Video discussing Sesamoid Fractures and use of Xrays

https://www.youtube.com/watch?v=I-SQjmo-hIc

Sesamoid Fractures: Typical Orthopedic Approach with Comments

     I have just retired. My time now can be more involved in this blog I started almost 14 years ago. One of the injuries I write about, and treated extensively, was sesamoid fractures. I just received emails from two readers about sesamoid injuries. All doctors will treat injuries slightly differently. When I read the article below, I would emphasize the importance of some treatments more. But, overall the article is well written. Exogen bone stimulators are a must to me. 3 months of cast or bike shoe immobilization is very important. Daily contrast bathing. Evaluation of Vit D and overall bone density is crucial. Orthotic devices with off weighting the sesamoid needed. Spica taping to limit big toe bend can get patients back into activity. Avoiding NSAIDS since they can retard bone healing. Ice activity aggravation. Hope this helps. Rich

https://orthoinfo.aaos.org/en/diseases--conditions/sesamoiditis

Hike and Bike Shoes for Immobilization of the Bend at the Forefoot

I have been using Hike and Bike shoes to immobilize the foot while not having the negative impact of a removable cast in some patients. There is one used in a plantar fascial tear for the 3 months I normally cast the foot with a removable boot. If the patient especially has a back problem, the evenness of wearing a pair of shoes like these can be great. Remember you are not able to bend your foot in push off, or it will hurt you. Therefore, it immobilizes the pull of the plantar fascia. Any metatarsal  problem could be helped by this, even if it is only part of your treatment to vary the stresses 2-4 hours a day. Sesamoid problems, turf toe, metatarsalgia or stress fractures may be helped. 

http://www.fiveten.com/us/kestrel-lace-womens-shock-blue

Recurring Sesamoid Fractures: Email Advice

Dr Blake,
I have had 3 different sesamoid fractures in 1 1/2 years.  One on left foot, one on right foot, then this morning my podiatrist told me my left was fractured again in the same place.  I was given clearance the first time so this is a new break.  I'm thinking this is due to a very high arch putting excessive pressure through my sesamoids. 

Dr Blake's comment: Definitely high arches can place more pressure on the sesamoids due to the downward positioning of the first metatarsal (more downward than in a flat foot). Designing orthotics for sesamoid injuries is difficult at times due to this situation. Sometimes the best orthotic is more on the line of the full length Hannaford style which evens the playing field better. 

 There was not any act in which would have caused this.  It slowly began to hurt and swell.  It got worse and by the second week I was at my podiatrist receiving the news that it was fractured again. 

Dr Blake's comment: It can be very difficult to make this call. The original injury probably caused some irregularity in the appearence of the sesamoid. This irregularity can look like a separation of fragments, even though there is solid internally healing. Also, Golden Rule of Foot: It is hard to break a bone in the same place a second time. This is due to the fact that bones typically "double heal" or get twice as strong as they were originally. So, a word of caution about rushing ahead on any surgery. 

 My dr suggested removing one of the pieces as he does not feel it will heal completely or if it does that the fracture is likely to happen again given the way this one happened.  They are putting me on the schedule to have a partial sesamoidectomy.  I'm fine with this as I do not want to fight this breaking for no apparent reason for the rest of my life. 

Dr Blake's comment: I have only seen only partial sesamoidectomy in my life, so I am not a judge. It did not help the problem, but my comment is not anyway scientific. I would be thinking complete removal of the involved sesamoid, or no surgery until the biomechanics of your high arches were addressed. Without the biomechanics being adequately with inserts so that you feel you have no to minimal pressure on the sesamoids, you will have one surgery, then another, and then perhaps more. 

 I have a few questions given my story.
Is it normal to break a sesamoid in TWO DIFFERENT FEET?

Dr Blake's comment: Yes, and it points to a biomechanical predisposition that you want/need to correct. And yes, there are also surgical treatments for this predisposition, if the predisposition can be eliminated. Typically, non surgical avenues can be explored with complete success. 

Is it normal to break the same sesamoid twice?

Dr Blake's comment: No, but it may have never healed completely in the first place, or the underlying predisposition never corrected. That could be foot biomechanics, shoes, diet, Vit D deficiencies, running style, etc. We look at all causes of bone injury, attempt to reverse/correct all these factors, and this is why it is hard to break the same bone twice. That being said I do have my failures also when I did not recognize a problem, say Vit D deficiency, or the patient did not say on track at correcting the problem, or I forgot to tell the patient their need for the corrective orthotics was a life long committment, or the correction of the problem was difficult to do and we hoped the bone would not break again. 

