Sesamoid Fractures General Rules

Sesamoid Fractures:

 

By Richard L Blake, DPM

 

The top 10 initial treatments for sesamoid fractures are:

 

1. Exogen (ultrasound based) bone stimulator for 6 to 9 months
2. Removable boot for 3 months to create a consistent pain free (0-2 pain level) healing environment with EvenUp over other shoe for balancing. This can be substituted by a bike shoe with embedded cleats for both feet.
3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths daily and twice on non-work days.
4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.
5. Learn how to use 1/8th inch adhesive felt to make dancer’s pads for the boot and for post-boot action (patients also love the Dr. Jill's Gel Dancer's Pads that stick to the foot or shoe)
6. Learn how to spica tape for post boot action
7. When you are not wearing the boot, avoid barefoot (house slippers like Oofos protect and cushion well).
8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!
9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.
10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot/bike shoe period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

 In my Book Secrets to Keep Moving, I review the 20 top general rules for sesamoids.

https://store.bookbaby.com/book/secrets-to-keep-moving-a-guide-from-a-podiatrist

1. They rarely do not heal.
2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
5. Follow up MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI. Always look at the first MRI as probably just your initial baseline MRI.

6.            The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis 

7.            Since we are dealing with bone, we must look at diet, Vitamin D3 levels, calcium/zinc/magnesium, and bone density.

8.            Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Re-strengthening, and Return to Activity.

9.            When the patient is in the Immobilization phase, the treatment visits should be thinking about (and acting on) the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, and cardio.

10.         Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase).

11.         One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.

12.         As treatment starts, the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc.) that maintains 0-2 pain level.

13.         The initial goal is to create this pain free environment for 3 months by whatever means it takes.

14.         Non weight bearing (via crutches or Roll aBouts) always increases swelling (which can be a big source of pain), so some protected weight bearing is crucial. Every step pushes fluid out of your foot.

15.         The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed.

16.         If you are basing treatment on x-rays alone, you may be way off base.

17.         Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques. Go to YouTube and type drblakeshealingsole Self Mobilization.

18.         Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist. Keep the joint/foot flexible and strong. No exercise should hurt however.

19.         Patients with sesamoid injuries are prone for setbacks so do not get discouraged.

20.         If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months wait to document delayed healing, some not. Self pay for Exogen Bone Stimulator is an option

 

How To Treat Sesamoid Fractures: First 3 Months

I hope this recent video on Sesamoid Fractures is helpful to many. Dr Rich Blake

Sesamoid Injuries: Questions

This is my answers to a student studying the treatment of sesamoid fractures with my comments in red. 

Thank you so much! Below are some questions:

1. Which method would you recommend for the rehabilitation of the sesamoid bone in the foot? 

     I prefer to treatment conservatively with a removable boot for awhile, then orthotics that can off weight the area. The only other method would be surgery, which may be unnecessary, and I think the last resort. Lack of response to treatment, coupled with MRIs showing bone fragmentation will sway me towards surgery. Any treatment done, if surgery is eventually needed, will help greatly in the rehabilitation (like designing a good off weighting orthotic device). 
2. Why this method? 

     My personality which is conservative, and seeing patients still having bothers after surgery sometimes, knowing that surgery is not always the perfect fix. Any treatment should get the patient to no disability, and conservative treatment can do that the majority of time. 
3. Which method would you say is the worst? Why?

     Neither, because both have their pros and cons. The surgical treatment for a broken sesamoid is technically easy, and gets patients back on the road quicker than stubborn cases of conservative treatment. The con of surgery is that you are potentially removing a vital bone, and surgical complications can lead to some permanent problem. Conservative treatment avoids bone removal (leaving your anatomy intact) and avoids surgical complications. However, conservative therapy may take up to 2 years to complete (generally 6-9 months is normal), which would be difficult in a highly functional athlete, with no complete guarantee that it will not, in the end, require surgery. 
4. What is the most common way of injuring the sesamoid bone in the foot? 

     From the impact of sports
5. Have you ever heard of someone getting arthritis in their big toe from a certain treatment?

