Help: Info emailed from patient

For sesamoid AVN, we had a long email correspondence throughout last year :-) the main things that worked were:

- initially, lots of rest, icing, massage

- walking in Hokas and Birkenstock sandals with metatarsal pads

- wearing dancers' pads in the initial stages (but I found that in the later stages they had a tendency to sustain the swelling rather than allowing my foot to press down on the swelling and evacuate it)

- taping my toe down

https://youtu.be/l_4HESXCG40

- doing the toe mobility exercises (from the video that you had sent me)

https://youtu.be/FBTeWbdGrzs

- I also did the Exxogen quite diligently for 4 months, though I'm not sure whether it helped or not (but who knows!)

- and a lot of patience, and trial and error to get things right

Second MRI showed a sesamoid that was fully inflamed, but no more signs of AVN according to my doctor Dr Saxena!

Kind regards,

Video Chat to Patient with Avascular Necrosis of Lateral Sesamoid Discussing Surgical Success

Video Chat to Patient with Sesamoid AVN and Contemplating Surgical Removal of Damaged Sesamoid
https://youtu.be/CMIBl0HB6rc

What does Sesamoid Avascular Necrosis (osteonecrosis) Look Like?

Bone Fragmentation is Noted in AVN (here of the lateral or fibular sesamoid

This view showed the tremendous inflammation between sesamoid and metatarsal (this is actually why the patient hurts)

Another view of the fragmentation on CT Scan (these pieces will never come together)

The view is T1 (meaning healthy bone should be white) of the bottom of the foot

This view is T2 (normal bones can look like this) but the T1 and T2 should be different. You can tell the lateral sesamoid is both darker than the medial sesamoid and the white within is just the inflammation seen between the fragments.

So, it you just looked at T2 here, you would be misled as the sesamoid are darker, and there is tremendous inflammation within the joint.

This is crucial to making the diagnosis of AVN with the lateral sesamoid dark on the T2 above and T1 here. A fractured sesamoid can be dark on T1, but should be very bright with inflammation noting healing potential on T2. 

I discussed with the patient, who has had 2 years of pain, that AVN has occurred and removal of the lateral sesamoid is recommended. However, if he wants to try one more year of conservative treatment, even when the fragments will remain separate (some of these just do not hurt), then daily Exogen bone stimulation, contrast bathing twice daily, and some regimen of acupuncture, could be tried. 

AVN Sesamoid: Email Advice

Hi Dr. Blake,

I’m so happy to have found your blog and YouTube videos, and I hope you can provide some insight and guidance for my situation:

About me: 38 y/o female, chemistry professor by day, professional belly dancer by night and aspiring amateur Muay Thai fighter all day, every day (thai kickboxing).

History: late in 2019, I started noticing some pain in my left big toe upon extension. The pain was never severe, so I kept training. Nothing a little tape wouldn’t fix (or so I thought). Then the pandemic hit, and I started running a lot since my gym was closed. The pain got worse, I did less and less. Still, the pain was never terrible but it was persistent. I saw my podiatrist, and he diagnosed me with AVN of the fibular sesamoid by MRI in early June 2020. This was confirmed with spect CT in early July. My x rays were normal, there was no apparent fracture or degeneration. Both the MRI and CT showed some soft tissue inflammation/edema but no tears. I went in a boot for 6 weeks, and I was given a bone stim (ortho fix) that I’ve been wearing for 3 hours a day for almost 3 months. My pain was at a 0-2, so I have been attempting to gradually step up my activity, but it seems that it’s always 2 steps forward, 2 steps back. My PT primarily does manual therapy, and I’ve been doing toe yoga and trying to go for walks or short hikes (In the shoe recommended by my podiatrist - hoka Bondi 6). Anytime I do this, my foot starts to swell again and be painful. I am so frustrated.

Here is my dilemma - I also have some mild/moderate scoliosis, and the lack of activity has severely flared up my back pain - to the point that the idea of spine surgery has been floated by my sports med doctor. As a result of the crooked spine, I have degenerative disc disease (Several herniations, stenosis and facet joint arthritis) that I have been keeping in check by remaining fit and active. Resting my foot and doing seated exercises (like a stationary bike) has been hell on my back. Obviously, abnormal gait and wearing a boot didn’t exactly help my back either. I need to get back to my regular training/dancing schedule to ensure that my spine stays functional and I avoid back surgery.

What is the best course of action to return me to normal activity as soon as possible? In your experience, does this type of injury heal with conservative treatment and is the person able to return to their activity? I’ve scoured the literature, and the lack of studies is frustrating, and what little there is focuses on surgical treatment. How do people fare after surgery in your experience? I’m not keen on doing unnecessary surgery but I am trying to balance the needs of my back with the needs of my foot. Lastly, what is your opinion on the use of NSAIDS during AVN? I am concerned about the anti-angiogenic effects.

Thank you for taking the time to read this and consider my case.