Would you suggest a different option?

Dr Blake's comment: See above, definitely do three things:

1. Treat this sesamoid fracture conservatively like you treated the first one
2. Have the biomechanics of your high arch feet, and all causes of bone weakness addressed.
3. Get a bone stimulator to use for the next 6 months (I love Exogen since it is 20 minutes per day)

How long can I expect to be back to a normal gait, and pain level?

Dr Blake's comment: Of course this depends on surgery or no surgery.

It is extremely swollen and painful now.  How can I relieve some of the pressure?  I am in a walking boot and ice twice a day and take naproxen to help inflammation.

Dr Blake's comment: Definitely add crutches or in boot accommodations to float the sesamoid to achieve a 0-2 pain level with your protected weight bearing. You should add the Exogen bone stimulator, and do daily contrast baths for deep flushing. You should have you internist look for Vit D deficiency and perhaps a bone density test should be ordered. 

Should I get a second opinion?  I am very comfortable in the surgical route given my dr has been working with me for a year and a half.

Dr Blake's comment: Yes, I love our foot surgeon, Dr Remy Ardizzone, but I always think patients should get a 2nd opinion, and not from someone in the same group. I would look at the member list of the AAPSM (American Academy of Podiatric Sports Medicine) for a referral near you. This does not mean you have to switch. You just want another smart person to give you an opinion. I tell my patients never to tell the 2nd opinion doc what the first doc says. Make it a true 2nd opinion. Just tell them your scenario, and that you wnat there advice on what to do from here. 

I have read about pt after these surgeries on your site but should it be the same for me with a partial instead of a full? 

Dr Blake's comment: Again, I claim lack of valuable knowledge.

Could I have a deficiency causing weak bones?

Dr Blake's comment: Yes!!!!

I'm a very active 31 yr old male with a 4 year old who loves to play sports.  I just want to be back to functioning without extreme pain.

Dr Blake's comment: As a father of 2 boys, I feel your pain and understand. I hope this helps you. 
Regards,
Lawrence (Name changed due to witness protection)

Sesamoid Fracture with Chronic Symptoms: Email Advice

Dr Blake,

     Thank you for offering to help folks out via email/blog!  I was diagnosed almost 10 years ago with a sesamoid tibial stress fracture in my left foot. It was via x rays and he mentioned a specific x ray was the only one to show the fracture.  I think it was a view into the front of the foot.  Is that a typical x ray view done? 
Dr Blake's comment: Probably was what is called the Plantar Axial xray which is a crucial one for sesamoid injuries. 
 I was in a boot and healed great as I had no issues again up until 8 months ago. 

      I am a very active person and exercise on a very regular basis. I moved to a different city so I saw a different doctor (podiatrist).  At the time, I was not sure if this was even the same foot as before.  He took x rays, said no fracture and plastered both of my feet for orthotic inserts - he did something to the inserts to lessen the stress in the area.  He also gave me a shot of cortisone.  
Dr Blake's comment: And we can assume that this helped resolve the situation at that time. 

     A week or so ago I started having intermittent sharp stabbing pain and then more moderate pain sometimes when walking.  The very sharp pain comes sometimes when pushing off foot to stand and start walking.  It is like level +7 pain.  I reached back out to the first doctor's office and confirmed this is happening in the same foot as the prior fracture.  I am not sure what x ray views the current doctor took and wondered if he might have missed a repeat stress fracture.  Could I have gone 8 months with that? 
Dr Blake's comment: You seem to have weakness in that area. Xrays are less than 50% accurate in diagnosing sesamoid fractures, since they can look irregular forever. You would need a bone scan or MRI to make the diagnosis of what is happening now. If you have been doing well, you have not been walking around on a stress fracture for these 8 months!! The flareup now can be a new injury, or an aggravation of this chronic sesamoid disease. Again MRI first, and if positive, CT Scan to 3D visualization of the whole joint. 

      I saw a great orthopedic doctor for a knee issue in January.  I think he has a partner in his office that is more focused on feet/ankles.  Do you think I should see an orthopedic doctor and should I have more x ray views taken or MRI to correctly determine what is wrong? Does a re-fracture happen often?
Dr Blake's comment: Get the MRI from the doctor you are seeing. If it is positive, ask for a CT scan. Then get his/her advice. If everything sounds logical, and no surgery is being recommended, stay the course. If not, get a second opinion. Never tell the second doc what the first doc said since you want as honest and unbiased a 2nd opinion as possible.