     The sesamoid is bottom part of the big toe joint. If the bone is fractured and irregular is can start arthritis forming on the under surface of the first metatarsal. When I x-ray and MRI or CT, I am always checking for signs of that. 
6. If you had to put your patient in orthotic devices, would it be a Morton's extension or a Dancer's pad (apologies if my terminology is off, while researching I realized some doctor's use different names)?

      The six basic designs for sesamoid injuries, which can be used in some combination, or with all of them are:

1.  Enough arch support or varus wedging to shift the weight back into the arch and over to the 2nd and 3rd metatarsals as you move through your foot.
2. Metatarsal arch support to shift weight laterally (towards the outside of the foot).
3. Dancer's pads (aka Reverse Mortons) to shift the weight laterally as the weight goes onto the metatarsals at pushoff.
4. Cushioning under the first metatarsal head
5. Minimal heel lift not to shift too much weight forward
6. Stiff forefoot area to minimize bend if needed (at least a design that does not encourage excessive big toe joint motion).  

7. What sort of side-effects could occur if one was to perform surgery to remove the bone(s)?

     I find that the crucial question is why did the patient get this in the first place. If the surgery does not correct that, and most of the time it can not, then removing the sesamoid puts the other at more risk. Losing one sesamoid is not the perfect scenario, but you are still highly functional. If you lost both sesamoids, you have not protection for the first metatarsal head. Removing the medial sesamoid does make you more at risk for bunions, but if you start wearing toe separators and yoga toes, and start doing abductor hallucis strengthening, you can minimize that. Typically when you injure something, there is an obvious cause, and several still important less obvious causes. After surgery, you have to know what the causes were and prevent them in the future. I find this area is addressed the best while the doctors are trying to avoid surgery in the first place, learning why it happened helps with designing treatments. Only some of the causes are: poor running or walking styles, poor shoe selection, inadequate fat pad, high arches, plantar prominent first metatarsals, training techniques, improper cleat placements, poor bone health, transient Vit D or Calcium inadequate intake, over pronation, stiff foot that does not adapt to ground, etc. I am sure I have left out quite a few. 
8. It was brought to my attention that some people are born with their sesamoid already in two pieces, do they experience the same problems of someone who has broken their sesamoid experiences?

     Yes, even when the sesamoids are congenitally in two or more pieces, they can still fracture or bruise these small bones. I feel having the bone in multiple pieces greatly confuses the diagnosis. It is too easy to say they are congenitally that way, so they must not be injured. These separated pieces can develop fractures, but they are even more prone to sprains between the bones. These sprains are impossible to fully diagnose, and seem to cause lingering pain more than from a fracture. So, when I see the bone in more than one piece, and the pain matches a stress fracture level, I am more worried that they are going to have a difficult time healing (at least quickly). I sure hope all these answers help you and other reading. Dr Rich Blake

Sesamoid Injury: Email Advice (General Rules to Go By)

Hello!

I'm a surgery resident from Finland and I have a problem with my foot, for a little over two months now. I'm writing to you because it seems I can't get adequate advice here. I would be extremely happy with any insight. I realize though that there are tons of people writing to you every week. But if you decide you could spare me a few minutes, here is my story.

I'm 33 years old woman, and I love sports, especially road cycling. During winter it's not possible here, so I had a trainer with my (older) road cycle on it and rode it with clip-less pedals as usual, with the road cycling shoes I've had for a few years and ridden thousands of kilometres without any problems.

 Well, I did a few sessions that were a little harder and then one morning after a session I had pain in my right foot, right under the 1st MTP joint. I didn't think a lot about it, the pain subsided during the day and I forgot it. But the next morning I woke up in pain. I then began to worry and read my books and googled, and it sounded like sesamoiditis, with pain when dorsi-flexing or plantar-flexing the toe. I changed to a hard sole shoe (hiking shoe) and when I got to work, I taped my big toe and added cushioning to my shoe (shaped to unload the sesamoids). Also I iced (2-3 times per day) the area and took ibuprofein and rested.

