Sesamoid Fracture Removal Post-Op Email Advice

Comment from my You Tube channel: drblakeshealingsole

I went 6 months on a fractured sesamoid without knowing it because it was misdiagnosed at urgent care. I then went a year trying the non-invasive treatments (post op shoe, full cam walker, bone stimulator and custom orthotics) before having the sesamoid excised. Now I’m about 2 months post op and I have reduced mobility in my big toe and numbness around the scar and the inside of my big toe near the web. Is this something I’ll have to learn to live with or can I do some specific exercise to gain more mobility and feeling?

Dr. Blake’s comment: I am not a surgeon, but have followed these problems over the years. Post operative healing to me goes in 4 time phases: 

1. First 3 months (Important to measure range of motion and get PT)
2. Next 6 months (3-9 month period post-op) Time where range of motion gains 1-3 degrees per month if that)
3. Next 3 months (9-12 month period post-op) Typically major gains in range of motion 
4. 2nd Year post op (5-10 degrees increase in range of motion can be gained)

     First of all right after surgery that tissue cut has to heal. This healing between the skin and fat layer, fat layer to fascia, joint ligaments, and joint itself gets to work by the inflammatory reaction of the body to trauma and fluid and scar tissue are the major players. Adding to the complexity of healing comes the bell shaped curve of how individual patients respond: some swell a lot and some not at all, some scar a lot and some not at all. And sesamoids have their own biomechanics that can make matters worse post op like:

• Pronation of the foot that is not being controlled with the pre-operative orthotic devices
• The presence of a plantar flexed first metatarsal that needs more dancer’s padding then average (see this all the time in high arched feet for example)
• The presence of very tight achilles and hamstrings that cause more forefoot pressure and should be stretched out

     So, what is the take home with all of this? You are too early in the course to make any conclusions. The reduced mobility is very typically due to both the scarring and swelling. The numbness is probably from the internal swelling pushing on the nerve, but if it was the lateral sesamoid removed, there could be some irritation to that nerve in between the first and second spaces. In general, that symptom resolves, but at times, it deserves some specific treatment. 

     To me, you should improve every month. February for example should be better than January and so forth. Since you have had your stitches out (for those who may not know), you have to work on swelling 3-4 times a day with medications, icing, and contrast bathing. Hopefully, you are in PT, and they are working on the joint range of motion. Have them review my video on Self Mobilization of Hallux Limitus and see if it appropriate. If it is, do it 3 times a day to begin to get the range of motion back. 

     I find that the range of motion (which should be measured monthly) of dorsiflexion naturally increases as you walk with limping more and more, and then run. In fact, sometimes my patients are stuck until they can run. You can also experiment with 1/8 inch padding under the big toe itself to encourage range of motion. 

     This is a perfect time for you to work on the inflammation, range of motion, strength of the foot, protection you get from orthotic devices, etc. I hope this points you in the right direction. Rich 

Incision Health??

Hello Dr. Blake,

I am 18 days post op from a medial sesamoidectomy. My podiatrist removed stitches on day 14. I've been advised to slowly ease in to walking part-time in a well supported shoe. With the remaining 80% of the time in a walking boot. 

I am concerned that my incision may not be normal. Looking at other medial sesamoidectomy pictures on the web, they seem to look "cleaner." Below are pictures of my incision at day 18. At times, I'm experiencing sharp pains when I touch parts of the incision. Is my incision normal? Or should I be concerned with the way it appears and feels? 

Dr Blake's response: 

I am not a surgeon, but the incision meets all the normal criteria: no oozing, no gaps, no infection I can appreciate. Rich Good Luck!

Post Sesamoid Removal and Neuroma Care: Email Advice

Thank you for inviting me to email you about my foot trouble.  

     In the middle of February 2015, I was in a car accident in which someone pulled out from a side street across my line of traffic.  I slammed on the brake and tried to swerve but ended up hitting him in the rear driver's side. My left knee got jammed into the dash and by that evening my right foot had started swelling up and got quite painful. 

     I went to walk in clinic to get checked out and they xrayed my foot. (Dr Blake's comment: x rays do not show small fractures ever or it can take up to 4 weeks).  She said she did not think there was a break.  A few days later I followed up with my primary who went by the urgent care's report and said it was sprain so ice and rest it and take a lot of advil.  I did, it was getting no better.  I went back to my primary a week later because both my neck and foot were not getting better so she sent me to PT.  My neck got better, my foot had no improvement.  It was hurting so bad it was waking me up several times a night. 

     After several weeks my PT said he thought it must be broken so  I went back to my primary who finally sent me to a podiatrist.  The podiatrist sent me for an MRI which showed the tibial sesamoid was indeed broken.  The podiatrist said that Urgent Care missed the break because they did not take the xray at the right angle. Now the pain I was experiencing was a sharp pain in the big toe joint area.  Driving was excruciating.  I also had pain between the 2nd and 3rd toes.  It felt as if there was a baseball under that joint, which changed to feeling like there was cotton stuck under there.  Sometimes it felt like it was burning. (Dr Blake's comment: This is nerve hypersensitivity kicking in. It is pain generating more pain by making the nerves hypersensitive inorder to protect you, tell you to get off it). 

    My podiatrist did not really address that concern but regarding the sesamoid he said that my options were to be completely non weight bearing for 2 months but that may not even work, or get the surgery (keeping in mind  by this point it has been about 2 months since the accident).  So on May 5, 2015 I had the tibial sesamoid removed.  After the surgery the doctor told me that not only was it broken but the cartilage between that bone and the joint above was blown out so he had to clean that up a bit. 