Kind regards,

Dr. Blake's comment: Definitely switch out of the boot for your back and into some bike shoes with embedded cleats. This will provide evenness in function and weight between the two sides, something your back will be happy for. Your physical therapist should be able to put you on a program to keep your back loose and strong as you go through the foot rehab. When will you get another MRI? I usually wait 6 months, but in your case, every 3 months to see some light at the end of the tunnel with the AVN healing. In your whole discussion, you mentioned nothing about all the other things besides Hokas: orthotic devices, dancer's padding on the orthotic and separate, cluffy wedges, varus cants, spica taping, carbon plates with first ray cutouts, etc. Send me a photo of coronal view injured sesamoid both T1 and T2 weighting to see the AVN. And yes, no NSAIDs, but you should be doing contrast bathing for deep bone flush and circulation every evening. Rich 

Turf Toe with AVN Sesamoid: Email Correspondence

     I have had a 2 plus month relationship with this patient after she first contacted me around January 3rd, 2020. I have given her advice and had her send her images on a CD to me. Below in red is a note I sent her in February. The original injury was early September 2019 playing ultimate frisbee in cleats. No acute incident happened. Late October 2019 X-ray which was negative except bi-partite fibular sesamoid. Late November 2019 MRI documenting AVN fibular sesamoid, intersesamoid ligament tear and lateral collateral ligament suspected tear. Podiatrist at that time wanted to do surgery, but she wanted another option. Shockwave for the sesamoid flared her up with significant swelling. She went on crutches, and started reading my blog early December for advice. She was able to calm it down with the crutches, contrast bathing, etc. 

Thanks for the update. Just went down and had a wonderful discussion with one of our radiologists who went over the joint with a fine tooth comb for me. Most of this we know, but she added a twist. Her findings were:

• Fractured fibular sesamoid with AVN 
• Stretched or torn ligament from the sesamoids to the base of the toe (places the sesamoids in the wrong position)
• Torn and partially healed ligament between the sesamoids (moving the fibular sesamoid laterally too far)
• Partially torn lateral collateral ligament with adhesions to the base of the first metatarsal causing chronic irritation (this is the part I did not appreciate)

So basically the sesamoid lost its blood supply (which we are trying to bring back with contrasts and bone stim), but it is also stuck down in the wrong position so motion of the joint is painful. 

Time will heal the ligaments more, so that part of the course is fine.

The questions are will the AVN come back (only another MRI in 6-8 months will tell us if our direction is solid). But even if it comes back, will it be stuck down (like a frozen shoulder is stuck in the wrong position and people can not comb their hair) too much, that PT will not be able to rehab? Alot of unknowns. I will help you with them. Watch my video on self mobilization for hallux rigidus on you tube under drblakeshealingsole self mob and start doing that twice daily. Rich

https://youtu.be/FBTeWbdGrzs

The Patient's Response today March 23rd, 2020.
Hi Richard,

It's been a month, and I wanted to give you an update on my situation! I apologize for not getting back sooner, but things have been completely crazy with the coronavirus situation. I'm adjusting to this new life. I hope you are doing well and that your business is not too impacted by the current situation! I imagine that your hospital is bracing for impact...

Dr. Blake's comment: Thanks for the good thoughts. I am in an outpatient clinic within the hospital so we are completely shut down and it may be for a long time. Trying to learn Zoom video so I can use Telemedicine some. Hard to give my patients orthotics and adjust them via the internet however. LOL. Hope you are well and practicing good social distancing!

So, here goes on the update - as a reminder, I'm the girl with the case of turf toe + AVN of the medial sesamoid. :-)

• Overall, I've been experiencing an incredible improvement that began towards the last week of February. The last 3-4 weeks have truly been a blessing and I'm starting to get my life back. It's strange that this would happen at a time where many are losing their lives, but that is the cruelty of life sometimes, I guess.
• I got off crutches and started to be able to walk for 10-15 minutes mid-February or so. Following that, I've been improving every day.
• I attribute a lot of my improvement to having gone to Physical Therapy over the last 3 weeks. He has truly helped me in actually pushing me to do a little more than what I thought I could. We do massages to decrease the swelling, but also strengthening barefoot on the ground and I even have graduated to doing small heel raises barefoot, which I am coping with very well!
• I have been able to take walks for longer and longer, (cluffy wedges have helped my toe mobility and gave me a further boost). I've finally managed to get back on my road bike using my clip-on shoes, which is just amazing. I used to swim a lot, but the pools have closed for the moment.
• I'm continuing the Exogen Bone Stimulator, along with PT, and revving up my walking and exercising. 

Dr. Blake's comment: I am so happy for you. By creating the 0-2 pain level, and gradually adding stress to the tissue, it sounds like it is responding well. So many of my patients need a PT which sees them at least once a week to gently but progressively move them along. Rich

My questions are quite straightforward at this point:

1. How slow or fast should my recovery go at this point? Am I doing too much? I'm trying to be really, really, careful, but I find that doing just a little more than what I'm used to helps bring me to the next threshold of recovery. Like, I need to feel a bit of pain, but not too much. Dr. Blake's comment: 0-2 pain which is very healthy is still pain. Yes, you will have pain as you do something that you think you are ready for but was not. You should take 2 steps forward, 1/2 step back at times. Each month should show improvement (sounds like you are much better than last month February). Just go with the rehabilitation gradually, do not think about time tables.
2. Is it possible that I am improving so much but that my bone is still dying? I will get a second MRI in May (at the 6-month mark) - what if my bone is still suffering from AVN? Will I need it removed even if my symptoms are almost none at that point?Dr. Blake's comment: The MRI is for some judgement of how the healing is going. Surgery must be matched up with disability. There is no reason to consider surgery if you have a non painful AVN. I am hoping the bone recovers. You made need another MRI summer of 2021. Your pain has always been from the injury, the inflammation, and probably nerve hypersensitivity. You are working on everything which needs gradual stress applied week by week. No more than 10% more each week, and you should be on the 48 hour recovery between the highest stresses. 

