Sesamoid Fracture: Email Advice

Dr. Richard Blake,

I recently broke my sesamoid bone walking in a new pair of work shoes. As you can see in the xrays the fracture gap seems wide to me. How does one bridge the gap? And should removal surgery be on my mind. I am three weeks into the boot and just ordered a stimulator. I am hoping a couple months on the 0-2 level promotes healing. What are your thoughts? Is full recovery possible after therapy? Thank you for your videos and time.

Very Respectfully,

Dr. Blake's comment: Thank you so very much for the email. I am glad you are in the boot, and should stay that way for 3 months. The bone stimulator should be a 9 month ordeal, even if you are back running by then. Here is some advice that holds true from another post. 

1. Put your foot on an ice pack 3 times daily for 10 minutes to reduce inflammation. You want to have all some symptoms from the break and none from the surrounding inflammation. Avoid anti-inflammatory meds since they can slow down bone healing.
2. Talk to your podiatrist about getting a bone stimulator from Smith and Nephew called Exogen. You place on your foot 20 minutes twice daily. The bone stim company will work with you insurance company so you know what you have to pay beforehand. The bone stim will probably for the next 6 months.
3. Discuss you Calcium and Vit D levels/intake with your internist to make sure they are not a problem. I would consider a bone density screen, and especially if you have any family history of osteoporosis. Get your Vit D 25 levels.
4. Make sure you can make that removable boot into a painfree environment. All podiatrists know that one well.
5. Learn how to do spica taping as shown on the video above.
6. Get a baseline MRI. Plan on another one 3 or 4 months later.
7. Have a PT show you some simple strengthening exercises to start doing now. Everyday you are losing strength, and it will take longer to get better the weaker your foot is, but you can not produce pain. My blog has ample exercises that you can review with the physical therapist including playing the piano, metatarsal doming, flat footed balancing, and inversion/eversion resistance band exercises.

Surgery is needed in 10% of the population, for many reasons. From 6-12 weeks in the boot, you will need to find someone to make good orthotic devices to protect you as you wean from boot to shoe. Some will use the rocker on the Hoka One One shoe to help, others just find the traditional athletic shoe is fine. Try to get some Dr. Jill's dancer's padding to begin using. You will need some protection, even slight, for up to 2 years at times, so the Dr. Jills can be used in sandals, high heel shoes, etc. Xrays are a small help, but MRI is crucial I think, especially if it gets to the point of deciding on surgery. I hope this helps you. Good luck in your journey as the country gets back to some normalcy!! Rich 

Sesamoid Fracture: Email Advice

Good Evening Dr. Blake,

I came across your blog and just had wanted some advice. My wife fell off a ladder doing some house work and fractured her sesamoid bone. She has been in extreme pain ever since. We have seen numerous doctors and foot and ankle specialist to help alleviate some of the issues she is having, to no avail. She injured her foot on December 31^st 2011. The pain has not stopped since. She is pain medicine but that just dulls the pain momentarily. All the doctors/specialist we have seen seem to be giving us the run around saying things like “this is a complicated situation I really cant help” or its got to heal on its own type answers but no relief from pain. I know sounds unbelievable right. Also she has been in a hard cast for about 5 weeks, then a soft shoe, and now in a boot. Pleas doctor provide some serious help, I hate to see my wife in so much pain.

Dr Blake's Response:

     Thank you very much for your email. Where do we begin? Sesamoid Fractures are normally treated for a year  and then removed if the problem is not responding. Therefore, due to the length of time you are a candidate for surgery. But, if you want to attempt to avoid surgery, over the next 3 months I would do the following:

1. Get a current MRI to check the status of the healing.
2. Ice the bottom of foot for 10 minutes three times daily, up to 10 minutes every 2 hours.
3. Create a pain free environment for all weight bearing activities even if that requires crutches, boots, special shoes, etc.
4. Make sure the shoes and orthotics that you are wearing do protect the area (go to a shoe store and try on various shoes with your orthotics and feel the difference each one makes at changing the stress through the area---you may be surprised what feels the best). 
5. Make sure your orthotics have some form of dancer's pad to float the sesamoid.
6. Get a bone stimulator if the doctor feels that the fracture is slow at healing (I love the Exogen unit from Smith and Nephew).
7. Since this is a fracture, bone health is critical. Have your Vit D levels drawn to make sure you are in a good spot. Get a bone density screen to see where you are compared to normal. If not already, start taking 1500 mg Calcium daily and 1000 units of Vitamin D.
8. Analyze what you are doing during the day that really aggravates and avoid that with a passion. 
9. Learn to spica tape (I have several videos on different techniques within this blog.
10. Consult with a pain specialist to help reduce the pain level so that you can rehab the leg. If the pain is too great, the patient will not weight bear, and the area gets weaker and weaker. 

I sure hope this helps you get an initial plan at least. Rich 

Enjoying another night at Oracle Arena, home of my Golden State Warriors