Dr Blake's comment: This was good news so you know the surgery was 100% necessary to avoid further injury to the metatarsal. 

    I went back to PT but stopped since it did not seem to be helping.  Last October I went back to the podiatrist because the big toe joint was still really hurting and the neuroma was still really bothering me.  He scanned my feet to make orthotics and gave me 2 cortisone shots at the big toe joint.  At first he was saying the pain was due to a bunion, but after the shot and after the difficult time he had administering the shot due to scar tissue he said the pain could be from the scar tissue.  He still did not address the neuroma.  The cortisone helped some for the pain.  I think it was late December before he gave me the orthotics.

Dr Blake's comment: I love to get orthotics to patients right after surgery, if they do not have them already, since I want them walking with sesamoid area protection. 

     In January, I went back because I just could not take the neuroma and at first he just wanted to pass it off as being because of a bunion but then he actually looked at my xrays and said that no that did not look to be the case so he gave me a cortisone shot between the 2nd and 3rd toe.  It helped take away some of the burning pain I was getting.

Dr Blake's comment: This doctor is just slow at doing good things!!!

     I wear the orthotics consistently in well fitting athletic shoes, but they don't seem to make much a difference. Actually the orthotics are so hard (and I did put a thin cushion on them) that when I get home I want to take my shoes off, but I don't because the doctor said not to go barefoot. My job keeps me on my feet alot on concrete floors.  I do have some antifatigue mats around and use them whenever possible.  But I find that if I have to stand or walk on those floors for even a half hour I can feel that neuroma and it feels like my foot is blowing up like a balloon. 

Dr Blake's comment: It is common to need up to 3 shots to calm a neuroma down. See if you can get the second one soon. 

     The big toe is becoming again painful (a sharp pain on the underside and side), but not all the time.

Dr Blake's comment: The surgery for a damaged sesamoid and undersurface metatarsal bruising can take up to 2 years to feel great. Typically a PT will be the most help getting the range of motion better, reduce the scar tissue, and get the muscles strong. I am assuming you are doing met doming exercises and simple self mobilization. Does spica taping help you?

     I went for a second opinion who said he had very little time, just said he recommended a couple more cortisone shots at that neuroma. 

Dr Blake's comment: What a comment!!! I apologize for the sacred profession of medicine. 

 I would like to get back to a normal life but if I try to walk too much, or run I pay dearly.  And I am not sure what to do.  Any suggestions would be greatly appreciated.  I can send you xrays if that helps.  Thank you so much for your time!

Dr Blake's comment: So, I would have the doc do at least one more neuroma shot with cortisone. Read on my blog about neuomas to see if there are other suggestions, like metatarsal pads. Get referred to a PT known in your area for feet and see what they say about the big toe joint and the neuromas. Keep me in the loop. Get a new MRI 2 weeks after you next shot. I would be happy to see the images. Just email me them by taking photos of each frame. What shoes or qualities in shoes have you found helped the most. 

Partial Sesamoidectomy: Email Advice

Hi Doctor Blake! 

     I have been reading your replies and not sure if you are still posting on this subject anymore but in hopes that you might I wanted to ask some questions. I actually had a partial sesamoidectomy. I think your anonymous writer is the only other person that I have found that has had this type of partial surgery. My doctor suggested this route because most of my sesamoid bone was healthy and no arthritis or any other ailiments. I had an injury many years ago that possible broke my bone in half but where it broke was nearer the bottom so it was too tiny to put a screw in. I had pain in my foot off and on for years but it was like flair ups and then the pain would reside and no big deal go on my way, however I had a cortisone shot done for my hip (which is another injury that I am facing and a couple of months after the shot that pain in my foot was back, it felt like a stabbing knife pain and this time it was not going away it was debilitating and extremely painful. I am not sure if the cortisone weakened the bone break even more but I can't really figure out what the culprit was all I know is I could not bear the pain any longer and this thing was not going way like in the past.

    So I went to see a foot and ankle specialist with an x ray he was able to see my injury to my sesamoid bone closest to the end of my foot. He could tell that it was an old break that happened a long time ago that did not heal properly. There was scar tissue between the bones where it tried to heal its self. So and every time I took a step the two bones were bending up and down, your sesamoid bone are not suppose to bend right!! Ouch! So of course I did the conservative route just like everyone else with no relief it finally came to a point that I had to make the decision to just have surgery done.

    I am 7 weeks out post op. My scar is healing great and I do deep tissue massages on it every other day. Toe strengthening and stretching. I am walking in a pair of comfortable boots, a tennis shoe with custom insoles, and some dearfoam thick comfy sleepers. I walk when I need to but I do a lot resting still and elevate my foot often. I still sleep with my foot elevated most nights. I took pain meds half dose for the first 3 days post surgery. I really didn't want to but I couldn't sleep and sleep is when we do our best healing so I took them to sleep.

    Now 7 weeks out I still have pain where the cutting took place. I think from reading this blog and the research that I have found this pain is normal and probably due to nerves being healed. My doctor said I could have this tenderness for up to 6 months, and possibly a year. I see my doctor again in 5 weeks which will be my 3 month appointment. My doctor did say however if the pain persist we may need to go in and take the other part out, but he mentioned that this is probably unlikely since the rest was healthy. If it wasn't he would have taken the whole bone in the surgery. He is under the impression the more original anatomy you have the better. I felt good with my decision to have a partial done. Now for me it just having patience and not over doing it. 