My foot did not improve and a week later I took an x-ray, which was perfectly normal, no bipartite sesamoid or anything. Then I went to see a sports surgeon, who confirmed my diagnosis, the fibular (lateral) sesamoid seemed inflamed. He recommended orthotics for my shoes and physiotherapy. He suggested it was because when I cycle hard, I curl my toes and had overworked the sesamoids by doing this, with indoor cycling there are no natural pauses like there are when cycling outside.

 I went and bought Sidas insoles (I have a high foot arch), which made my foot stop hurting while walking in just a few days. I went full-weight bearing the whole time, no crutches, and I also have been working the whole time. The foot-specialized physical therapeut I got to see a few weeks later, he examined my foot, and said that my 1st metatarsal-tarsal ray was lower and more mobile than on the other side and did not work as normal, like when dorsiflexing my ankle, the big toe lagged behind compared to all other toes. I got exercises to correct this as well as new custom orthotics, that support the arch and try to raise the 1st metatarsal ray upwards. Both the sports doctor and the therapeut said I could cycle with the orthotics if I wanted to.

I still iced the area, did all my exercises and got a few new ones to correct the alignment of my whole leg - I seem to have my whole right foot pointing naturally slightly out. Most days the foot was quite ok, did not hurt much at all and I was able to walk normally. I went to a congress a few weeks ago, where I had to stand up and walk a lot during the day, and the toe became worse. I treated with ice and rest, and the pain subsided again.

 I started aqua-jogging to do SOMETHING (I love sports), and I've continued to go to the gym the whole time. Last week I had a good week with only a few stings of pain, and really felt I was getting better. Last weekend I was able to go cycling for a short, 10-mile ride, which did not really hurt (just felt the stupid foot being there) during or afterwards. Also I use kinesiotape, my therapeut showed me how, to "rise" up the 1st metatarsal ray (taping from under the 3rd metatarsal joint, then the tape goes across the dorsum of my foot and up the lateral aspect of the ankle), don't know if that has been helpful or not.

I was pretty hopeful that this would heal. But yesterday, when I forgot to put the tape on (don't know whether this has anything to do with it or not), it started to hurt again. No excess use - actually, I got a lumbago a few days before this and could not go to the gym either - no further trauma. Now I feel a kind of a burning sensation coming and going, extending all the way up the plantar aspect of the big toe, independent of whether at rest or standing/walking. It hurts more to walk than before. The fibular sesamoid is still a bit sore when palpated, but moving the toe does not really hurt. I've been wearing hiking shoes with very stiff, cushioned soles the whole time, and I have now Birkis shoes for work, they are also very stiff and quite thick and I use them with my orthotics. I'm losing my patience with this. I asked an orthopedic surgeon at my work about my foot, about whether to get an MRI scan, but he said that it would make no difference, that sesamoids heal notoriously slowly/badly and that he thinks surgery is a very bad idea anyway, so no help there. I found your blog, and read everything I found about sesamoiditis, and started to do the contrast bathing as well. But a lot of my questions go unanswered.

Sorry about the long story. I would like to treat this once and for all, properly, to get it healed. I'm just so tired of my foot feeling either painful or just not normal, and sometimes even I think amputation would be a great solution... Should I get a MRI scan done - what is the benefit? Is this pain relapse just a part of recovery? Can I ever cycle again - and if so, should I switch my cleat position to midfoot (road cycle shoes don't have much lee on this) or do other adjustments. Do you have any suggestions for me to promote healing? I'm desperate for help - and if I lived in the same continent, would definitely book an appointment.

Thank you a lot anyway, if you got this far in my long e-mail...

Dr Blake's response:

     Yes, I made it through. You explain everything very well. And, I think you are doing well for what we know. You have to treat the worse case scenario without the benefit of a MRI and CT scan. X rays are notoriously poor for diagnosis of sesamoid injuries. The worse case scenario, and definitely my diagnosis of choice, a sesamoid stress fracture. I love MRIs as a baseline of image, so push for that, and if we can see the images, it may change some of my thoughts. 