Thank you so much - Angela (name changed)

Fibular Sesamoid Fracture: Email Advice

     I just found your blog trying to research sesamoid treatments and I wish I had found it sooner! I have been in a walking boot for four months to treat a fibial sesamoid fracture and I'm starting to get frustrated. Every visit to the podiatrist shows improvement on my x-rays, but I'm confused by the questions he asks about pain. He says that if it hurts the bone is moving, but how can it be moving when I wake up in the morning and it's been up and elevated all night long- and still hurt.

Dr Blake's comment: There are so many causes of pain after you hurt a body part, that blaming it on one specific thing may not be correct. The pain is most likely due to the swelling that collects in the area, that is a totally normal part of healing, but loves to sit there and interfere with movement and compromise the circulation and nerves. 

    I've been reading some of the posts and concerned about all the information that I haven't seen before, literally the only treatment has been this boot that I was told was to avoid having to do surgery- but not to remove, but to pin?

Dr Blake's comment: Unfortunately I have no experience with treating sesamoid fractures that have been pinned. It has always seem too small a bone to do something like that, but new technology is being introduced almost daily. I have only seen one unsuccessful surgery where the surgeon removed one half of the two bipartite bones. 

 The more I'm reading the worse this is sounding.
Dr Blake's comment: If you have been in the removable boot for 4 months, you have done everything right up to now. But, it is time to move from the Immobilization Phase to the Restrengthening Phase of Injury Healing. The Restrengthening Phase should continue your 3 times per day icing/contrast bathing, your Calcium and Vit D intake considerations, your protected weight bearing with orthotics and/or dancer pads and/or stiff soled shoes, a gradual strengthening program from the core down, and a gradual return to full weight bearing with no barefoot. 

 In the past month I swear it's been getting worse and the boot itself is driving me nuts and starting to hurt the other parts of my leg. Any advice?
Dr Blake's comment: Typically after 3 months in a removable boot, the negative effects of immobilization start to take their toll and pain syndromes develop. How to begin protected weight bearing without the boot is the next goal and many of your new soreness will abate. 

 My next appointment is in the first week of May and I'd like to sound like I know my options. 
Dr Blake's comment: Sorry, I just had some personal family problems that needed me so I am late with this response. 

My podiatrist is a nice guy, but this is getting really frustrating, according to him I should have been healed by now.
Dr Blake's comment: You can ask any athlete if they continued to have pain when their injury was healed and the majority would say affirmative. You need to respect pain levels over 0-2 and increasing as you work out. You need to gradually stress the injured area to prevent flares. Working with a good physical therapist on lower extremity strength and flexibility at this time on a weekly basis will also get their regular feedback on activity levels permissable.

Dr Blake's comment:

     Thanks for the email. When you see him, ask the following questions.

1. Can an orthotic device be designed to off weight the sore sesamoid?
2. Can you go to PT to learn joint mobilization, spica taping, dancer's pads, foot strengthening, and anti-inflammatory techniques?
3. Can you get a baseline MRI to see where you are at, or CT Scan? There are many reasons to get a MRI other than healing of sesamoid for it can show if other structures are involved.
4. If he thinks you are slow at healing, can you get a bone stimulator?
5. What shoes, like hiking boots, can you wear to begin to wean off the cam boot?
6. Has he had cases like this that heal without surgery? This is check if he has a bias. 
7. Does he feel you can heal without surgery? If not, who should you see for a second opinion?

Typically, the next 3 months should be geared towards gradually getting out of the cast, developing a good orthotic, gradually increasing activity, gradually understanding good vs bad pain, and daily continuing to ice and contrast bath. Good luck. Rich

Sesamoid Fractures: Email Advice

Dear Dr Blake, 

I have had broken sesamoid bones in both feet for over a year! I've had a bone stimulator since December (4 months) and the pain comes and goes. I am trying not to have surgery but I have just had it at this point. I've had heel spurs and they treat me as if I am avn (avascular necrosis). I have been to 2 different doctors at this point and I just don't know what to do.