   I guess my question to you is does this sound normal at about the 7 week mark? Also I can feel that partial sesamoid bone like your other responder, and it feels tender but the super sharp pain is gone since that smaller part is out. My other question is do you think it will take longer to heal with a partial sesamoidectomy since there is still bone left and I heard that bone takes longer to heal. Or should I have just had the whole thing removed from the beginning?

Thanks
Kimberly

Dr Blake's comment:

     Kimberly, Thank you. This is such a rare procedure, that the med profession is learning on you. Everything sounds good. It is early, but I love the concept of leaving the good part in there. Please keep us in the loop with monthly or bi-monthly updates. I would think that it will take less time to heal if you leave 1/2 in, but I really do not know. Good luck my friend. Rich

Post Sesamoid Removal: Email Advice

First of all, Happy Thanksgiving to all of you. Whatever our circumstances, we all have some thing to give thanks for. I am very grateful for all the love I receive from family and friends and people I interact with. 

Second of all, I want to thank my readers for today this blog went over 1,000,000 page views. It is mind boggling, and humbling. I am proud and honored to have helped some of you, by at least pointing you in a different direction to try. Thank you. Rich

      Hi, Dr. Blake! I have a quick question for you... While I continue to have pain and issues after my tibial sesamoidectomy, bunionectomy, and fusion of second toe procedures, I have been pushing along using orthotics, TENS, stretching, PT, etc. I find that trekking in woods or doing some hikes (granted, I have been learning my limits...) is easier than walking on flat land, as I don't have to push off as much... I also row, use weights, and do Pilates/yoga to stretch and strengthen...


     My PT thinks I need to focus more on using my ankles/other muscles instead of my toes as much when I walk. With my high arch, I realize that I will continue to have issues after all of the surgical procedures, but I will live with it. That said, I am curious--my last MRI from a couple of months ago showed that I had "thickening of the flexor hallucis tendon near the lateral sesamoid", which is thought to be due to "chronic stress injury and/or post-surgical changes." This was shown on the MRI from April as well. Can this be considered flexor hallucis tendonitis?
Dr Blake's comment: Yes, that can be considered chronic tendinitis with more scarring and less inflammation at the time of the MRI. 

     I am just trying to figure out how to approach it at this point, as when I have very bad pain cycles, the first met head (right in ball of foot) is very painful to the touch, and feels inflamed constantly. It hurts no matter what I do. So when I am active, I make SURE to sure to use orthotics or rocker shoes, apply Voltaren gel, etc.
Just wanted to get some thoughts from you!
Thanks!!
Dr Blake's comment: You are probably doing what you can. There is so much force on the ball of the foot with a high arch foot. Make sure you use Cluffy wedges and dancer's pads (as described in this blog). Ice pack with reusuable packs daily for 10-15 minutes even when there is no pain. Attempt to strengthen the FHL and FHB tendons as best as you can (FHB with met doming and FHL with towel curling exercises). I do have patients with high arches that custom orthotics make too much of an arch. With the arch high, the metatarsal can get pointed downward too much. To check if this is the case, try a simple OTC orthotic like Sole. Place a dancer's pad on it. Check if the pressure on the ball of the foot is less. I hope this helps some. Rich

Sesamoid Surgery: Email Advice

Hi Dr. Blake,
Four months ago I had a sesamoidectomy after 2 years after the onset of my pain.  My post surgery follow-ups were with the orthopedic's assistant who was pretty clueless about the recovery.  He ended up referring me to a physical therapist which has helped reduce the scar tissue and increase my big toe range and strength as well as helping me to stop walking on the outside of my foot as I had for 2 years. 

     But I am now at the end of therapy and I still have stubborn scar tissue which is somewhat tender to walk on. Also as soon as I began the therapy and strengthening and stretching the toe I began getting numbness and tingling in the toe.  It's pretty persistent, but the "toe curls" increase that sensation.  This may sound strange, but that nail seems to have slowed/stopped in its growth.

Dr Blake's comment: Surgery is an incredible event that your body must deal with. All bodies deal alittle differently, but overall the surgical area gets the majority of the blood supply for healing, some being shunted from other areas close by. The nail may be alittle poor on blood supply for a while, but should come back to life within the next year. 

    So I am curious to know what is "normal", how long these symptoms may last, if they may be permanent and what I might still do to promote recovery.   Thanks for any insight or experience you have in this area.  

Regards, Bill (name changed)

Dr Blake's response:

     Thank you so very much for the email Bill. You are on the surgical plateau from 3 months post surgery to 9 months post surgery. It can feel like nothing is happening. This is when you stop PT in general, and do your daily stretching, strengthening, scar mobilization with Blaine Surgical Scar Kit, Hallux Self mobilization (as described on my videos), anti-inflammatory measures like icing and contrast baths, and wear your protective shoe inserts. Continue to honor the pain, keeping between 0-2 pain level. The next big change will be between 9-12 months when scar tissue maturation occurs. You will see during this period that the exterior skin changes from red to white. You will gain some range of motion. Your gait (walk) push off will be better. 

     So, during this next 5 months, when nothing happens quick, be diligent on daily stretching, mobilization, strengthening, scar manipulation, anti-inflammatory, and protection. It is hard to do, but very important, and for some, crucial. Hope this helps some. Rich

     

Sesamoidectomy: Patient Comments

Dr Blake,

I just wanted to send you a note to say thank you so much for taking the time to write your blog. It has been a huge help to me over the last year as I've gone through the drama of a sesamoid fracture. I thought I'd share my story with you. I'm sure you've heard plenty that are similar, but I hope you don't mind adding one more to the list. 