So, what do we know about sesamoid injuries that may help? Here are my top 20 plus pointers when teaching about sesamoid fractures. 

1. They rarely do not heal (and never need amputation!!!)
2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
5. Followup MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.
6. The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis (self pay MRIs of this area are $500 in the San Francisco Bay Area).
7. Since we are dealing with bone, we must look at diet, Vit D3 levels, calcium/zinc/magnesium, and bone density.
8. Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Restrengthening, and Return to Activity. 
9. When the patient is in the Immobilization phase, the treatment should be thinking about the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, cardio. 
10. Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase). 
11. One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.
12. As treatment starts, the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc) that maintains 0-2 pain level.
13. The initial goal is too create this pain free environment for 3 months by whatever means it takes.
14. Non weight bearing (crutches or RollaBouts) always increases swelling, so protected weight bearing is crucial. 
15. The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed. 
16. If you are basing treatment on x-rays alone, you may be way off base.
17. Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques.
18. Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. See the foot strengthening exercises all over the blog. Keep the joint/foot flexible and strong.
19. Patients with sesamoid injuries are prone for set backs so do not get discouraged. 
20. If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months, some not. Self pay for Exogen Bone Stimulator is around $500. 

I hope this helps you. Rich

Patient's response: 
Hello again!

Thank you so much for the previous answer. I hope you could be so kind to answer a few more questions.

I went and got a MRI taken today and watched it through with the radiologist right away. It appears I have fractured the medial sesamoid (and I thought the pain was in the lateral one, oh well...). The fracture is a simple one, so the bone is broken in two (diagonally), and it appears that it might already be healed from one side (one third of length of the fracture). No other problems were found. So, you were right, and thank you for that, now I know what I'm facing. I'm attaching an image from the MRI here for you to see.

The bone swelling in the fractured medial sesamoid appears white in this image

The medial sesamoid is seen with a crack line running diagonal. 

So it has been 11 weeks now since I supposedly injured the sesamoid. I haven't known what I have had so I probably have been treating myself wrong and been treated and adviced wrong. The whole time I've been to work and wearing stiff, thick-soled hiking shoes with orthotics. I can walk for short distances, slower than usual though, without pain. But if I walk too much, or stand for too long, the pain comes back (of course I try to avoid this), but the pain isn't too bad, I haven't been needing painkillers. From your posts, I see that I should be in immobilization phase? Is what I'm doing enough, or should I get a walking cast or something?
Dr Blake's comment: Yes get the boot, you are in a delicate time right now for healing. I would wear the removable boot with an EvenUp on the other side for the next 6 weeks as much as possible to insure the fragile fracture has a good chance of complete healing. You must side on conservative. Put your custom orthotics in the boot. 

I'm icing twice a day, and also contrast bathing every evening. Fortunately I can move my toe without pain, so I've been doing strenghtening exercises for the foot and the joint isn't stiffening. I eat a lot of dairy, and also take calcium, vitamin D and magnesium supplements. I go to the gym, to mainly do upper body exercises and core, and do aquajogging as cardio.
Dr Blake's comment: Sounds great. The next 6 weeks will bring you a more healed sesamoid, a less inflamed joint, a stronger foot and maintain your cardio. 

What can I expect? Do you think I'm progressing right with the foot? When could I go to Return to activity-phase and try to start cycling, or walking longer distances, and how? The radiologist suggested that a CT scan shows bone healing much better, so later on I might be going to get one. I'm also going to enquire whether I could get a bone stimulator (Exogen).
Dr Blake's comment: Definitely you want the 6 months of bone stimulator. I like the CT scan, but you could wait on that for now, since you are subjectively doing very well. Remind with the cycling the injury could have been produced by pushing down on the big toe joint too forcefully, so I would wait for at least another six months. You could do a stationary bike with the pedal in the arch now. Walking in stable shoes and orthotics, with a progression to a walk/run program, to progression to long distance running is a more controllable program from my distance with you. A physio there many look at your cycling mechanics and say you are fine to cycle, or recommend modifications to cleat/orthotic/clip, etc. Good luck. 

Thank you again so very much, you are a footsaver :)