Sesamoid Fractures Handout Reviewed

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Sesamoid Fracture: What You Need to Know

Dr. Blake’s Patient Handout

Sesamoid fractures—small breaks in the tiny bones beneath the big toe joint—are stubborn injuries that often take months (or even up to 2 years) to fully heal. But with the right strategy, most patients recover well.

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✅ Top 10 Initial Treatments

1. Bone Stimulator (Exogen) – Use daily for 6–9 months to enhance healing.

2. Boot or Stiff-Soled Shoe – Wear consistently for 3 months to keep pain at or below 0–2.

3. Ice and Contrast Baths – Ice twice daily + nightly contrast baths (twice on days off) to reduce inflammation and swelling.

4. Custom Orthotics – Designed during the first 3 months to offload pressure from the sesamoids.

5. Dancer’s Pads – Learn to make and use these felt pads to relieve pressure (adhesive felt from Moore Medical works well).

6. Spica Taping – Learn taping techniques for use after the boot phase.

7. No Barefoot Walking – Always wear protective footwear, even at home.

8. Stay Fit – Begin safe cardio, core, foot, and ankle exercises as early as possible.

9. Nutrition Check – Ensure good intake of Vitamin D, Calcium, Magnesium, Zinc, and screen for bone density issues.

10. Activity Modification – Gradually return to normal activities over 2–6 weeks after the boot; avoid increasing pain.

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💡 Key Insights from Dr. Blake

• Most sesamoid fractures heal, though slowly—be patient.

• Imaging is crucial: MRIs or CT scans provide clarity, especially 5–6 months after baseline.

• Sometimes the problem isn’t a fracture—diagnostic accuracy matters.

• Bone health is key: Evaluate nutrition, vitamin D3, and bone density.

• Recovery follows 3 overlapping phases:

  • Immobilization

  • Re-Strengthening

  • Return to Activity

• Avoid phase mismatches: don’t resume activity too soon.

• Your treatment team should plan for the return-to-activity phase from the start.

• Protected weightbearing (not non-weightbearing) is usually best—walking helps flush out swelling.

• Contrast baths are the gold standard for swelling reduction.

• X-rays alone are not reliable—advanced imaging is often needed.

• Joint mobility must be preserved: Start pain-free range of motion exercises early.

• Strengthen early: Even modified strengthening helps prevent long-term weakness.

• Setbacks are normal—don’t lose hope.

• If you’re dealing with a fracture, get a bone stimulator early (self-pay if necessary).

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📺 Bonus Tools

Visit YouTube and search:

• “drblakeshealingsole Self Mobilization”

• “drblakeshealingsole foot and ankle strengthening playlist”

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📌 Final Thought

Healing a sesamoid fracture takes time, consistency, and smart treatment choices. Stick with your plan, monitor your symptoms, and don’t hesitate to seek expert care if progress stalls.

Sesamoid Injuries: Thoughts on Chronic Inflammation

Patients with sesamoid injuries deal with three types of pain: mechanical, inflammatory, and neuropathic (nerve-related). I thought this discussion with a patient would be helpful. They are trying to progress from non-weight bearing (NWB) to a weight bearing (WB) removable boot. 

Hi dr Blake, I seem to be finally making some progress as pain has significantly decreased. Starting the day of thanksgiving I have been on a knee scooter 95 percent of the time not stressing my foot at all. When I do need to walk it’s not more than a few hundred steps a day in my walking boot. I’m getting ESWT done weekly and have had a few sessions of dry needling with my PT. My custom orthotics have come in and they have been helping with the sclerotic sesamoid pain on my left foot.  I also have gone back to the gym to try and fight some of the atrophy I have faced all this time by doing NWB leg strengthening exercises. Though the pain has decreased, the inflammation is still present, and especially at the end of the day is it worse. I’m not sure when it is time to transition out of the scooter and into the boot or if I ditch the boot. Because even when I use the boot the inflammation is present. I don’t understand why inflammation is still there if it’s starting to heal, I would imagine if it’s healing the inflammation would subside. So it’s really hard to not get discouraged that maybe I’m not healing after all even though the pain has lessened. I tried to read the blog and find more out about inflammation but was hitting a dead end. Does it sound like I’m on the right track? Thank you

You are definitely on the right track, putting good pieces of this complex puzzle together. Dallas, there are two types of inflammation, acute (right after an injury), and chronic (related to the body's attempt at healing). Since inflammation causes symptoms, it is one of the hurdles you have to understand more. Swelling, which I assume you are doing contrast bathing in some regularity, will limit you, but you can still progress. Everything has to be done gradually. If you have been in a good place (0-2) for the last month, begin to transition from knee scooter to boot with your orthotics within the boot. The transition should be 2-3 days at one hour and then progress in 30-60 minute intervals every 3rd day as long as the pain remains low, and your expected increased pain is back to normal the next day. Hope this helps. Rich 

Tiem Bike Shoes with Embedded Cleats

For times when I want to immobilize the bend of the big toe joint for a while, but do not want the unevenness of a removable boot, I use bike shoes with embedded cleat. A patient came in with one the other day that I am using for a plantar fascial partial tear. I also use for sesamoid fractures, plantar plate tears, and hallux rigidus. 

Plantar View with Embedded Cleat

Top View of Tiem Bike Shoe

Cross Section Heel 
Area showing Partial Tear Plantar Fascia

Sesamoid Fracture Treatment: A hope to avoid Surgery

Hello Dr.Blake!