I fractured my lateral sesamoid (I think - it's the one closest to my 2nd metatarsal) July 2012. I was referred to a podiatrist, and at my first appointment she diagnosed me with a stress fracture of the 2nd metatarsal even though I kept saying that the source of the pain was right around that sesamoid. Nothing was showing up on xrays at this point so she told me that it had to be the 2nd metatarsal and that the pain was just deflecting for some reason. 

I was put in a walking boot for 6 weeks, which I diligently wore until I was told I could start to wean myself out of it. A week after I was finally out of the boot completely the podiatrist told me I could start a walk/run routine and build up slowly, as well as slowly begin swing dancing again (a hobby that my husband and I do together). I danced for a total of 30 minutes in 1 week and my foot ended up swollen and in more pain than before. I couldn't get in to my podiatrist for a week, so I put myself on crutches, ice, and elevation until I could get in to her. By the time we got to do an MRI a week after the swelling, I had managed to get all the inflammation down, but could not get comfortable in the walking boot again. So the podiatrist suggested spica taping and a dancers pad in walking shoes. The MRI also showed a fracture on the sesamoid at this point but nothing wrong with my 2nd metatarsal. So, I started doing my research online and found your blog, watched your videos to learn how to tape, and went from there. I used your taping method and a dancer's pad for 6 months straight while I went through the rest of my story. 

Dr Blake's comment: A bone stimulator would have been great at this point, and some discussion of dietary calcium and Vit D3, and the use of icing and contrast bathing daily (my favorites). 

By January 2013, my husband and I had to move to a new city for work, so my podiatrist sent me on my way with a referral to a PT for 6 weeks to try and get my foot healed completely in our new location. Four weeks into PT, the PT told me she thought I still had a fracture based off of my reaction to ultrasound therapy, and sent me for more xrays/MRI and suggested I go to a new podiatrist. My regular doctor also sent me to an orthopedic surgeon for another opinion. 

These xrays and MRI showed the fracture had not healed, the bone was fragmented, and there was signs of necrosis. 

Dr Blake's comment: Necrosis alone can be treated with bone stimulator, necrosis with bone fragmentation sounds surgical to me. 

The orthopedic wanted me to just stay off of my foot for another 9 months and see what happens. Just taping and a dancer's pad was all he wanted (oh, and he said soft-soled shoes, which I found really bizarre after reading your blog). I wasn't happy with a wait-and-see solution, as I had pretty much done that for 9 months already and couldn't understand how another 9 months would help. The new podiatrist, on the other hand, felt that with the state of my sesamoid it would be wisest to remove it. He said he didn't see much hope in it healing considering the damage he was seeing, and that we were at the stage of last resort. Normally I do not jump on the surgery band wagon quickly, but I didn't see much of an alternative either. Even the orthopedic had given the same diagnosis on my bone, he just wasn't willing to cut it and was hoping for a miracle. I queried e-stem but the podiatrist said I probably had about a 30% chance of that working, and considering I had just found out I was pregnant he didn't think the crutches for 9 months would be a safe idea. 

Dr Blake's comment: Congratulations!!!!!

So we waited until I was in my second trimester, got my midwife and an OB to both approve the surgery (they also felt it was better to take the bone out before baby was born so I had more time to heal before caring for a newborn), and made a plan with an anesthesiologist to do the whole surgery with a block instead of a general anesthetic. I took the brave step and had the sesamoidectomy 2 weeks ago, 13 months after this whole thing started. The good news is that the bone ended up not necrotic or fragmented when they got into my foot. It came out all at once, but either tissue or cartilage (the doctor said he'd have to order a lot of labwork to tell) had grown into the fracture, so the podiatrist said that it never would have healed properly and it was probably good we took it out (I hope this sounds right. It was a little overwhelming to hear right after surgery). 

Dr Blake's comment: I hate MRIs for the read of avascular necrosis. It scares many patients into unnecessary surgery when bone stimulators can help. I am unclear however how the bone fragmentation was not fragmented. I think MRIs show more internal disarray that we read as external disarray (ie. fragmented). But, soft tissue in the fracture would mean it could not heal. So, let's accept that as fact. 

Although I'm only 2 weeks out, and still non-weight bearing (I go for my 2nd post-op appointment this afternoon to see if I'm ready to start moving into weight bearing), I'm amazed at the difference I already feel. I used to get sesamoid pain even sitting on the couch or lying in bed, and now I don't. I haven't really needed any pain killers except for maybe a couple of times in the last 2 weeks. Normally the pain is staying below a 2 (yay good pain!), and icing the back of my knee (a trick one of the OR nurses taught me in recovery) reduces the swelling enough to lower the pain if it gets any higher. I have a little bit of weird nerve sensation in my big toe, but I see from some others on your blog that this seems to be a fairly common feeling post-surgery. 

Again, I just wanted to thank you for your blog. Your different posts on this issue has been helpful to read and has made it much easier for me to know what to ask and what to expect. I'm hoping that my foot continues to feel as good as it does now, but I'll admit I'm slightly nervous for the weight-bearing stage. 

Fingers crossed! 

Dr Blake's comment: The love this patient is really pouring out to anyone of you with sesamoid problems is easily felt. Thank you for your real time experience and honesty, something I can not give the reader. It is immensely vital. Keep me in the loop and to a gradual but easy healing!!! Rich

Post Sesamoid Removal with a Unusual Twist of Cartilage Removal: Email Advice

Dear Dr. Blake

     I had to have a sesamoid bone removed, the one where the incision is on the side of my foot. I also needed to have cartilage removed because it was dead or dying due to the injury. I had to wait 6 months after the injury for the surgery to get approval.