Dr Blake's comment:

     Thank you so very much for your email. I have had several patients in your situation who have opted to try to avoid surgery. Classic orthopedic logic would have you have the sesamoids removed and move on with your life. And, no one would blame you for that. Surgery on the feet is difficult with many decisions to make (for example, one foot or both feet at the same time with surgery, will you have permanent disability post op, how much physical therapy will your insurance allow, etc??) Personally, I try to avoid surgery on these important bones, but it is hard for you if you do not have a partner in healthcare to team up with you in this process. Typically, you need to continue twice daily using your bone stimulator, eat healthy with Calcium and Vit D supplements if necessary, get a baseline MRI and CT scans if possible. The CT scans are better at deciding on AVN (dead bone) or not. Ice twice daily and every other day do a full contrast bath for deep flushing. Get foot inserts and shoes that make your walk comfortable, pain level 0-2 max, which will allow you to do much needed protected weight bearing. Without good weight bearing daily, even in a removable boot, the joints freeze up, the ligaments can tight, the muscles weak, and the bones demineralize. Every day that passes without flareup means your sesamoids are getting healthier. The fact that the pain comes and goes is a good sign. Email with other aspects of your history. I hope this helps some. Rich

I have tried to email back on your blog, but it is not working? I have now been to a 3^rd doctor and he had me just take a CAT scan. My question is if I do have AVN, how will the bone stimulator still help me? Also I do have orthotics, but I have flat shoes from the podiatrist, what do you feel is better to wear? This all started by running 3-5 miles a day on the concrete. I ran literally almost every single day. I have very arched feet I guess, or so I have been told. I at this point feel my feet will never be the same.  I appreciate your time very much, thank you.

Dr Blake's response:

If you want to send me the CD of the CT I would be happy to look at it. Bone Stimulators are perfect for AVNs that have not fragmented. If the CT Scan shows the bone in multiple pieces, then surgery is your best choice. Orthotics in some sort of shoe that seems to protect the sesamoid area would always be the best bet. With flat soles shoes, if you can not wear orthotics in them or some sort of accommodation, there is too much pressure on the sesamoid area. Rich

Sesamoid Fracture: Email Advice

Dear Dr. Blake,

First, thank you so much for being available for patients and allowing patients to contact you with all their concerns. I feel so much at ease simply knowing the fact that I will be heard! 

Here's a brief history of my sesamoid injury.

Last year in May 2012, I had missed a step while climbing up a staircase and because of that I hit my right foot on the edge of this sharp step. However, that entire day I walked around bearing the pain and only a day later I found out about the fracture on my sesamoid bone. Photo-1 (attached) shows my fracture.

The fracture line is clearly seen in the medial or tibial sesamoid. 

 My doctor asked me to take care and wear good shoes and also gave me some oral medication. I went regularly..And by August 2012, he said I am all good now since I experienced no more pain on the area under my foot.

So I got back to wearing slippers, trendy sandals n high-heeled shoes, walking barefoot at home, gym-ing, running etc. However, there were sometimes when I noticed some discomfort but it didn't last too long and so I forgot all about it.

It was only two days back (Sept-2013, a year later) that I noticed some weird pain and I got concerned since its been a year and I still notice discomfort there. So i got an Xray done (Attached: Photo-2) and I was taken aback when I saw that the sesamoid bone is in two separate pieces now. I went to the same doctor and he said he'd have to put me on a 3-week medication (since i'm leaving for a trip next tuesday) and he said we'll check how you are once you get back. Else we'll have to get it operated (removed).

Here the sesamoid fracture appears widened. The first and second x rays are 15 months or so apart and there has been relatively little pain in this. 

-

Now Dr. Blake, I'm concerned. I don't feel good knowing the fact that I'm going to be walking around with a broken bone in my foot. What do i do? Can the bone ever get healed without having to remove it? And am i placed with a certain level of disability for life?

Please give me your advise on this since I'm leaving on a trip as well and I'd be exploring places on foot! Now I'm very worried about having a fun trip and a walk-stress-free life ahead!

Awaiting your reply.

Thanks and kind regards,

Paula (name changed)

Dr Blake's comments:

     First of all, x rays are the worse form of followup on these problems. The bone can look irregular due to increased water content across the fracture, but internally can be really solid. So, relax for now. If you read all my blog posts on sesamoid injuries you will realize you have a lot you can do to help your self. Here are my suggestions to work on over the next 4 months. 

#1 Get a baseline MRI
#2 Make sure bone density is good
#3 Make sure Vit D3 levels are good
#4 Make sure your diet is good with daily 1500 mg Calcium and 1000 units VitD
#5 Ice pack bottom of foot for 15 minutes once daily and also as needed
#6. Learn to spica tape of increased activities
#7 Learn to make dancer's pads to off weight the sesamoids even in heels
#8 Have custom orthotics designed to off weight the area
#9 Use common sense in avoiding activities you know will bother you. 