I am happy I found your blog post about fracture seasmoids. I’m hoping to get some advice or maybe just some encouragement!

So here goes! I am pretty active and enjoying hiking, running and workout classes. I suffered from turf toe back in 2016...after therapy and taping it got better. A few months later similar pain returned and it was diagnosed as sesamoiditis. Last year we found I had a complete fracture of my medial seasmoid. I was put in a walking boot for 6 weeks and the pain went away but fracture didn’t heal. The podiatrist told me to leave it alone if it didn’t hurt. Fast forward to a few weeks ago when I finally got a second opinion and I am now non weight bearing and using a bone stimulator twice a day. My biggest question is this, do you really think that after a year this fracture could heal without surgery? I’m pretty skeptical.
Dr. Blake's comment: Depends on the gapping or the fragments, the amount of avascular necrosis that has sent in, the biomechanics of your foot and activities placing stress or little stress on the fracture area, the overall fragmentation, the bone density and Vitamin D levels, eating habits, etc. You want to do the contrast bathing as a deep flush. A CT scan would give us the best imaging at this point.
     I have many patients that the sesamoid does not look great on any imaging, but do fine, and as long as we can keep the pain between 0-2, and they are happy with activity levels, I just follow them.


The pain wasnt unbearable I just wanted the second opinion because I am 32 and work a pretty physical job (PT assistant in an inpatient setting) so on my feet many hours a day.  I also enjoy running and hiking. Those are things I wasn’t able to do the past year so I have substituted with using a stationary bike and weight lifting. I have been using a dancer pad and started wearing hokas which I love but the pain still lingered. I feel like I’m too young to just give up but I am really hesitant to get surgery for this. My podiatrist said if this doesn’t heal she would like to do a bone graft and use it to pack in between the non healing fracture. It seems like more trauma to my foot than I’d like to deal with. I know I should be more positive because maybe this can heal with NWB and bone stimulation but again I’m skeptical. I should also mention I started taking a vitamin supplement to help bone healing.

I’m sorry for the long email I just thought you should have all the info.
Dr. Blake's comment: Unfortunately, I have had no experience the results of bone grafting. If you find any articles, please send my way. I just want to know if you have surgery, they are just not experimenting with you. I am not a surgeon, so I have to leave final decisions to surgeons, but send me one or two images of the fracture from a CT scan and I will give you some thoughts. Have your Vitamin D level measured. Go 6 months on this course, although at some time you will have to switch from NWB to a weight bearing boot for 4 weeks and then back into your Hokas. The bone stimulation should be 9 months period. Hope this helps. Rich

Thank you in advance for even reading this and thank you for what you do!

Sesamoid Fracture: Email Advice

     Hello, I have been reading through all of your blogs looking for all wisdom you have shared regarding sesamoid fractures. 

     I am a 53-year-old male in good physical condition(ran 3 times a week prior to the accident and continue to lift though only upper body now). On June 19th of this year, I fractured my right tibial sesamoid when I jumped from a lift at work. The fracture was initially misdiagnosed as a normal bi-partite bone so no conservative treatment was administered. It was very painful and swollen bottom, top and side of the foot.

     On Aug 3 was released from care by the "work care' Dr. and told that the swelling and pain was most likely gout.  On Aug 30 after a very painful flare-up went to urgent care center suspecting gout. Uric acid test, as well as fluids drawn from toe joint, showed no sign of gout.

     Saw a podiatrist on Aug 31 who took another x ray of the foot as well as an x-ray of the left foot for comparison and she confirmed the fracture. Was placed in an air cast rocker boot and told to restrict activities. Had another x-ray on Sept 30 (at the four-week point in boot cast) Podiatrist said she saw little if any healing.   
Dr Blake's comment: During the initial stage, if though gout was misdiagnosed, were you able to get fairly pain free for healing? X-rays are very poor to follow the progress of sesamoid, or any bone, fractures. 

    Started using a bone stimulator (first a borrowed Orthofix for a week, then for the last week I have used an exogen 4000 each day. Had a cat scan on Oct 11 that notes say bone is in the healing stage. Saw my podiatrist on Oct 14. She said upon examining the cat scan the two fragments were healing and would continue to do so but they would not fuse back together but that was fine it shouldn't be a problem. After all, many people naturally have bi-partite sesamoids. 
Dr Blake's comment: We see a ton of sesamoid injuries, most have healed enough that the patients are back to full activity with initially some protection of orthotics, dancer's padding, cluffy wedges, and spica taping. If we forced all of these patients to x-ray, even when clinically they have had a full recovery, the x-rays or CT scan would only show partial healing. It is the internal strength of the healing fracture that matters, and of course, some probably develop a non-painful non-union. This is why I like MRIs to follow sesamoid injuries. MRIs tell the amount of bone healing, and comparisons say 6 months apart, can really give us an idea how the healing is going. I get CT scans when I am worried about avascular necrosis or first metatarsal bone problems. 