    Now, it is very painful to walk and my great toe joint is bending back and to the left. I use my hands to move it every night. But every morning it is so stiff and it is painful when I am bending it. Is it possible that during the surgery one of the tendons was accidentally cut? 

    I had the surgery in march 2013 and I still do not have normal sensations in the toe. It is partially numb and feels tingly when I touch it. If I am on my feet and fairly active it swells up, turns a bluish color on the top of the great to joint, and the pain gets worse. I always ice it in this case. MY question is I have a job that requires me to be on my feet for most of the day. I must wear boots as well and I dont think my foot would even fit into my work boots. Are these symptoms normal for the surgery ? When can I anticipate being 100 % Thank you for your time Doctor.

Dr Blake's response: 

    Thank you so very much for the email. You had major surgery on your big toe joint that may take several years to mend. Since you had cartilage also removed, the healing pattern is not as predictable as just removing a sesamoid. Basically you have an arthritic joint, and everyone is hoping you can walk on the damaged bone afterwards. See if you can push to get an MRI and send me the disc or email me some images. If you get to that point, I can help you decide which ones to send, but you can look at typical MRI images for Hallux Rigidus in my blog. 

     Start working with the podiatrist/orthotist to get boots 1 size longer so you have ample room to fit a protective orthotic device in there. Ice for 10 minutes twice daily the bottom of your foot, and do contrasts baths once daily to remove deep swelling within the bone. Massage into the area Neuro-Eze twice daily to help with the abnormal nerve sensations. I hope this helps some. Rich

PS We always must assume that the surgery was done correctly and that the expected outcome is for full recovery. However, complications of some sort occur in 10% of all surgeries (mostly minor). If your surgeon did not paint a doom and gloom picture after surgery, they are expecting complete recovery. However, you need to respect your symptoms and gradually increase activity, as you create a pain free environment, and work on the inflammation. Hopefully you are in shoes, removable boot, inserts that are protecting it as you walk. From there, you can safely and gradually add more motion and less protection, but you have to find out exactly what it takes to get pain free at this point. 

Post Partial Sesamoidectomy: Email Advice

Dear Dr. Blake,

As you know from our previous emails, I had a fractured sesamoid. After going all of the treatments, I had the surgery 11 weeks ago. My doctor made a partial sesamoidectomy for the fibular sesamoid, he only took the smaller piece of the fractured sesamoid, which already has AVN.

 6 weeks after surgery, I noticed that there are some color changes in my foot and lower leg, so they made a doppler and found out there is a thrombophlebitis around my ankle. They gave me antibiotics and anti-inflammatuar drugs and also compression socks. After 1 month, i went thru the dopler again, and now there is no clot or anything just minimal chronic venous stasis on my upper legs.

 But when I dont wear compression socks and stand on it long time, my foot which i had the operation from goes red and warm, but when i elevate it, it immediately turns normal. I have swelling as well, but not very bad. I am not applying ice or heat because I'm afraid it will affect the circulation. I never iced after surgery. 

Dr Blake's comment: Typically patients who develop thrombophlebitis are on anti-coagulants for 6-9 months so yours must have been minor. The fact that you can elevate and the circulation returns to normal is great. However, you should always be wearing, minus sleeping, the compression hose for the next 6 months all the time. Since you had surgery, and the healing process goes on for the next 9 months quite actively, you should ice pack at least once a day for 10 minutes, and do one set of contrasts each evening. 

Apart from this, before the surgery I have mild halux valgus deformity with no pain. My incision is directly on that part of my foot, i mean around the bunion area, and now it hurts with touching, do you think it will go away?

Dr Blake's comment: yes, but get a Blaine's scar kit from a local pharmacy and massage the scar for 5 minutes twice daily. It should be cross frictional, across the grain of the incision, and non painful. 

I am reading a lot, but there is not much about partial sesamoidectomy, I hope the remaining part will not hurt. Do you have any experience? I am still wearing tennis shoes with custom orthotics, I don't know when I can switch to regular shoes and even to heels(if possible).

Dr Blake's comment: Surgeries of this sort can be rehabbed gradually and progressively. First you build up your walking, without limping, and without pain over level 2, up to 60 minutes with tennis shoes. Then you slowly introduce wearing of dress shoes (wide enough not to push on the scar). When you are up to 2 hours in dress flats without symptoms, than gradually begin to wear 2-3 inch heels with a dancer's pad. 

Another thing I wonder if I can feel the sesamoid by touching, because I can feel something like a bone when I touch which is more palpable than it is onthe other foot.

I'll appreciate any answer to my concerns:)

Thank you very much...

Dr Blake's comment: Sure you can touch the sesamoid since it is right under the skin. Can I ask why you decided to the partial and not complete sesamoid removal? My readers would definitely like to know what went into your decision. 

Post Sesamoid Surgery in Pain

Dear Dr. Blake,

Our son had a soccer sports injury at 17 where his sesamoid fractured.  Unfortunately it never healed and the bone died. We live in on the East Coast near Boston. So it was removed and afterward my son spent many months in rehab trying to get to a point of comfort so he can run again. 

He hasn't been able to run or walk without discomfort and pain since.  He's had countless visits to experts doctors that have tried to help.  But no luck or real progress.  So we've since gone back to our referring orthopedic physician to try again.  He said that my son has full range of motion and doesn't think it's the sesamoid area because that area is healed properly.  The doctor feels it inflammation and recommend stiff shoes and maybe ingested cortisone to help with the inflammation.  But at this point basically nothing has worked as prescribed and it still hurts even when he walks normally. 