Thanks so much for all your help.

Kind regards and good luck with the current situation. My thoughts and prayers to you and your family. Stay safe and healthy! And you!

Sesamoid AVN: Email Correspondence

https://www.drblakeshealingsole.com/2019/08/sesamoid-avn-email-advice.html

For anyone that might read through this with similar problems - I am the patient in this email correspondence. As I write this comment I'm 6-months further along - it's Jan 2020. I'll update again in another few months. I spent about 6-weeks non weight bearing on my left foot and then another couple of weeks after that in one of those big boots you can walk in. I spent 3-months through to November contrast bathing every night and I've been using an Exogen bone stimulator on my left foot every night for the last 5 months. After the boot I transitioned into New Balance Fresh Foam More shoes with some home made orthotics to off-weight the sesamoids.

For whatever reason over the summer my right "good" foot also became painful in that big toe region and I freaked out and ended up getting that MRI'd as well. It continues to be sore in that same sesamoid big toe joint area but the MRI showed up pretty benign. I've continued to exercise throughout although being pretty conservative with my activities. I haven't tried pushing it too hard yet but I'm curious to see how my feet handle more aggressive activities.

My current status is a pretty much constant low level discomfort and stiffness feeling in both feet in that sesamoid/big toe joint area when I'm walking. It ebbs and flows a little bit but I haven't had severe flare-ups at all in the last 6-months. I've done a little walking bare foot, played with my kids fine, swim regularly even pushing off walls, bike rides, done a couple of short hikes, and worn dress shoes for work on occasion. It's not perfect and I haven't done any running or played soccer at all - the background level of things doesn't really feel much different to when I was diagnosed with these issues 6-months ago - but it was really the flare-ups and not being able to walk without hobbling that was the most debilitating. 

I'm not willing to take any more aggressive steps like surgery at this point. Especially considering my right foot acted up as well and there's not really any way to pinpoint exactly what the problem is with that. I was taking a lot of anti-inflammatory meds to be able to function before I got formally diagnosed with this issue last summer. I'm not taking any now and so I at least feel like I'm establishing a good background level of functionality. It's concerning to me that the background level of pain and discomfort hasn't really improved or changed at all in the last 6-months but at the same time I'm working on finding the balance with how highly I can function activity-wise. My next step is to get some custom orthotics and further define what kinds of footwear can help me diversify into increased and more aggressive activities.

Sesamoid AVN improved by Shockwave and HBO treatments: Sesamoid Relief

This was a response to my blog post. This wonderful patient sent me 2 articles on the use of Shockwave therapy on AVN for sesamoids.


https://www.drblakeshealingsole.com/2018/12/sesamoid-injury-with-possible-avn-email.html




Thank you for your answer Rich :)
I will follow your advices and ask my doc about a CT scan and Vitamin D check.

I am attaching 2 articles about the use of shockwave therapy in sesamoid injuries, for sure it will be of interest for you.

About the help/use of HBO I did not find any reports in English, but here in Germany you find this information on many medical websites (mainly for AVN in the hip and knee). I had contact with one doc who confirmed that he personally made good experience in treating bone marrow edema and AVN in the foot (ankle and sesamoids) with HBO.

I keep you updated.
Have a good start in the new year!


Dr. Blake's comment:
The 2 articles are following:


1)   Saxena A, Yun A, Patel R, Gerdesmeyer L, and Maffuli N. Radial Soundwave for Sesamoidopathy in Athletes: Pilot Study. J.Foot Ankle Surg 55(2016): 1333-1335


The treatment protocol that showed promise was 3 treatments 1 week apart. The treatments were 2500 pulses per session, 2.4 Bar and 13 Hz.


2)   Thompson D, Malliaropoulos N, and Padhiar N. Sesamoid Osteonecrosis treated with Radial Extracorporeal Shockwave Therapy. Brit Med Journal Case Report 2017 (accepted 5 May 2017).


The treatment protocol that showed promise was 8 sessions, 2000 pulses per session, 1.2 to 1.8 Bar of pressure to patient tolerance, 5 Hz.


I am so excited that another help for these sesamoid injuries with avascular necrosis has settled in. I currently have 2 patients that are fine, but any running keeps irritating the sesamoid area with some avn issues. With new techniques, medicine has to find the place for it. When do we offer it to patients, at the first sign of problems, or only after bone stimulator for 9 months? For me now, it is for the few patients (less than 5%) that seem to have issues after extensive treatment and are considering sesamoid removal. But, it may be appropriate much earlier in the treatment.

Sesamoid Injury with possible AVN: Email Advice

Dear Richard,
As so many others I found your blog and I agree that it is one of the most valuable sources about sesamoid problems. Thank you so much for providing it! You are truly one passionate doctor. As many others I am suffering from sesamoid pain and I would be very thankful if you find the time to answer to my message.