    From the countless blogs and articles I have read this doesn't sound like the optimistic report that she is giving me. Can a non-union fractured sesamoid continue to function properly? 
Dr Blake's comment: Very individual. You would assume that the higher level of activity an athlete does, the less chance that would be comfortable. There are too many ifs, ands, and buts in your case. Get an MRI soon, and be ready to get another one 6 months from then to check on healing. The MRI is so sensitive to how sensitive the bone is now by the bone edema noted. Unfortunately sesamoid bones, since weight bearing, can be very sore, even when technically healed, due to nerve hypersensitivity, inflammation in the bone as in presses against the ground or first metatarsal, and from mechanical pulling of the tendons, the bending of the toe, the foot pronation force,etc. They can be so easy to teach, and then some are very challenging. 
     I currently don't have pain in my sesamoid area. I am however still in the walking cast boot. In addition I have a pre-existing bunion on this foot that has never presented any symptoms prior but now seems to become red, swollen and very tender a few times a week. When it does this there is also pain in big toe joint when moved. I am committed to using the bone stimulator for as long as necessary, do contrast baths once a day, ice once or twice daily. I also take calcium, a multi vitamin and vitamin D. I have attached a copy of the CAT scan report. I also have disk with images of all x-rays and the CAT scan in my possession. Any advice is greatly appreciated and much needed.Thank you very much for reading this.
Dr Blake's comment: You have a great attitude since you want to keep that sesamoid. Please get the MRI (do not need contrast dyes), and then send the discs and I will be happy to review. Good luck. Rich The CT Report sent:

Sesamoid Pain: Email Advice

Hi Dr. Blake, 

Thank you for providing so much information on your blog. It really is so kind of you to selflessly help so many people. I was hoping you could provide some thoughts on my current sesamoid issue. 

I started feeling pain in the ball of my left foot around the beginning of 2016. I didn't go to a podiatrist until December 2016, as I ignorantly thought the pain would eventually go away. The pain was always a dull ache. I continued to run, do plyometrics, and perform lunges and push ups during this time. 

The podiatrist in December 2016 took xrays (attached both right and left to this email) and determined I had a fracture. As the injury had been there for a long time, he said it probably was already partially healed so directed me to stop running for 6-8 weeks and put padding in my sneakers. I follow his direction but did not see any improvement.

2 Views left tibial sesamoid December 2016

 I continued with this non-impact activity and padding method until mid-april when I came across your blog and started wearing a boot with a dancers pad for three months. I iced twice a day and contrast bathed at night. I also was weight training and cycled on a stationary bike in a surgical shoe during this time.  The pain level was definitely within 0-2 so I thought it could be healing. After three months, I decided to try to get an MRI so I visited a doctor recommended by you, Dr. Dan Altchuler in Santa Monica. He took xrays (attached), thought potentially I could be feeling pain because my sesamoid was slightly pointed and suggested potentially performing a sesamoid planing to shave off the point. He was surprised that it didn't hurt me more when he was putting pressure on my foot and moving my toes in certain ways so he directed me to stop wearing the boot and padding. to see how it felt without anything. 

Recent Xray showing left tibial sesamoid irregularity July 2017

My foot definitely felt weaker from non-use and I had to force myself to put weight through the full foot, as I previously had inadvertently been putting weight on my outer foot. I didn't feel any pain while walking unless I went up on my tippy toes but I did feel a dull ache at the end of the day. I starting wearing padding again which has helped. I told Dr. Altchuler that I wanted to get an MRI, especially before any surgery. I have the CD and have taken a few images (the program doesn't have set images but instead I use a slider to change the image so I don't know if I'm using it correctly but I tried to screenshot images that appear most clear). I also just got the report today. I will try to scan tomorrow and sent it to you. I have an appointment with Dr. Altchuler tomorrow and will update you on what he thinks. 

MRI showing intense inflammation/bone edema in tibial sesamoid

I completely understand if you don't have time to review the attached images or the report I will send tomorrow, but I would greatly appreciate if you could share any thoughts you may have!!

Thank you so much!!

Dr Blake's comment: Thanks for sending me the views. Since I am not a surgeon, I am not sure about the planing procedure. The pain right now from the August MRI is the intense inflammation still present in the tibial sesamoid. It is trying to heal!!As you put weight down, that sesamoid pushes against the first metatarsal and gives pain. You have been in a boot long enough, but no Exogen. That could be a wonderful new chapter. You have to commit to a year of activity modification to continue the 0-2 level, 9 months of Exogen twice daily, icing and contrast bathes, orthotics with dancer's padding or just dancer's padding if the 0-2 pain level can be attained, repeat MRI in one year. You could get a CT scan to get a clearer view of the sesamoid for avascular necrosis, which could speed up the decision making. We need you to weight bear for mineralization, but not to crank up the pain. Hard, but doable. You were doing a great job on creating the healing environment. The bones can desensitize so doing surgery in the next year makes sense only if you are frustrated too much. No one would blame you, but I would just recommend taking the whole sesamoid out, and not risk not doing enough surgery. Again, I am not a surgeon. I am assuming you can do alot, and continue in a 0-2 pain level now, while adding the Exogen bone stimulator. With the hot MRI, you do not know if the sesamoid hurts because it is still partially fractured, or it is just very sensitive due to bone inflammation. I hope this makes sense. What are your thoughts and I will put them below? 

Fractured Sesamoid: Email Advice

Hi Dr Blake!

After scouring the internet in a desperate search of hope for my sesamoid injury, i have stumbled across your blog (thank goodness)!

I am dealing with a fractured sesamoid that i believe may have occurred in April 2017. When i originally felt the pain from the fracture, i did not think anything of it , as i have suffered from PF for years ( I am a 24 y/o female ). 

The pain began to increase in my left, big toe, so I finally made the decision to visit an orthopedist on May 12th. I was beginning to worry how my pain would affect my 1 year work trip to an unsafe location in the middle east, where i would be on my feet 7 days/wk , ~12 hrs/day. 