He's 19 years old now and we don't know what else to do.  So I'm looking around for someone that's the best at foot therapy to find a way to get him back to where he was prior to surgery.  We've used orthopedic foot beds, Physical therapy, cortisone injection, rest, hydro dissections and no luck.  We feel the doctors we have know what they are doing but they have stated that my son might be that 1% who just isn't going to be able to heal properly.  I can't accept that and I'm now looking for alternatives.

Any thoughts and ideas would be welcome.

Dr Blake's initial response:

Michael, thank you for the email. I am sorry for your dilemma. It is very rare to remove the sesamoid and still have pain. Since the sesamoid is removed, that is no longer the source of pain, so what is the source of pain? Could it be that the sesamoid was never the source of pain? Nerve entrapments, bursitis, tendon injuries, joint capsule injuries, metatarsal head injuries have all been mistaken for sesamoid fractures non healing?  Does he feel he has the same pain as before surgery? What are the recent (last 6 months) tests that I can look at? If you put local anesthetic into the joint (diagnostic injection) does all his pain go away (see the post on diagnostic injections)? Does he feel the inserts off weight and protect the area? It is important to analyze each thing at this point. If we can put 10 things together, which all make 10% improvement, we may get some improvement. What are the things that have helped him even a little? Does the area look normal compared to the other side? Does a graphite plate or spica taping help? Any answers to the above will help me. Rich

Richard,

All good questions which I will look into.  I'd have to secure more details on tests, x-rays and such.  Let me speak with my son on these topics and get back to you.

Dr Blake's comment:

     There is always a source of pain, and identifying that source of pain seems the most important task right now. Testing with bone scans, MRI, xrays, CT, thermography are commonly used. Diagnostic injections with local anesthetic can test small and different areas at a time to see if numbing up one spot, like a tendon, can give complete temporary pain relief. Physical examination of tendon function, joint motion, areas of soreness, nerve sensitivities can help identify what is wrong. Partial or complete symptom relief with all the measures of treatment utilized can also help identify the problem based on what makes it feel somewhat better (off weighting, nerve gels, icing, taping, rigid shoes, etc). 

     I just saw a patient Evan (name changed) that I have not seen in 5 years. He was 16 when he had a fractured sesamoid removed. When he was 17, almost 1 and 1/2 years post surgery, he was still in pain. He was a very good runner (4:26 miler pre injury). His treating surgeon was great, but had no answers to why he would still hurt. Physical therapy did not help. Evan went on to run 4:13 in college, and will run competitively for years to come. How did he get better? By analyzing his gait, I found that he crushed his big toe joints into the ground at forefoot loading. So inserts to protect that area (the area of the sesamoids) were custom made for him (which he no longer needs). By ordering every test imaginable, I discovered that his joint, the other sesamoid, the capsule (ligaments), the tendons were all fine, and he had no bursitis. The area rarely swelled even with level 9-10 pain. I suspected nerve entrapment, and diagnostic nerve injections gave complete relief of the pain for 3-4 hours. When Evan told me, that the pain he was having post surgery was the same as pre surgery, I began to also think the sesamoid was not the original source of pain, so removing it would have logically not produced pain relief. I suspected the nerve was continuing to be irritated every time he tried to run both before and after the surgery. When Evan related that he hurt the same during and after running, I decided to see how much he could run without making him worse. So, after 2 years of not running, Evan started a Walk Run Program to get up to 30 minutes running. Then Evan processed to running 60 minutes straight, and he was released to go back to Track for his senior year when he was up to 10 miles straight. Evan understood that he could not run through sharp pain, pain that increased while he ran, and could not limp. Those were all signs of bad pain. Evan's pain stayed the same through this 6 month course of training. And, if you asked Evan what his pain level was, he would say 7 or so. The custom orthotics protected him, but the nerve remains very sensitive to any pressure for a long time (several years). But, Evan nerve did heal eventually, he learned to run softer and apparently faster. 

     Evan is a great example of why when I rehab athletes who run as part or all of their sport, that I want them to run at least 3 times a week. Can they run one mile or 5 miles before the pain increases? There are hundreds of possibilities during rehab created by this procedure. So, Michael, for your son, that is info I would also love to know. 

     I sure hope this helps you focus on getting over this hurdle. Rich

Part of Diamondhead seen along Waikiki Beach

Sesamoid Injury S/P Surgery: Email Advice

Okay any help would be appreciated. 5 years ago I had a stress fracture in my sesamoid bone The one Under my second toe. I continued to work out on it and the pain went away.
Dr Blake's comment: You have two sesamoids, extra bones like kneecaps, under the ball of your foot (sub first metatarsal head). One of them is closer to the side of the foot (tibial or medial sesamoid) and the other is closer to the 2nd toe/metatarsal (lateral or fibular sesamoid). It was probably the lateral sesamoid that you injured. 

You can imagine the irregularity in the sesamoid that is injured here showing bone remodeling and some break down. 

 About a year later it came back with a vengeance . I tried conservative therapies for a year. Boots, rest, massage, cortisone. Well the bone had necrosis and was completely removed.
Dr Blake's comment: Sound like you did the right thing. Once a sesamoid is removed, the other sesamoid is now more prone for injury and requires a lifetime of dancer's pads and/or orthotics to off weight the area.

A blue dancer's pad is easily applied to the shoe insert that came with the shoe to off weight the area. 