The entire black sesamoid (black is normal for this image) is seemingly demineralized and has this white shape

Summary:

• 45 year old athletic man, working as a professional mountain bike guide in the summer (not riding with cleats!). Office job in winter time.
• First subtle pain at the ball of the foot started around 1.5 years ago when wearing fancy shoes in the city. Plus some pain on the side of the big toe joint, mostly when pressing on it.
• First saw a doctor in October 2017 (which is 14 months prior to this dictation). X Rays were done, showed no arthritis in the big toe joint. Doc said it is an inflammation in the joint plus the tendon of the lateral sesamoid. Prescribed Arcoxia pain killers for one week, rest and orthotic insoles with stiff extension + gait analysis. Approx. 4 weeks later I started carefully with cross country skiing again, I cannot remember major pain so I continued sports with only very little discomfort. Dr. Blake's comment: So, this was the beginning of it bothering you, but it was manageable. 
• August 2018 aggravation of pain on the side of the big toe joint and at the ball of the foot when biking and walking. Difficult to walk normally. I began to walk on the side of the foot not trying to bend the big toe. Dr. Blake's comment: I am assuming it was fine, or at least slight between November 17 and August 18. 
• End of September new appointment at doctor, ordered MRI. Diagnosis = the lateral sesamoid has problems with the blood supply. New orthotics and rest prescribed.
• November 2018: went to 2nd doc. He looked at the MRI and said the lateral sesamoid is „mushy“, dead and damaged (AVN). Very pessimistic, also about surgery. Started shock wave therapy with this doc on Nov 22nd cause I found good case reports about it. Also send MRI to a friend/radiologist who said there is bone marrow edema but no fracture and only maybe AVN and I should try shock waves. Dr. Blake's comment: Yes, conservative management is fine at this stage. I am not qualified to assess shock wave for this however. My read today would be CT scan ASAP to see if you truly have AVN, then Exogen bone stimulator, and contrasts and acupuncture to get the bone healthy over the next year. Weight bearing is crucial for mineralization. Assessment of Vitamin D levels to make sure you are not deficient. Even bone density especially if the Vitamin D is low or low normal. Experiment with Hoka One One shoes, off weighting orthotics, biking shoes with embedded cleats, all in attempt to have you do as much weight bearing while keeping the pain level between 0-2. 

I am attaching some photos of the MRI. If helpful I am happy to send you the full pictures via wetransfer/dropbox etc. What is your opinion about the condition of the lateral sesamoid? AVN? Fragmented? Or just edema and still in one piece? Dr. Blake's comment: Please send me a disc of the MRI and CT scan when done at 900 Hyde Street, San Francisco, CA, 94109. 
My plan of action is following:

1. Continue shock wave therapy (6 more sessions 3 radial and 3 focussed, then rest and give the bone time to revitalize)
2. Wear insoles at all times in stiff soled shoes (longer walks 5 mins+ in heavy mountain boots). Will try dancer´s pads. I read your advise not to be barefoot at all, however I have no pain standing barefoot on my foot? It is even more comfortable than in shoes. Dr. Blake's comment: With general rules, you have to see what applies to you. Listen to Your Body and how to attain the 0-2 pain levels. Sound like Barefoot for you is just fine. 
3. Contrast baths daily Dr. Blake's comment: Very important to flush out that bone edema. Try twice on weekends. 
4. Vitamin D + 750mg calcium daily
5. Taping the big toe joint so the joint is stabilized when longer walks are required.
6. Massage the area. Passive stretching of the big toe helps, but I read not to bend the big toe at all? Can I bend it passively? Dr. Blake's comment: This is one of those that has to do only with pain levels. Typically you restrict the toe motion while exercising to limit the pain, and you keep it loose when you are at rest. 
7. Thinking about hyperbaric oxygen therapy. Have you any experience with it? Dr. Blake's comment: If you find an article supporting its use in AVN, I will run it by the doctors here that run our HBO program. 
8. Make a control MRI in 3-4 month (6-7 month after first one). If no progress to be seen consulting foot surgeons about surgery options. I have heard very contradicting opinions about the surgery. People who are totally happy and returned to sport activities and others who had even more pain. What is your experience? I am afraid about losing my profession and outdoor life. Dr. Blake's comment: The few patients I treat with sesamoid surgery typically are happy with the procedure, so I do not feel bad about recommending it if it comes to that. The failures are from bad luck, bad surgery, inadequate evaluation of what is causing the pain, etc. The inflammation in your MRI is excessive and will distort the viewing of the bone and the decision making. I would get a CT scan now, start Exogen, contrasts, pain free activities, perhaps acupuncture, get another MRI in 6 months, and probably another CT scan in 12 months. Some of my patients cycle with the weight on the pedal not the ball. See the posts on how to design weight bearing floats for the big toe joint so you can do yoga, Tai Chi, stretches, etc without irritating the sesamoid. 