The orthopedist x-rayed my foot and told me, "you have an old split bone in your toe". Because he did not go into any further detail and simply told me to cushion my foot better, I continued on thinking this was an injury i had acquired many years ago from dancing ( and that has simply flared up temporarily ). 

As the pain became more severe, and my time in the US limited to only a few wks, I found a podiatrist. He immediately diagnosed my problem as a fractured sesamoid (left, big toe) and put me in a Cam Walker (which i have been wearing now for about 3 weeks). He wanted to over-treat the injury as he knew i was intending on leaving the US very soon.

I was also given 2 separate EPAT treatments to help with my PF.

Fast forward to my appt. this week, I told him i was  not getting any better and i had doubts that my foot would improve before my deployment. We both decided I should tell my employer that i needed to delay 2-3 weeks and they were OK with that.

My podiatrist ordered an MRI (which i had just a few days ago) and the results are disheartening. It says it is looking like a non-union and i am devastated as i have been planning for months to move overseas for this work trip.. I am now unsure what kind of time-frame to put on this injury and do not think i will be ready to leave in 2 weeks.

I am still in the cam walker (about a 3 pain level, i mostly feel a constant dull ache), i am trying gentle massage, cold/hot therapy, etc. I do get nerve pain/tingling in my toes when i lay down/ sit down. And my big toe has definitely lost its range of motion (which i am now starting to work on).

I am at a loss. Do you think this has any potential to heal in the next 2 months? 

I really don't know what to do at this point.

I really appreciate any insight and thank you so much for your time!

Sincerely,

Dr Blake's comment: These injuries can take quite a while (6-9 months) to heal, and if you rush them for whatever reason, you risk starting over. You are in the right boot now. You need to maintain a 0-2 pain level over the next year. You need an orthotic with dancer's padding to off weight the area, and can allow you to get out of the boot faster or get into a Hike and Bike shoe. instead of the boot. These shoes are not to be bent across the ball of the foot in an active pushoff, but are easily adapted by my patients and will protect the sesamoid. So, if you can get a protective orthotic to shift from boot, to Hike and Bike, to normal athletic shoes (consider Hoka One One Bondi), over the next two weeks, you should be well protected and can go on your trip with the Hike and Bike shoes, and a removable boot as a backup. Continue to ice twice daily, and do a deep flush with contrast bathes in the evening. Good luck and I hope it helps some. Rich

Sesamoid Fracture: Email Advice

Dear Dr. Blake, 

I hope you are well and thank you for your great book, blog and guidance that have been instrumental during this challenging time.

I have seen a few doctors and have felt that your book and blog were the most informative and caring/humane and that is why I am reaching out to you desperately at this critical point in my life.  It would mean the world if you can let me know your thoughts, insight and valuable advice, and of course this can be shared on your blog to benefit everyone.

Summary:

- Athletic and active 31 year old individual trying to get his life back

- Pain on and off for over a year under big toe

- Sudden sharp pain end of December 2016 while walking

- Increasing pain, saw doctor few months later in 2017, X-Ray Feb 25 (attached): Left medial sesamoid fracture.

No obvious fracture to the sesamoid can be seen on AP view

Plantar Axial View clearly shows the break and sclerosis (over whitening) seen in Avascular Necrosis

- March 22 started complete non-weight bearing (NWB) with crutches and had foot in walking boot with barely any foot/toes movement for 6 weeks (believe this probably wasn't the best path to take after reading your book and blog recently)

Dr Blake's comment: After all the walking you did not knowing you had a fracture, the fracture fragments are together, so it is not considered unstable. Some believe in non weight bearing for a time to let fragile bone elements get stronger, a theory, but I also find that the bone demineralization and swelling build up from non weight bearing which may cause 3 months of soreness for 6 weeks off the ground.  Then, after the 6 weeks, it is hard to evaluate the symptoms accurately. 

- Used to wear Dr. Scholl's flat feet soft orthotics in regular shoes, and the person that provided me with the boot attached a rubbery material to harden/lift the arch even more and cut out the part under the sesamoid so that it floats (image attached).

- MRI Taken on April 16 (after ~3.5 weeks in NWB).

- X-Ray taken on May 2 attached (after 6 weeks NWB)

- Saw doctor on May 3 (6 weeks NWB) and MRI report and video with images (file can be opened using Google Chrome) attached

- Avascular Necrosis of left medial sesamoid

- Plantar Plate Tear

Bone Demineralization from Non Weight Bearing

Arrow pointing to Intact Plantar Plate Ligaments

Arrow pointing to Massive Bone Edema ?Avascular Necrosis of Tibial Sesamoid

History:

Flat feet, overpronation, previous left ankle sprain several years back (no fractures), other than that healthy

Goal:

I would like to bring my sesamoid bone back to life if possible without aggravating the fracture and hopefully healing it at as well and getting back to normal active life.

Based on reading your book/blog, here are my proposed next steps and please let me know if you would prefer any alteration/addition.

Next Steps:

- Ordered Exogen bone stimulator to start asap, 3x day: morning, lunch, evening.

Dr Blake's comment: Twice daily fine!

- Starting Contrast baths

Dr Blake's comment: Start with 1 min hot and 1 min cold alternating each for a total of 20 minutes each evening. As you feel better, see if you can progress to 2 hot 1 cold for 18 minutes without feeling like the joint is getting stiffer. 