I hope this helps you get moving in the right direction. Do not be concerned over your new x ray for it does not tell how strong the bone actually is. Rich

The Patient's initial response:

Thank you so much, Dr. Blake!

Your responses have helped me understand my situation better! In fact I feel a lot better, too. I will keep all those points in check. As of this Tuesday, I'm leaving for Europe and I plan to get myself good shoes first and get regular with all the other points.

Thank you again!

Much regards,

Fractured Sesamoid with Surgical Complications: Email Advice

Hi Dr. Blake,

I have been reading emails after emails on your site trying to find a similar situation to mine. I have been through 6 doctors in the last 5 years and I have hit a wall. I will tell you I am only 26 years old.

I fractured my  lateral sesamoid in 2008 of my left foot. I was casted multiple times,placed in a boot, fitted for orthotics, and had many cortisone shots. After 3 doctors I had my Lateral sesamoid removed in 2011. I got pregnant in between so I had to wait the year. My foot didn't hurt when I was pregnant but the moment my foot unswelled it was back.  The doctor who removed my sesamoid used porcine graph without my permission, I was allergic and it caused a HUGE mess. The doctor vanished on me. I found another doctor and she went in and cleaned out what the prior guy did 1 month later. My incision was infected, I had a hole in my foot. I got it cleaned out and now there is a thin layer between my bone of the foot and skin on the side from incisions. You can literally feel the bone. They say if i every get cut there it would be directly on the bone.  If anything touches it, it hurts right away and even makes my nerves crazy sending shocking sensations up my toe. That is the least of my problems.

Dr Blake's comment: I am so sorry.

Since that seaamoid was removed the pain had not improved. I was still unable to walk correctly or pain free. Over the course of 1 year my big toe starting turning in and the pain was increasing.

Dr Blake's comment: It is hard sometimes to know if the pain is coming from the sesamoid which is in the joint vs some other arthritic process within the joint like Hallux Rigidus (although you are quite young for that). 

My doctor suggested transferring the tendon and fusing my big toe. She said this would alleviate all my problems. I had that surgery in Jan-13. I have had nothing but more problems. Pain in my arch, above my toe joint, ball of my foot and now my toe hurts from the screw. I got orthotics and more cortisone shots. The shots no longer work.  Her next step is to lengthen the tendon. I would rather not have surgery on my foot again so I decided to get another opinion and changed doctors.

Dr Blake's comment: When they fuse the big toe joint, they typically fuse for a slight heel. The bend in the toe produced forces more pressure on the sesamoid area underneath. 
My new doctor did an MRI and x-rays. My medial seasmoid is fractured now and I have fluid in my tendon as well as chronic edema and arthritis in the joint.  This doctor casted me for 2 weeks after finding that out. If anything, this increased the ball of my foot pain drastically but the pain directly over the sesamoid is gone. I had NO pain when I was casted. With every step now I hear a cracking noise. This doctor says the tendon is not healing around the sesamoid. (That entire tendon hurts all the way up my calf, ankle. I saw a physical therapist and she had me in tears just from barely pushing on it). He is out of options on what to do other than remove the remaining sesamoid. He feels a Plasma Rich Platelet injection may do the job and heal everything in my foot. Well, my insurance denied that and I can't afford it right now. I am frustrated and extremely upset that I will never be able to walk normally without having pain. I can't hold a job that requires standing or walking. I can hardly go grocery shopping. The zoo? Mall? no way! I am in tears in the middle of it and at the end my foot is very swollen and I can not bear weight, it feels like my entire foot is broke. I am out of options and do not know what to do. I have been rubbing the essential oil lemongrass on the ball of my foot and arch and toe for 4 days now hoping it will work. Please help me! What can I do? What is your advice or opinion on this situation?

Thank You!

Dr Blake's comment: 

     Thank you so very much for your email, and I am so sorry for the problems. I have more questions, then answers, so while we try to get some direction, place yourself into as pain free environment as possible. This is probably with a removable boot with accommodative floating of the big toe joint with an EvenUp on the other side. 