Is there anything else you can recommend me? I read you are recommending the bone stimulator, does it make sense in my case? Bioventus Exogen seems to be available here in Germany.
Richard thank you so much for your time and hopefully short answer. Of course you can publish this message on your blog.
Now I wish you a merry Christmas and hope you will spend it with your family and friends and that you are having a good time!
Best wishes from Germany,
Dr. Blake's comment: Good luck to you my friend!! I hope this helps you. 

Avascular Necrosis of the Tibial Sesamoid

Dear Dr. Blake:

I recently commented on one of your blogs posts on PodiatryToday.com, before I came upon your blog. You seem to know much on the subject of sesamoids and their issues, more so than any doctor I’ve encountered.

I’m a 20-year-old college student with avascular necrosis of the right tibial sesamoid. I was diagnosed with stress fractures in my right foot 4 years ago, and when those failed to improve, I was eventually diagnosed with AVN 2 years ago by an orthopedist. He put me through conservative treatment (orthotics, carbon foot plate, Exogen bone stimulator) for a few months, but my symptoms persisted. He recommended surgery. I sought a second opinion from a podiatrist, and he recommended that I continue with whatever conservative treatment I was already doing. So here I am 2 years later still doing the Exogen bone stimulator every night and wearing orthotics in my sneakers (or dancer’s pad if I’m barefoot). I ice when there’s pain; sometimes I do a hot soak with Epson salts. I was an avid runner before I was diagnosed and have since quit because I still have pain when I run. I’ve found solace in swimming, rowing, and weight training but still sometimes get pain when rowing or going for long walks/hikes.

Long story short, my problem has steadily worsened over the past 2 years, and I was led to believe that it would continue to worsen until surgery was the only option. Reading your blog suggests otherwise though. In other emails from people with AVN of the sesamoids, you discuss treatment options that my doctors never mentioned, mainly spica taping, dry needling, contrast baths, foot mechanic evaluations, Neuro-Eze, bone density/Vitamin D screenings,  and CT scans to check for bone fragments. You also say that the chance of the injury re-occurring is very low in the case of the 14-year-old Irish step dancer, whereas my doctors told me that I would have this injury for the rest of my life with no hopes of improvement. 

But is there still hope for me, 2 years after the initial diagnosis? Is it common to have this injury for so long with gradual worsening over time? Is it still possible to reverse the effects this late in the game? I know you can’t answer specific medical questions over this forum, but do you have any words of wisdom for a frustrated young athlete? 

Thank you for your time.

Sincerely,

Dr Blake's comment: Thank you so very much for reaching out. I would love to tell you some positive words, but there is so much we need you to do to find out what is really going on. I have to assume you have good bone density and overall healthy. Definitely if you want me to help you need a CT scan (your Primary can order) and a bone density screen. Also, this should be sent to me with your current MRI (within 6 months). They can be mailed to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. I do no charge for this. I hope I can help. Rich

Discussion on Avascular Necrosis of the Sesamoids: Email Advice

Hi Dr. Blake,

I hope all is well ! I read over your blog and focused on the AVN posts, which were helpful.

About a year ago, I started noticing a dull pain in the ball of my left foot, but nothing unbearable. This must have been from walking around in a bad pair of shoes for a week. The dull pain did not at any point between April 2016-December 2016 get any worse.

 I did however decide to go see a podiatrist in December to see what was going on. He put me on two different anti-inflammatories separate times and took x-rays (normal results). In January, after not having felt an improvement, he ordered an MRI. This is when we discovered that I have AVN of the fibular sesamoid. He put me in a post-op shoe for a few weeks, which did not help at all. In fact, it made the pain worse. I decided to get another opinion so I went to see another podiatrist who gave me a cam walker to wear for 6 weeks. She also suggested a bone stim. I wore the boot every day, but felt pain when I was walking in it.

Dr Blake's comment: Both the shoe and  walker typically stop you from bending the big toe joint but put extra pressure on the toe. So you need some form of dancer's padding to float the sesamoids even in these contraptions. Definitely if someone mentions AVN, because of the high risk of surgery if the bone stim not work, you have to use the bone stim for 9 months. 

 After 5 weeks, I realized that it was also aggravating the problem and starting hurting other parts of my foot (assuming this is because it forces you to walk in an unnatural way). I switched to sneakers with Hapad dancer’s pads and have been wearing them for the last two weeks. I found a third podiatrist who recommended orthotics. I just received my custom orthotics today and after putting them in, I feel a bit of pain when I walk in them (the same amount as when I wear the dancer’s pads). Not sure what to think of this...I also ordered an exogen bone stim, which will arrive tomorrow. Following the doctor’s suggestions, I will be using the stimulator once a day for 20 minutes for 3-5 months. 
Dr Blake's comment: This is a hard call. You have pain from 3 sources: mechanical (being off weighted by the hapad and/or orthotic, inflammatory (do the twice daily 10 minute ice pack, and once daily contrast bathes), and neurological hyper-sensitivity (try Neuro-Eze, pain free massage). Everything needs to be perfected. Look at each component since a littel change in anything can potentially make a big difference. Can you tolerate a bit more arch? How about a little more dancer's padding. If you are not immobilizing, perhaps a hike and bike shoes for several hours per day to rest the area better. Sometimes just go anti-inflammatory program, or consistently wearing spica taping. 