- Physio Therapy (PT) in the morning before work, workout with upper body weights and stationary bike in the evening after work

- Setting an alarm for every 30 mins just to move my ankle around (and toes?) a little throughout the day 

Dr Blake's comment: Excellent, definitely can not hurt yourself with moving your toes on your own. Don't forget using oil or gel to massage your foot for 2 minutes three times a day to de-sensitize the nerve over-reaction of protection. 

- 1 week partial weight bearing in boot w/ help of crutches, then get Evenup for other foot and walk in boot.
Dr Blake's comment: Get some 1/4 inch adhesive felt (moore medical) and make a dancer's pad for the foot of one or two layers to float the sesamoid some.

- Continue Calcium, Mg, and Vit. C and D supplementation with healthy diet

Questions please:

- Do I have a good chance?

Dr Blake's comment: For sure. One of my concerns is the plantar plate tear. Did you have a fall, the only way to tear at your age, or is this an other read? It will take 9 months or bone stimulation, contrasts, good bone health, and keeping the pain level between 0-2 in the healing range. You have to be willing to take the sesamoid out if it does not work, and it can take one year or so to figure it out. May need some help from friends to keep you focused. Have a surgeon picked out in your mind, but vow internally that you are going to prove you will not use their help. This is what I would do for myself. 

- Do I take any blood thinners to help blood flow for AVN, ex: aspirin?

Dr Blake's comment: Never heard of that research, so probably not. 

- I do not see swelling or feel pain (unless I press w.finger on sesamoid there is some). Do I need to ice? Not sure what is best given AVN and want to promote blood flow.  If iceing then how long and freq. please?

Dr Blake's comment: Icing gets a bad wrap on stopping blood flow, which is only temporarily. Read about Hunting Phenomenon below. 5-10 minutes is all you need to quiet the inflammatory aspect twice daily. 

http://www.sportsinjuryclinic.net/treatments-therapies/cryotherapy-cold-therapy/effects-cryotherapy-cold-therapy

http://www.sportsinjurybulletin.com/archive/1066-cryotherapy.htm

- Contrast baths, do I end with hot water to promote vasodilation?

Dr Blake's comment: No, always end with 1 minute of ice. Hopefully, the 2 articles above will help you understand icing or cyrotherapy better. 

- Spica taping? Any other foot or toe limiting movements I should apply?

Dr Blake's comments: If I ask 20 patients with this problem what is crucial, there would be 4 distinct camps. 5 would say spica taping is crucial, 5 would say Cluffy Wedges are crucial, 10 would say dancer's padding is crucial, 5 would say custom orthotics are crucial. Just got to try everything to see what is crucial for you. 

 Any while sleeping?

Dr Blake's comment: Typically nothing is needed. 

- Move toes around? Piano and other toe moving exercises? Both plantar flexion and dorsiflexion are good and won't deter healing or just stick to plantar flexion and ankle and 

 leg exercises?

Dr Blake's comment: We have to avoid impact stress, like jumping down hard, or forceful push off, but moving of the toes, ankles, knees, and most exercises can be slightly modified to take pressure off (like dropping your sesamoid into a hole made of four books so you can do balancing or stretches, or putting the weight in the arch with the pedal when stationary biking). Just listen to your body. But we need motion, some weight bearing, strength, cardio, etc. 

- When sleeping do I elevate foot on a pillow or does it press on calf muscle and limit blood supply?

Dr Blake' s comment: It depends how it feels in the morning. Swelling up or down. If down, no need to do anything. If up, try books between the boxstrings and mattress at the foot of your bed, and gradually raise up. Try 1 inch to start. 

- I am wearing a thin dancer's pad as well stuck to foot, do I keep that on?

Dr Blake's comment: Yes, you will be wearing dancer's pads for a long time. Typically, people can figure out how to attach it to the shoe or shoe insert. Here is where you buy a roll of the 1/8th inch adhesive felt to make your own. 

https://www.mooremedical.com/Index.cfm?Ntk=all&No=0&Search=Search&Ns=TotalRevenue%7C1&Ntx=mode+matchpartialmax&Ntt=Adhesive+Felt

- Would I do Exogen before or after the following: icing, contrast bath, PT, exercise?  Any particular order you would recommend for all these to make sure I promote blood flow and healing?

Dr Blake's comment: Icing after you do walking or exercises that you think may irritate things. Contrast baths usually in the evening as a deep flush to daily move out the swelling trapped in there. Exogen twice typically early am and before bed. 

- Massaging foot? just pressing hands (and on sesamoid too?) or shall I get a foot roller (any recommendations?)?

Dr Blake's comment: At this point, I would gradually increase pressure with your 2-3 times daily sesamoid and total foot massage just with your palms. You will have to go lightly around the sesamoid at first, but it is vital to de-sensitize the nerves to be right on the sesamoid area. 

- Cluffy wedge for now or later down the line or not needed?

Dr Blake's comment: Now, and as long as need that protection. Sometimes, it is hard to tell initially, but so many of my sesamoid sufferers swear by it. It may be more important when you are taking more normal steps. 

- How long in boot before transitioning to post-op shoe, then how long after that to hard-soled shoe?  If I insert carbon graphite inserts in my regular shoes, will these be too harsh on sesamoids? If not when can I do that?