Sesamoid fractures take minimum of 3 months of casting and the cam walker should do that. We need to protect the other sesamoid as well as possible. I am sorry that I have no experience with PRP to help you with that decision.
     The fusion should have taken care of 2 of the 3 sources of pain in a bad big toe joint: the pain produced by pressure in the joint and the bend produced by bending the joint. This leaves the 3rd source or the pain produced by weight bearing on the area. This is where temporarily (2-3 years with your problem) you need to off weight the area with various forms of arch support and dancer's pads.
     If you are working on the mechanical aspects of pain, you have 2 other areas to deal with: inflammatory pain and neurological (neuro-pathic) pain. For the inflammation I would be icing every several hours for 10 minutes placing an ice pack on the bottom of your foot. For the neuropathic pain, I would see a pain specialist. It can take you 2 or 3 to find one that really gets it for you. But, I would start working on that right now. 
     The nerve person, pain specialist, will have topicals, patches, oral meds, and other tricks. If you read some of my posts on "Complex Regional Pain Syndrome" you can get a feel for what that speciality has to offer. You will also read that is it important to be touching the area gently AMAP as long as it does not hurt to desensitize the area. 
     I am sure hope this starts pointing you in the right direction. You may have to have the metal removed, since that could be a source of irritation and only needed until the joint fuses at 12-15 weeks post surgery. Typically, they wait 1 year to let the area calm down after surgery before removing the hardware. Rich 

Hi Dr. Blake,

Thank you for writing me back. I never thought about visiting a pain specialist as the pain is bearable when sitting but once I step on my foot it sky rockets and doctors pretty much just cross me off the list and are unable to help me any longer.  I guess I dont understand why my foot is unfixable. My body has automatically compensated so I walk on the side of my foot. My physical therapist says its the weirdest thing. I can only do that barefoot or in flip flops though, but being barefoot hurts as well on the side all my weight is on. When I wear a shoe it no longer allows me to walk like that, which is why the doctor gave me orthotics but those still cause pain at the ball of my foot and arch. I seriously can't wear a shoe to walk, it hurts the worst! I know its bad to wear flip flops but it is the only way I can get around. I have done a dancer pad in the past ( first sesamoid injury) and it did not heal it. I can do one this time to see if it helps again. I did read about lipstick on the ball of my foot, I will try to do that as well. I do apply ice and apply heat, I do not feel it helps. It brings down the swelling temporarily but then when I walk it swells right back up. I have been using Voltaren gel 2-3 times a day and I am unsure if that helps either. I continue using it in hopes one day it will. 

Dr Blake's comment: Orthotic devices can be designed to put your weight on the outside of your foot with some inversion force. Many orthotic lab offer various techniques to start, and then the podiatrist/physical therapist has to do some in office tinkering. But, it can be done to get you into shoes. You can also invert/varus cant the outersole of a shoe to get your to the outside of your foot. This is so much better (for the next 4-6 months) than having you have to do it with gait changes and abnormal muscle contractions. Nothing will cure this in the short term. You need to use 8-10 things that each seem to make some difference. By putting them all together, you may get at least 50-60% better. 

To be more specific my most recent surgery in January was: Hallux Interphalangeal Joint Fusion with Screw Fixation with Jones Tenosuspension of the Left Foot.  She said I had first metatarsophalangeal joint capsulitis as well.  The pain is a lot worse after this surgery than with the first. I wish I would have never got it done!

Dr Blake's comment: I am so happy they did not fuse the big toe joint, best news you told me all day!!! The Jones tenosuspension I never see, so what did they do? Please make it as clear as you can. Even a copy of that paragraph from the op report. 

My MRI findings say: Postoperative changes. Moderate osteoarthritic changes and moderate disc space narrowing involving first metatarsophalangeal joint. Mild T-2 weighted increased signal involving the lateral sesamoid at the plantar aspect of the distal first metatarsal. Flexor Hallucis longus tenosynovitis. Fluid within distal flexor hallucis longus tendon sheath

Dr Blake's comment: Definitely want you to send me a disc of the MRI so I can see. Send to Dr Rich Blake 900 Hyde Street, San Francisco, California, 94109. Sounds like some arthritis in the big toe joint which has not been addressed yet, and maybe why you continue to hurt!!?? Hope??

The MRI is my most recent diagnosis. After that I was casted and now I am still in pain unable to bear weight if not it worse after casting which he thinks is from tearing the tendon now... Did I say this already? 

Dr Blake's comment: The MRI did not talk about torn tendons, so that is good. Alot of patients hurt so much worse after casting since the immobilization allows for stiffness, weakness, fluid retention, bone demineralization,etc. Get into the removable boot with accommodation and start putting some weight on it gradually. Massage as painlessly as possible, and as often as possible. You need protected weight bearing and mobilization, and anti-inflammatory for the next 4-6 months. 

I just realized I was backwards on my sesamoids-sorry- I had the medial removed and I still have my lateral?   I just know my outer seasmoid closest to the right foot was taken out and I still have my inner sesmoid closest to the left pinky. 