I am very worried that the pain is only going to get worse with the orthotics. If I feel pain when I walk in the orthotics, does this mean that it will not subside? My last hope is the exogen. I really am trying to avoid surgery at all cost because I have heard awful stories. Unless the pain gets unbearable, I do not even want to consider it. 

Dr Blake's comment: The real reason not to do sesamoid surgery initially is that in the long run it can effect the joint, and the lower leg biomechanics. We try to leave in what was originally there. But, it is a very successful surgery, and not too difficult to heal from. So, when a few of my patients need it from time to time, I do feel I let them down alittle, but I am happy they can gain relief. Whatever they have learned before surgery, in trying to prevent surgery, they can use post operatively to protect the joint. You would need to find a surgeon skilled at this surgery with good results, expectation to get back to full pre-injury activity, with a little sesamoid protection of the other one. 

Do you have any recommendations as to what I can do? Nothing seems to be working and it’s starting to put me down. I used to love running, but I haven’t been on a run in 2 months because I am worried I will worsen the situation.  Even before I started wearing all these shoe-alternatives, I would go on runs a few times a week and the pain was stable. I am so confused!!! I feel as though I should never have gone to see a podiatrist and ignored the problem because now the pain is worse. Are there any exercises I can do that will help?

Dr Blake's comment: You have to give this time. One year from now until you are feeling very fit is not uncommon. Avoiding the bend of the joint for the next 6 months is a start with the hike and bike shoes, spica taping, carbon graphite inserts, or just stiff shoes and orthotics. Just try to create a consistent 0-2 pain level in what you do. Bike, swim, and elliptical without lifting your heels are common exercises. Keep your foot strong with metatarsal doming, single leg balancing, inversion and eversion resistance bands, and FHL strengthening with theraband as long you only work the plantar flexion range. A physical therapist should be able to give you a good program, but protect the sesamoid also. Definitely this should include 9 months of the bone stimulation twice daily, and icing twice per day, and contrasts at least 5 evening a week for a deep flush of the stagnant blood flow trapped in the sesamoid. 

I live in NYC and am still trying to find the right podiatrist. Do you have anyone in mind?

Dr Blake's comment: Contact any of these 3 pods to get a name of someone good near you: David Davidson, Robert Connenello, and Karen Langone. 

I would appreciate any suggestions you can give me because I have been feeling hopeless.

Thank you for taking the time to read this.

Best,

Below is the report for my MRI that I got done in January:

Study Result

Narrative

History: 23-year-old female with left forefoot pain for 4 months. Evaluate for sesamoid injury.

MRI of the left foot

Technique: Routine multiplanar imaging of the left forefoot was performed on a 1.5T MR scanner according to standard protocol.

Comparison: None available.

Findings:

A skin marker has been placed along the plantar-medial aspect of the forefoot at the level of the tibial hallux sesamoid.

There is a homogeneous low signal of the fibular hallux sesamoid on T1-weighted and fluid-sensitive sequences, likely reflecting sclerosis, which can be seen in the setting of avascular necrosis. The tibial hallux sesamoid appears within normal limits.

There is no evidence of acute fracture. The joint spaces and alignment are maintained. The articular surfaces are intact. There is no significant joint effusion.

The visualized extensor/flexor tendons and ligaments are intact.

There is no Morton's neuroma. There is mild first webspace intermetatarsal bursitis.

There is no abnormal signal in the musculature to suggest atrophy or denervation.

The subcutaneous tissues are unremarkable.

Impression:

Findings compatible with avascular necrosis of the fibular hallux sesamoid.

Avascular Necrosis: Article supporting Bone Stim

Some of my patients get avascular necrosis (dead bone) after a sesamoid fracture. I have seen patients heal just fine with prolonged protection with orthotics and dancer's pads, improved bone circulation with contrast bathing daily, creating the 0-2 pain free environment for healing, and the Exogen bone stimulation. Attention should also be made to the overall bone health with healthy diets and Vitamin D deficiencies. Occasionally, it is apparent that a Bone Density screen is needed. Poor bone health overall will definitely slow us down. This review article on avascular necrosis, like all articles on this subject, are all weighted toward surgery, but does have many good points on conservative treatment and appropriate imaging. For the sesamoids in particular, get a CT scan if AVN is noted. The chance of healing is low if the bone has fragmented, which only the CT scan really shows well. 

https://curesearch.org/Avascular-Necrosis

Recovery from Sesamoid Avascular Necrosis:Can he avoid surgery?

Hi Rich

I hope fall's arrival is treating you and your family well.  I noticed that on a video or two you are wearing cornell gear.  I graduated from cornell in 1984 and my daughter graduated with both her BA and MS. 

Dr Blake's comment: What a wonderful school!! I actually went to Cal Berkeley, but my oldest son Steve went to Cornell. He loved it, and really blossomed as a young man.  

wanted to give you and update.  It has been 6.5 months since my injury and Since labor day, I have resumed partial weight bearing, after 12 weeks NWB (bc of avascular necrosis).  Have had PT since july and ongoing.  Progress has been slow, prob 75 to 80% weight bearing, but can't seem to do more than that without getting pain beyond (0-2) and getting some swelling on the big toe joint.  Feel stalled for past 2 weeks.  Still in walking boot 80% of the time and using crutches to control weight bearing 100 percent  of time.