 Everything was fine and pain free. About 6 months ago I was barefoot trying to get a door open and kicked it hard. I fractured my other sesamoid in the same foot. So stupid of me! It is Once again not healing. I don't know what else to do. It hurts to walk. I am 29 very active and in good shape. I know having the other sesamoid removed can cause problems, but do I have another choice? For this current fracture have tried rest, ice, cortisone, and A boot.  Any help would be appreciated. I am scared and frustrated. 
Dr Blake's comment: Get an MRI now to document the bone edema in the sesamoid and possibly first metatarsal head. Create a pain free environment with boot and off weight pads, crutches if needed, possible RollaBout for prolonged standing, make sure your calcium and VitD are great, get a bone density if any suspicions about bone health are raised by your PCP, 3 times daily do 10 ice pack and/or contrast bathing, avoid cortisone and all anti-inflammatories (NSAIDS can slow down bone healing), use the next 3 months to create a good athletic and dress orthotic that protects well, get a bone stimulator to use daily, use the next 3 months to find shoes that limit the pressure on the area. Goals: 3 months to get the above accomplished and hopefully bring down the pain 90% or so, and use the next 6 months to gradually remove all the protection, one piece at a time biweekly. 6 months after the new MRI you get another MRI to document treatment success and decide how much more to do. I sure hope this gets your next 3 months organized. Keep me in the loop. Rich

Post Sesamoid Removal

I hope we can follow Mark following his surgery in April 2012 to remove the fibular sesamoid. Bob and I had some correspondance before he went under the knife. He made the right decision. Here is his initial comments in the long road ahead. In 2 years he will have the power back into his foot. This first 3 months post op is for initial scar reduction and elimination of swelling. Then there are small gains from 3 to 9 months as initial strength is regained, activity gets back to some level of normalcy, and the pain level is controlled by daily icing, orthotics, shoe selection, some activity modification. From 9 to 12 months, the body's nature process occurs and more scar reduction occurs (the interior and external scar looses water content and the scar tissue thins). This sets the stage for a fast or slow recovery of more strength (more power, more endurance, or speed of contraction). So, it is in this second year, the true time when athletes get back to where they were pre injury. But, everyone has a slightly different time line. 

Hi Rich,

One month post-surgery update -

Excised fibular sesamoid was larger than expected, arthritic, and developing a spur.  

I was in a walking flat shoe first week or so.  No even up strap on leveler needed (no cam boot prescribed).  Doc said it was ligament healing, not bone fracture healing, no need for a cam size boot.  No problem.

So after a month, much improved.  No pain in ball of front area, some odd nerve/tendon feeling at tip of big toe but, absent that, uneventful.  

Occasionally sore after long period of walking and flexing foot, otherwise ok.

Incision site at side of big toe, gone.  No scar.

So far it looks like a great decision and I remain active and optimistic.

Regards, Mark

Mark, Thank you and I will post on my blog so people can see that there is life after sesamoid surgery. When you see the blog post, if you could continue to update your progress (probably a few ups and downs), that would be wonderful. Rich If you were given any post operative instructions specific to this surgery, could you send along. When were you told you could start lite running? What is your workouts now? Bike? Swimming? Do you have your orthotics to protect the area? 


Here is Mark's original email with my response. You can see this problem had been going on for quite awhile. 