Any other advice? Does that added info help you any?

Have you seen improvement in ultrasound therapy or the electronic shock therapy? My doctor also mentioned a bone growth simulator, but thinks that is a 1-5 chance of working. 

Dr Blake's comment: These toys are all about timing, and it is really hard for me to assess that right now. 

I feel like I just need cushion at the ball of my foot, can they do implants or anything of that nature? I know, that may be a crazy thought. 

Dr Blake's comment: Have your doctor look at the Hannaford orthotic design on my blog, perhaps his lab can make something similiar. Dr Suzanne Levine in New York is injecting collagen for cushion into feet. She can advise if possible in your case. 

Did I read that you suggest wearing a boot for 2-3 years? Maybe I interpreted that wrong? 

Dr Blake's comment: The goal is to create a pain free environment and then gradually wean from it. If that requires a removable boot for 2-3 years, then that is what you do. Hopefully not, for that would rack havoc on the rest of your body. 

Also I can still move my big first big toe joint which is painful at the joint and ball of the foot. I have limited motion of that joint. When I move my big toe down my entire foot shakes.  My big toe is also up like a hitchhikers toe but not as drastic.  I have used a JAS system to regain motion but it really aggravates things and makes it worse as does Physical Therapy.

Dr Blake's comment: You really sound like some arthritis is in the joint causing a severe pain syndrome. The MRI will help me understand you better. You need to move the toe, but painlessly. Get small gains very week. Only a few physical therapists can do this. See my video on Self Mob for Hallux Limitus. Thanks for all your clarifications. 

Thank you for taking the time to read this.

Sesamoid Fracture: Email Advice

This email was received 8/15/13. 

Hello Dr. Blake, I just contacted you through your website but wasn't sure if it went through. I also forgot to add that I'm 35; thought that might be important to the osteoarthritis diagnosis. Here is my message again, please forgive if you already received it:

 

I've been using your blog as my go-to guide for the last 3 months. I sustained a stress fracture to the sesamoid bone closest to the outside of my left foot while coming down stairs wearing wedge heels.

Dr Blake's comment: This is called the tibial or medial sesamoid.

My first podiatrist diagnosed it as sesamoiditis and ignored my repeated phone calls saying I was in immense pain. Time to switch doctors. My current podiatrist took x-rays, by this time it was 24 days after injury, but found them inconclusive and ordered an MRI. In the meantime I was put on crutches. 10 days later, after insurance finally approved it and the results came in I got the news that it was indeed a stress fracture and was told I needed a plaster cast. I bargained my way into getting walking boot with the promise that I would treat it as a cast, sleeping in it and never walking on it.

Dr Blake's comment: I always try protected weight bearing since the cast holds in so much fluid that you need some weight bearing to drive the swelling out of the injured area. Protected weight bearing is with 1/4 inch layered adhesive felt to protect the area while allowing pain free weight bearing on the non injured parts of the foot. You can purchase a roll of 1/4 inch adhesive felt padding at www.mooremedical.com 

I've been a model patient and recently went back for my six week check up. (During this time I did take calcium, magnesium, vit d, and vit k, but only for one week as it caused stomach upset.) The doctor stressed the fact that this injury is very slow to heal and that if I move my big toe at all it impedes healing. He pressed on the ball of my foot and I yelped in pain. He said it wasn't healed. He said if it was healed I would have no pain at all. I thought this strange since I broke the big toe on that same foot 9 years ago and can remember being in pain for a few months after it healed. Surely this bone would hurt for a while even after healing! (Sure enough, reading your blog confirmed this!) So, he ordered another round of x-rays. I did question this since the fracture was found through MRI and not x-ray, but he said he wanted to order a bone stimulator and insurance would require a new set of xrays. I consented.

Dr Blake's comment: For many injuries, like sesamoid, pain to palpation can be present almost forever, and it a poor indicator of healing. Functional pain, the pain you get from advancing from non weight bearing to weight bearing, and from weight bearing in a cast to weight bearing in a shoe with protected padding is more important. 

For one of the images I had to get down in a runner's stretch, completely pulling my toes back. (I did have to do this with the first round he ordered, but this was before we knew what the injury was.) Since he had just said moving my big toe would impede healing, I was wondering why in the world we were doing this, but I knew I needed the bone stimulator and had to do it. The tech and I had to bend my toes back and forth repeated trying to get mobility back in them so that I could get them back far enough for a good image. This maneuver left me in pain for several days afterwards.