Dr Blake's comment: Of course, the daily routine of pain level is fine. You can not push it. You should be bone stimulator daily, ice pack twice daily, contrast bathing in evening, massage 2 minutes 3 times a day with the palm of your hand, 1500 mg calcium, 400 units or more Vit D, 1/2 inch adhesive felt in boot as dancer's padding off weight, and a soft orthotic with 1/2 to 1 size larger shoe in the wings. 

  Since injury, I Have seen 2 ortho foot and ankle MD's who counsel patience and slow rehab, and the diagnosing podiatrist (Ivan Herstik, MD, do you know him?  affiliated with NY School do Pediatric Medicine, says he has done over 100 of  these  with many good outcomes ) who feels I have maxed out on conservative measures and recommends surgery.  He feels risk of arthritis and other factors could limit my mobility in the  future even more if I do not get the medial sesamoid excised as I am only 54.

Dr Blake's comment: No, I don't. I would see one of the podiatrists in New York for their opinion that I know: Dr Karen Langone, Dr David Davidson, Dr Robert Conenello, and Dr Joseph D'Amico. Arthritis can be watched for as joint limitation and plantar changes of the first metatarsal. With all the followup MRIs, typically every 6 months, it is hard to imagine missing the development of arthritis. It is still with you in the discussion of "preventative surgery" and I do not have a great feel of those 2 words used together. 

I am going to get custom orthotics from a well regarded pedorhist next week or so. I may also try aqua therapy at Burke Rehab.  Still getting once a week acupuncture and exogen (5-10 min 3-5 times a week, cannot tolerate more as it sometimes causes more swelling and pain if I do too much) and contrast foot bathing 1-2 times a day.   My thinking is that if I cannot walk with minimal assistance (cane) and keep pain level manageable by Thanksgiving (only 6 weeks away), then I will likely get surgery.  My QOL has been low to nonexistent since april.  thanks goodness I have supportive family to help.

Any advice or reflections would be helpful

Dr Blake's comment: I try to tell the patients I am treating to give me a year. If their quality of life is still too hampered, and usually we have now 2-3 MRIs by then which do not show enough improvement, then surgery is needed. But, it is rare to have the surgery, but only 1 out of 20 get significant AVN. If you haven't gotten, please get a CT Scan in the next month, because it is the best test for AVN and for arthritis. The protocol for sesamoids that alot of docs use is 3-4 months to heal, and if not, remove. I have many patients that healed fine in that time, and some taking several years. Vital to the surgery is the manufacture of good off weight bearing orthotics for the year post op. It is also vital to the avoidance of surgery. 

By the way, for my Left foot sesamoiditis, I am finding zero drop or low drop sneakers helpful.  Altra shoes in particular.  Tried Hoka Bondi but the early stage rocker design was too much (although super max cushion ) and seemed to aggravate the sesamoiditis , maybe because toe was curved toward in that early stage rocker design?  they recommended constant 2 which has later stage rocker and is a more stable cushioned shoe, but I will wait to try until I see how I am doing over ext 1.5 months

Dr Blake's comment: I love the Hokas for sesamoids, and typically the Hokas with orthotic with dancer's pads with spica taping can work. But not for everyone, and the subtle differences in Hokas can make a difference for sure. Good luck and thank you for your kind words. 

Your blog is great and dedication to help others is admirable.  making another donation today

Best

Possible Sesamoid AVN: Email Advice

Dear Dr. Blake,

First of all, thanks so much for the invaluable website. Your knowledge - and the experiences shared on the website - have provided me with so much support and education whilst I've battled through the sesamoid minefield!

Here are my details:

• Active 27 year old;
• Pain in the area of my right lateral sesamoid for about 5 weeks;
• Before the pain started I ran about 5 miles 3 times a week;
• I think a spin class, in which I had to wear tight fitting cycle shoes and pedal right over the sesamoid area, triggered my pain, but from MRI images my doctor thinks it has been fractured for years.

For the first week or so the pain was intense. So intense I could walk only on the outer edge of my foot.  So intense it kept me awake at night and even the pressure of the bed sheet hurt!

After the first week the pain got much better - I started wearing a gel dancer's pad and think that helped to take off the pressure from the area.

Since then, the pain is always there, but it's minor. I can walk "normally" and the pain is a 2 or 3. It's just really annoying. Occasionally it gets worse and is more like a 4 or 5; doesn't seem to be any rhyme or reason to this - it can get worse even when I've been lazing around all day and haven't been on my feet much.

I'm too scared to run - it feels like I'm living my life on a tight-rope right now and that one bad move will put the pain right back up and undo any healing I've helped promote. Does that make any sense? I'd give anything to put back on my running shoes and go for a run - I don't think it would cause pain during the run but I'm terrified of making it worse.

My doctor thinks my lateral sesamoid is AVN and said the MRI shows "signs of degenerative change" around the area. 

His view is that I should try custom orthotics (they'll cost me nearly $1000) and then if it's still causing me pain in 3 months, surgery is the only option and is "risky" with "potential side effects". I get the impression he thinks I should just "live with this". Apparently I should avoid getting a shot because it could make it worse?