Dr Blake's comment: The post op shoe is if you can not take any weight transfer onto the sesamoid, so that can be first or never. The boot, with an built in dancer's pad (sometimes up to 1/2 inch float, is more the starting point. Hard soled shoes can be a long time away, with soft soles (like Hoka One One with a Rocker, or Altra Olympus with just cush and zero heel height (drop)). There is a lot of experimenting that can be done as you begin to get comfortable walking in the boot, and you know on the horizon as shoes. Get familiar with Road Runner Sports and Zappos. These are online places with great policies on shipping and returns. 

- Boot is large, shall I bike in socks and put weight on arch/heel, or bike in post-op shoe at this stage?

Dr Blake's comment: Start with weight on heel initially, and after 5 times, and if you are feeling good with that, try a few times with the weight in the arch. As the weight goes into the arch, there is a little more pull on the tissue that attaches to the sesamoid. You can not hurt it, but the extra pull may be irritative right now. 

- Is Evenup high enough to balance other side of body? Purchasing one right away as already feeling a little hip aching?

Dr Blake's comment: Yes, there are 2 parts to the EvenUp, and one can be removed if the EvenUp is too high initially. Women typically have little problem finding a shoe with the correct heel height. More struggle for men. 

- When would I start acupuncture vs dry needling? which one?

Dr Blake's comment: Technically, they are the same, although many practitioners separate the nerve part and the muscle part. It is up to the skill and purpose of the practitioner. I always feel acupuncture is one of the best ways at increasing blood flow, increasing our body's own immune system, and desensitizing nerves. So, if given a choice, I tend to recommend acupuncture. Dry needling, is really acupuncture, but used for muscles more I think. 

- X-ray followups how often roughly? F/up MRI in 3 months? CT scan?

Dr Blake's comment: I would get a CT scan now to get the bone health. I would get a followup MRI 6 months after the first one to check progress. 

Any other advice or your usual inspirational words would help a lot and I really appreciate your valuable insight and support during this difficult time.

You're a life-saver, sorry for the long email and thank you from the bottom of my heart.

Sincerely, 

Dr Blake's comment: I looked at the MRI he sent by Google Drive, pretty cool that it can be done that way, and saw massive joint swelling which can wash out the visualization of the ligaments (so I emailed him to get a feel if there was any chance he could have torn his plantar plate). You could definitely see the sesamoid fracture with healing edema. 

Thank you very much for looking into it Dr. Blake. No high impact activities or falls. First time I had ever felt some minor pain in this area was a few years ago after walking around for a few hours in the city wearing very thin shoes.  Following that long walk, I had on and off pain every now and then in both feet, more prominent in the left.  I also think I might have not be walking correctly since I had sprained my left ankle several years back and was advised by a physiotherapy student/friend to put my weight on the area under the big toe while walking.  I have very flat feet and overpronation naturally though and have been wearing the Dr.Scholl's OTC orthotics pictured in my original email.  I used to play a lot of soccer but haven't been playing for over a year.  Before NWB I was going regularly to the gym to workout (5x per week): lift weights and bike, eliptical and run on the treadmill (~10 minutes each at high speed).  The night before the day I got the sharp sudden pain (fracture I believe) I was squatting a little heavier than I usually do at the gym, not very heavy weights though around a total of 160 pounds.  I was healthy and eating well with a daily Centrum multivitamin and at least a glass of milk a day. It was winter and I would probably go weeks with no sunlight at all though (work indoors most of the day and cold and cloudy weekends usually).  It was around Christmas and I had received winter boots as a gift and they were actually pretty tight on my toes, and the sudden sharp pain (fracture) hit me while wearing these after wearing them for about a week.

Thanks again for asking and that's all I can think of.  

Kindest regards,

Sesamoid Fracture: Email Advice

Hey Dr. Blake,
Thank you for all the hard work you put into your blog. I injured my sesamoid bone three months ago and your blog is the only thing I've come across with any good information. With that said, I have some questions if you have the time and can help me out.

I am a runner, but take very good care of my feet. I have never had any pain or problems anywhere but my right knee (once, after a half marathon last May). In November, I was on a walking break during an easy run and felt a "crunch" in the ball of my right foot. It was followed by immediate pain and I knew I must've broke something. Went in to have it x-rayed that afternoon, nothing looked off. The doctor said this is normal with fractures and to return in 4 weeks if the pain was still present (didn't mention anything about a boot at this time, just told me to try and keep weight off of it). The tricky thing about the timing of this, though, was that this happened the Thursday before I was set to perform in a musical for the weekend. I worked for 3 months rehearsing and wasn't about to quit right before opening night. So, I danced on it for three days (icing it when I could), and started some serious time off right after the weekend was over. My doctor wasn't thrilled that I chose this, but said I should be fine just for a weekend. 4 weeks later, the pain was still there. I went back and they re-did the x ray, this time there was a fracture visible in the sesamoid bone towards the inside of my foot (I believe you call this the medial sesamoid). He put me in a walking boot and scheduled a follow-up for 6 weeks later. He asked me to limit weight bearing activities, but told me I could swim, stationary bike, or do other things that didn't require my body weight. This appointment was mid-December.