http://www.drblakeshealingsole.com/2012/03/sesamoid-injury-vs-hallux.html

Email Correspondence Tuesday: Notes 5 Months Post Sesamoid Fracture Removal

Blogging on Tuesday is now Email Correspondence Day Hi Dr. Blake, It has been about two months since we last emailed and I have a few more questions for you.  Right now I am at five months since surgery after removing the fibular sesamoid bone from my right foot. Things have improved a bit since the last time we talked, I have gotten orthotics that sort of help but I haven't managed off setting the sesamoid bone area. The fibular sesamoid is the one closest to the 2nd toe and the one shown here irregular, not round like the tibial sesamoid. Both lie under the first metatarsal protecting the main joint from trauma, and helping the tendons which travel into the big toe to work better (same two functions of the kneecap).  Dr Blake's comment: Needs to be more arch support designed into the orthotic device or more of a dancer's pad. Very crucial at this stage and pre-op in attempting to prevent surgery in the first place.   I have started going to acupuncture which has not really helped with the pain but is definitely relaxing I wont ask her about icing though :),  and I am still going to pt to which he has been working on breaking down the scar tissue in order to increase the mobility of the great toe joint. It appears that the joint is mobile, but the scar tissue around it prevents the movement. It seems I have created a mass of scar tissue that is not going away without a fight. Dr Blake's comment: See the blog post on Hallux Limitus/Rigidus Self Mobilization. It normally gains 10 degrees if done daily. Have them measure the joint range of motion of dorsiflexion (see photos below). You need 60 degrees to walk normally, and 75 for most sports. If you are quite restricted, you could have local anesthetic shots to numb the joint, and the doc or PT right after do the same mobilization work. This is normally done once a week for 4-5 weeks, or until normal range of motion is obtained. If you can find out what the Range of Motion of dorsiflexion and plantar flexion is now, that would help seeing progress over the next 7 months. This mobilization technique gets at the deepest scar tissue around the bone within the joint well.   I am heading to see the surgeon this week for another follow up and the pt would like me to ask his opinion of other options for dealing with the scar tissue. Pt feels like he has gotten as much as he can broken down and is concerned about damaging the upper layers in order to get into the deeper scar tissue. During the pt sessions I have not used the equipment like I see other patients using other than the bike to get my foot warmed up and he has spent the rest of the time using several other ways to heat up and manipulate the area to get things moving. Dr Blake's comment: Range of motion of the joint post operatively improves in 3 waves. The first improvement is during the first three months as the swelling and pain resolves (you are behind right now). The next improvement is slow as activity naturally bends the joint, but the improvement plateaus from 3 to 9 months (with few degree changes per month). Then, the final improvement is from 9 to 12 months as the nature maturing process of scar occurs and the scar thins externally and internally as it loses most of its fluid. The scar on your skin changes from red to white and shrinks in size. So, but 1 year you have done through the 3 nature driving forces to improve the range of motion. It is up to the health care provider to tell you if you are behind that nature curve or not. If measurements are taken before surgery (rarely), that would be great to compare. But, if they are started now, you can at least go from here.   I have been a good patient and using ice and heat, stretches, working on breaking the scar tissue and strengthening my poor little foot. In the last two weeks I have begun to participate in karate class either going through the motion of kicking the heavy bags (without contact and mostly kicking with the noninjured foot) and doing katas with not so great stances, and of course I have to work all day on my feet.  The podiatrist I consulted with before surgery suggested to go in through the top of the foot rather than the bottom to help reduce the amount of scar tissue and right now with the amount I have gathered I am very pleased the surgeon went though the top, I don't need any more scar tissue in there. My pain level is consistently at a 5 and still goes up to maybe an 8 on really bad days. I believe I have a pretty high tolerance to pain and am not a big sissy, but maybe not. :) Dr Blake's comment: Pain leads to swelling and muscle tightness. You have to control the excessive pain to get it into the Good Range of 0-2 for a 3-4 month period. This may require a weight bearing removable boot. Whatever it takes!! So in a round about way I am getting to my questions. Do you think I may be expecting too much and too soon as far as doing too much workout wise? Dr Blake's comment: Definitely since you are not able to keep the Pain Level in the Good Pain range. Just because you had surgeon, you can not ignore pain levels above 2. It is discovering what you have to do to keep your pain between 0-2 that you discover good treatments and true measures of disability. You also can gauze in a positive way how you are doing month to month.  I am generally at the dojo 2 to 3 times per week and if I work out it is for about an hour, otherwise I am modifying an exercise video a day or two a week and riding the boring stationary bike.  My other question is what are your suggestions about breaking down the scar tissue? I am smashing and massaging my foot in order to break it down. The pt guy mentioned that there may be other ways to help with that which may include a shot of some kind or numbing my foot and essentially get it moving. This scares the hell out of me considering this saga of my life has gone on for 14 months now and only for the last month maybe have I worn regular shoes with the orthotics and without along with the spica taping all day during the work day. Dr Blake's comment: A small amount of local anesthetic is placed into the top of the joint, then the same mobilization is done that is on my video. These are directions that you want moved to free up the deep scar tissue. They are not the normal motions of the joint. Mobilization takes 2-5 minutes at most. Short Acting Local called Lidocaine or Xylocaine, starts in 5 minutes and lasts for 1 hour. You ice pack for 10 minutes after and go about your life. Any podiatrist and PT could do it if they watched the video. The joint dorsiflexion and plantarflexion is measured before the injection each visit spaced 1-2 weeks apart. After 4-5 sessions, you wait one month to rest the joint, but continue everything else.  When measuring the big toe joint dorsiflexion (aka first metatarsal-phalangeal joint), the landmarks used are the bisection of the toe in relationship the bisection of the first metatarsal (see the two lines marked) A goniometer (something that measures angles) is used to measure the dorsiflexion bend of the big toe joint. The toe is moved on the stationary first metatarsal to firm resistance and then the angle measured. 60 degrees for normal walking is needed on average. 75 degrees needed for high heels and most sports requiring you go up onto the ball of your foot (i.e.. tennis, etc). When I get home I take the shoes off and begin the evening of icing and stretching.Do you know about any of these methods to get my foot moving? Its almost like if it could just be shaken out like a towel then maybe we could have more mobility. Dr Blake's comment: The 25 minute routine I would do each evening is 5 minute hot soak, 2-5 minute self mob, and 10 minute ice soak or pack. Gentle cross frictional arch massage from ball to heel with massage oil for 5 minutes before the ice pack would also help. Do not try to push the joint through normal range in pain at any time. Walking tends to stretch the normal direction just fine.   Finally the outside of my calf has been killing me and the ankle continues to feel weak while walking. The pt said that the calf is connected in some way to the arch area of the foot (which is always achy) and is sore because I have been using the foot more than I had been. I thought I have another question, but it is gone at the moment. Dr Blake's comment: If you are in pain, you will compensate and strain the ankle and leg muscles. It is normally the outside or lateral ones when you are trying to favor the big toe joint (medial or inside). Get the pain under control ASAP.  Again I really appreciate your willingness to help those of us online who need more information and suggestions of what to do next while we try to heal from breaking this nasty little bone. If I lived in Northern California rather than Southern, I would definitely be knocking at your door and have thought several times about a road trip to visit you. Yours is the only blog that I have found where I have gotten good information that I can use immediately in order to help make things feel better. Thank you, thank you in advance for your help! Dr Blake's comment: Remember a couple of things about post op joints (applies to feet, ankles, knees, and hips). First of all the first year post op is to regain range of motion, begin a workout program, manage all swelling and scar tissue issues, and develop tone back in foot muscles. But, it is the 2nd year that is truly the Restrengthening Year. This is the year from 12 to 24 months post op that the power, quickness, endurance, agility of the foot and lower leg muscles make their triumphant return. You are gaining strength now, but the main focus is pain control, re-establishing your base of exercise, and removing all unwanted scar tissue and swelling ( all this can not be accomplished unless you get the pain under control. I sure hope this helps. Rich Stacie (name changed to protect the innocent)