I'd be so grateful for your thoughts: does this look like AVN to you (MRI pic attached)? Apparently he thinks it is AVN because the lateral sesamoid is "black"? If it is AVN, can the sesamoid recover from this? If not, when it "dies" completely could it become symptomless?

An article I read by you online suggests a CT could help to diagnose AVN and that an Exogen bone stimulator could help; what is your thought on this? Your article actually resonated with me so much because it sounds like my exact situation, I couldn't believe what I was reading because I feel exactly the same as this patient: http://www.podiatrytoday.com/blogged/treating-possible-case-avascular-necrosis-sesamoid-bone

Best wishes and thanks again for the great website,

Dr Blake's response: Thanks for your kind words and patience with my response. I am sorry I could not put the image on my blog, but it had your name in the corner. However, it looks like a normal healing fracture of the sesamoid, the black on that view is the bone swelling. On the images that show normal bone black, the sesamoid will look white. The initial healing of a fractured sesamoid is 3 months, and I do not like my patients to push off during that time. They typically wear an Anklizer type removable boot, with a insert with a dancer's pad. You can go out and buy OTC inserts that provide cushion at the front of your foot and some arch support. You can buy 1/8th adhesive felt from www.mooremedical.com to use for your dancer's padding. You can use the 

https://www.powersteps.com/product-pages/original

powerstep insole above to attach the dancers pad and even apply more arch. If the area under the sesamoid is still too hard, you can sand down the buld in half. Work on the swelling in the tissue with twice daily 10 minute ice packs, and evening contrast bathing. Before you get out of the boot, get your CT scan and look for the sign of AVN called fragmentation. I have had patients become asymptomatic with AVN, but it takes a year to know where it is heading. You typically qualify for an Exogen bone stimulator at 3 months post initial MRI or xray if the ordering physician repeats the test and documents delayed healing. The 4th and 5th months are the months that you begin to wean out of the boot into normal shoes. You have to be maintaining 0-2 pain levels and this rule dictates what you need (what does it take to keep the 0-2 pain level): carbon insoles, custom orthotics, rocker shoes, spica taping, etc etc. Hope this all helps and makes sense. Rich

Possible Sesamoid AVN: Email Advice

Good morning Dr. Blake

I found your blog by searching help for my condition, I was just diagnosed with an avascular necrosis of the sesamoid bone. 

I have an increasing pain since last august, at the beginning that was nothing, just like small cramp when I was walking but it gets worse since November. I did X-Ray and MRI and my doc in France concluded a " contusion " of the sesamoid bone and I had some insoles to wear in my shoes, but it doesn't do any real difference and the pain continue to increase. 

Finally, I saw a doc here in the US and he told me that was a AVN after taking new X-ray and MRI where we can see more cyst in my bone. As I understood, that the worst case we can have for this bone, and I don't even remember any event in my life around last summer as a bad jump or a fall ! I don't smoke, I don't drink any alcohol except a glass of wine every two or three weeks.... 

My doc wants me to wear a walking boot for 6 weeks to try to ease the pain, and he will give me my options then... But he never talks about healing the bone, only release the pain ! 

Is there anything we can do to heal the bone ? Dis it happens to someone ? I'm only 24 years old, I never had any bad health problems before, I don't run, I'm normally active but doing low impact workouts for years... I'm getting very pessimistic, I will enter in one of my most important year for my career as I will graduate soon, and I'm afraid that this condition would ruin all my hopes ... 

Dr Blake's comment: 6-9 months of Exogen bone stimulator, along with some weight bearing with orthotics and dancer's pads can turn this around. I believe avascular necrosis can only be diagnosed on CT scan, so consider getting one. If the bone has fragmented, definitely consider surgical removal. 

Does the surgery help ?  My doc told me that if we remove the bone the other bone can get the same... Will I walk normally again someday ? :( 

Dr Blake's comment: Since you did not deserve this, is there any problem with bone density or Vit D deficiency?If you are a vegetarian or vegan, you may want to temporiarily change or at least get a dietician to consult.I have never seen the other bone have a problem, but sure it could. This is one of the reasons you try to save the injured one now, even if it seems alot of time. And it is never at a good time to injure this bone. 

And my other foot begins to be painful too, but the X-ray shows nothing abnormal ... 

I'm trying to walk less as possible, I'm wearing a " step " bracelet and I set the vibration at 5000 steps, and try let it vibe as late as possible in the day ! But i'm working in a lab and you always have to go get stuff in other buildings or just walk in you own building because your experiment requires to go to different rooms.

I also stopped to workout, I was doing occasional weight lifting (no squat or lunges) and some " horizontal " bike, a thing I can do without using the ball of the foot, but I don't have the feeling it helps my bone. Should I stop everything ? I stopped for 2 weeks now. 

Dr Blake's comment: We need circulation, leg strength, cardio, and weight bearing. This is a good time to test things out to see what does and does not bother you. Simply putting the pedal of a bike on the arch can off weight the area enough to help. 

Sorry for the tone of my email, I'm completely down by the news...

Dr Blake's comment: Send me a photo of the 3 xray views when you can to see what they are calling AVN. And ask about a CT scan.

If you have any advice to give me, I would be so grateful ! 

Best,