I got along okay for 6 weeks, but I really miss running. I swim 3 days a week and do Pilates once or twice a week, too. When I went in for my 6-week follow up last Monday, the x ray didn't show any improvement at all. I'm feeling very discouraged. He mentioned that I'm a candidate for surgery now that it's almost been 3 months since the initial injury, but I'm wary of that option. My questions for you are:

1.) To me, this seems like a very acute injury rather than a chronic stress fracture. My doctor keeps using the words "stress fracture," but should I be treating it differently if it was a sudden, trauma-induced injury?
Dr. Blake' comment: Both are treated the same at this point. Stress fractures you never see the fracture line, and acute fractures yes. A stress fracture never goes  "crunch". So, you have a potentially healing fracture of the tibial or medial sesamoid. The nature of the injury is suspicious of some underlying bone health issue (like Vitamin D Deficiency) so that needs to be checked out. Did you change to a less padded or stiffer shoe just before that could have increase the stress?
2.) What can I be doing to help this darn stubborn little guy heal? I read some of your advice in the sesamoid post "advice when not healing well" and I bought some hapad metatarsal pads and dancers pads for my shoes, but I'm wondering if I need further immobilization?
Dr. Blake's comment: Yes, it is typically get the bone health evaluated and treated if needed. Get the biomechanics secure with off loading in all things, even the removable boot. Spend 3 months in the boot, and if you have attained the 0-2 pain level, begin another 2 to 6 weeks weaning out of the boot with no increase in pain. This usually means experimentation even begins now with orthotic supports, dancer's padding, spica taping, shoe change (possibly Hoka One One). I love of course Exogen bone stim, so see if you can use that for 9 months. It is way too early to consider surgery.

3.) Have you seen runners be able to return to the sport after healing their injury? I'm not finding anything encouraging online and I'm supposed to run my first marathon this November. My training doesn't start until June, but I'm starting to think it's really unrealistic and it's getting me down.
Dr. Blake's comment: Yes, runners get back to running for sure. You should not have any deadlines on your calendar, because that we potentially have you rush through the rehab and take too many risks. Set goals to get better not participate in events right now. Goal #1: Get out of the removable boot in 5-6 weeks into an equally painless environment.
4.) Is it a bad sign to not see any healing in an x ray after 6 weeks? I've been so careful and the only time I haven't been in the boot is when I'm in the pool or the stationary bike at the gym, at home relaxing, or using my Birkenstocks to take my dog for a walk (I don't feel pain when wearing those shoes).
Dr. Blake's comment: X-rays can be 2 months behind showing the actual healing of the bone, so are poor indicators of bone healing at times (and this is one of them). I love MRIs to follow. You need a baseline, and 6 months from now, if you need another one, that comparison baseline can come in handy. Good luck and keep me in the loop. Rich
Again, thank you so much for doing what you do. And if you make it this far, thanks for reading!

Sesamoid Fracture: Email Advice

Hello Dr Blake,

I hope it's ok to write you an email. I didn't know if it was better to write an email or post a reply on drblakeshealingsole.com. 
Thank you in advance to read my request here...

• Feb. 2014; sesamoid fracture
• Only in July 2014 (5 months after the fact) Doctors told me that it was fractured 
• Walk boot (camwalker) for 2 months

Dr Blake's comment: Here is where the initial mistake happens. The cast typically should be on  for 3 months creating a 0-2 pain level environment. Then there is a 2-6 week weaning out of the boot all the time maintaining that 0-2 pain level. If you can not maintain it, there is more time in the boot while the shoes and orthotics and taping and physical therapy are modified/started, etc. 

• Stopping all activities, pain while walking
• Till end 2015 (2 years without change); many appointments with different specialists all through that time
• My pain was chronic and I was looking everywhere for answers (tried dancers pads with relief)
• In December 2015, for the first time, an orthopedic surgeon gives me an answer. He suggests surgery to shave/smooth the bone fragments to alleviate tendon irritation and pain. He told me that my case is very rare, seeing only one in 5 yrs.
• 1 year passed and I finally got my surgery on November the 4th, 2016 (partial sesamoidectomy); which was anything but standard and required on the fly adjustments and «had to go deeper » (as the doctor said)

Dr Blake's comment: I have no experience, except one patient that it did not work. But, it is too small a sample to come to any conclusions. If it doesn't work, you have to finish it off with a complete sesamoidectomy, or find another conservative solution (thus the email). 

• 2 months later; still can’t walk, I've got less pain but the inflammation persists and is distributed – sometimes I feel it in my big toe... lots of tension in tendon. 
• I do daily massaging and stretching within pain threshold (not "assez fréquemment et sérieusement)
• Still not capable of foot flexing for movement

Conclusion:

Where do I go from here? Was told before the surgery that I would be better in 2 weeks, it’s been nearly 3 months now!

Dr Blake's comment: Any time a modified approach is taken that does not produce results, then a full sesamoidectomy is considered. This is similar to the hundreds of knee meniscectomies I have seen fail, only to have the patient go on to a knee replacement. Any foot surgery can take up to 9-12 monthes to get back to normal activity and still be considered in the normal healing. You were just told the most wished for course. 

But after the surgery, I was told it needed to be adapted and was a little "artistic" procedure.

What would you think in your professional opinion are the next steps to take?

Dr Blake's comment: For all I know, the surgery could be very successful, but it just going to take awhile. Typically start doing the normal things that work on the 3 sources of pain: inflammatory (ice and contrast bathes), neuropathic (massage, neural flossing, avoiding pain over 2, local anesthetic injections), and mechanical (boot, rocker shoes, crutches, orthotics with a good arch and dancer's padding). Create that 0-2 healing pain level environment and hope monthly you can gradually do more and more. 

Scheduled for 2nd post op appointment with not much difference in between.

The surgeon believes in a positive outcome (claimed pain free for a start!) maybe to keep my morale…

Thank you in advance for your opinion!

*If you need my last xrays, let me know!

Dr Blake's comment: I hope this helps you. I tell my patients if the surgeon tells you a month, give it at least 3 (and I love surgeons, we need them, but they can oversell the rehab part). Part of them making you feel good about having the surgery. Why didn't they just remove the whole bone? Was that logical? Ask for Plan B if this surgery does not work after a year. Rich

Sesamoid Fracture: Email Advice

Hi Dr Blake,

Thank you very much for writing this http://www.drblakeshealingsole.com/  blog.  Your website is the only one which has wealth of information regarding sesamoid issues. I have been following your blog and taking advise.

I have sesamoid fracture, I have been to 3 podiatrists, the advice so far, I got was, custom insoles and surgery.

The pain I have has gradually begun over many years, 5+, more so in last 3 years. My right tibial sesamoid has a fracture.

It started as little bit tingling and 0-2 pain while driving long distance, slowly the pain grew. I ran with the pain and even experimented with barefoot. The pain eventually got lot worse and even walking in dress shoes became painful.

My first podiatrist made a custom insole (it’s been over a year), which help off-loading my weight. The pain did not go away and he wanted me to go for surgery. As I was researching, I stumbled upon your blog. I changed podiatrist and pushed him to do MRI and prescribe Exogen bone stimulator. I got my MRI done June 2016 and finally got my Exogen Bone Stimulator on 18 Aug 2016. I have been using bone stimulator since then and had 151 (5 months) treatments so far.

Dr Blake's comment: Are you creating a 0-2 pain level? Due to the time from injury until now, it will take another MRI after 9 months of bone stimulation, to compare and see if you are improving/healed. So, in May (3 months or so from now) get a new MRI so we can compare them. 

I took your advice and started icing, contrast bathing and Spica taping. I have to admit that, I have not been regular with icing and contrast bath, last few weeks have been better. The pain and inflammation is down. I walk couple of miles back and forth from work. My pain is between 0-2 for few months now. But if I overdo anything, like brisk walking for couple of miles, I will see some soreness the next day. I have no issues bicycling or doing weight machines in Gym. I can’t do free weights as it puts lots of pressure on sesamoid and I see soreness for the next few days.

Dr Blake's comment: See if you can pad your foot with an off weighting (my four books with a whole in the sesamoid area) so you can do your free weights. The day you walk briskly, only do 2 ten minute ice packs or ice soaks that night and no contrasts bathes. If something particularly irritates it, heat in any form can inflame it more. 

I sometimes wear Salonpas Pain patch (camphor, Menthol, Methyl Salicylate) and it helps. Should I use this on an on-going basis? Will it interfere in anyway with healing?

https://www.amazon.com/dp/B00FOB5BOK/ref=cm_sw_r_cp_ep_dp_UlMGyb2Z6RMZJ

Dr Blake's comment: No that is a great idea, and I should recommend those more. Just do not use before activity to deaden any pain, you need to feel if you are irritating it. 

Does my MRI point to any other underlying issue like blood supply issues with sesamoid or the biparte causing damage to tendons or first metatarsal? Which may force me into surgery?

Dr Blake's comment: The MRI report did not discuss anything bad like metatarsal damage or avascular necrosis (patient shared some photos with me of her foot, and the orthotics, and MRI report over google drive with drblakeshealingsole@gmail.com). I was confused that the orthotics have no off weighting padding, they need to be full length and have a dancer's pad incorporated. You do not need another orthotic, just have the top-covers redone with the above.

If I can continue to do what I do, will it heal eventually?

Dr. Blake's comment: No guarantee, but no negatives right now. With the new MRI you will get a good idea of the healing. 

I live in NJ and work in NY city. I would like to know, if there is a podiatrist you know in PA/NJ/NY area which shares your view and can help me.

Dr Blake's comment: I recommend these these in no particular order: Dr Karen Langone, Dr Robert Conanello, and Dr David Davidson. They are around NYC, not in, so there will be some driving. One of my patients just saw Dr Joseph D'Amico in NYC and really liked him. He is at the school of podiatry I think.

Here is the MRI report from lab.

--------------------------- Report Start -------------------------------

Final Report

History: Chronic forefoot pain for 6 months. No trauma. Possible sesamoid fracture.

MRI of the right foot

Technique: Routine multiplanar imaging of the right foot was performed on a 1.5T MR scanner according to standard protocol. Field of view is focused on the metatarsophalangeal joints.

There is no prior study available for comparison.

Findings:

A Vitamin E marker has been positioned at the plantar aspect of the first metatarsophalangeal joint.

There is a fracture of the tibial hallux sesamoid, with associated bone marrow edema. Associated high signal of the adjacent first metatarsophalangeal medial plantar plate is also present, suspicious for underlying partial tear. There is strain of the abductor hallucis tendon. Subcutaneous edema is present within the adjacent plantar soft tissues. The fibular hallux sesamoid is unremarkable.

The joint spaces and alignment are maintained. The articular surfaces are intact. There is no aggressive osseous destruction. There is no significant joint effusion. There is no synovitis.

The visualized extensor tendons and ligaments are intact.

There is no Morton's neuroma.

There is no abnormal signal in the musculature to suggest atrophy or denervation. The subcutaneous tissues are unremarkable.

Impression:

Nondisplaced fracture of the medial sesamoid with associated bone marrow edema as described above. Associated grade 1/2 strain of the adjacent insertion of the abductor hallux tendon.

Dr Blake's comment: Keep your focus on the nondisplaced fracture aspect. Great sign. Good luck. Rich