Dr Blake's comment: Sports medicine as a discipline evolved around the concept of protected weight bearing, sensible motion to keep things moving as best as possible, and anti-casting as much as possible. I love to move things, weight things, touch things. The more normal the stimulus, the faster healing back to full function occurs. For every day you completely immobilize an area, it can take up to 4 days to get the area back to function. And, returning to a function state can be painful, but not a sign you are not healing. 

The results of the x-ray was that the sesamoid bone now has osteoarthritis in it. He said it was due to the fact that the bone is receiving no impact through walking in order to build it. He ordered the exogen bone stimulator and said to stay on crutches and come back in 2 weeks.

Dr Blake's comment: Osteoarthritis takes a long time to settle in, but the changes in the bone could be related to the fracture healing and the demineralization from non weight bearing. It is almost impossible to predict what this means in relationship to the final outcome. 

I go back in 5 days and insurance still has not approved the device. Fortunately a friend had one and I've been able to use it twice a day for the past 4 days. I also switched brands and have been back to taking calcium, mag, vit d, and vit k for the past 9 days.

Dr Blake's comment: Remember the goal standard is 1500 mg of Calcium daily (diet and supplement) and 1000 units of Vit D (unless you know your blood levels). 

I called the doctor yesterday and told him I did not want another round of x rays. He said he wasn't planning on ordering any, just performing another physical exam (presumably to see if it still hurts when he presses) and at that time he would consider ordering another MRI.

Dr Blake's comment: The first MRI is the baseline. The second MRI should be minimum 3 months (and up to 6 months if you are doing a bone stimulator). I hope you do not feel pressed into a quick solution!!

He did say removing that sesamoid left me in danger of developing bunions later on and that surgery would be a last resort. In the meantime, I've been on crutches for 8 and 1/2 weeks and have lost so much muscle in my calf and foot. My foot even has muscle spasms now, which from my very scientific research on the internet seems to be coming from loss of muscle integrity.

Dr Blake's comment: Unfortunately you are developing "cast disease" or "cast rot". If you want to calculate your road to healing, take the amount of time it takes to get you to full weight bearing without a cast, and crutches, and times by 4. At that time, you will have recovered from the damage caused by the cast. This is why I always say that a cast is a "necessary evil". When needed, it can allow something to heal, but it sure takes a long time to get your foot back, grossly and subtly also. 

In your opinion, what should be my next move? In reading your blog, it seems like it should be continued use of the bone stimulator, vitamins and supplements, and transitioning to walking in the boot for 3 months. But can I just "start walking" after not touching my foot to the ground for 3 months and losing so much muscle?

Dr Blake's comment: No, inside the boot you will need cast accommodation with 1/4 adhesive felt or an orthotic that off weights the sesamoid. You need to continue daily icing 10 minutes 3 times, learn to spica tape, and perfect the orthotic you will be wearing out of the cast. The rest of what is said is true.

I really appreciate any help and advice you can provide. Thank you for making your blog available, I would have been lost without it!

Dr Blake's comment: Great, I am glad it has been somewhat helpful, and good luck finishing this healing. 

Sesamoid Fracture: Email Advice

This email was received August 11th, 2013 for time reference. 

Hello Dr. Blake,

My name is Michael (name changed)  and I am in my early 20's. I have been a runner for the past 5 years and I love it. Back in December 2012, I tripped over my big toe (not while running) and knew right away that something was wrong. I went to the doctor to get it x-rayed but, since the metatarsal bone was not broken, my doctor told me nothing was wrong and to ice/rest for a couple of weeks. I did this until the pain was much better and the swelling went away and then slowly returned to running, biking, yoga, and all of the other things I love to do while still incorporating stretches and strengthening exercises I had found online for my foot. 

Dr Blake's comment: I would have to say that from the sounds of things that your original injury definitely healed. 

The pain was almost completely gone (would just have some issues from time to time) until I decided to skate one day in June. I pushed out and immediately felt a sharp pain in the ball of my foot where I had injured it before. After putting it off for a couple of weeks, I finally decided to go to the podiatrist. He x-rayed my foot and immediately found that one of my sesamoid bones was fractured. I have now been in a boot for 4 weeks and have two more to go and when I went back for my half way check up the fracture was still there and I am now on cortisone pills for the swelling and inflammation.

Dr Blake's comment: A fractured sesamoid should be immobilized for 3 months, while an off weighting orthotic is being designed to help with the gradual weaning process of boot to athletic shoe. That process along can take 2-6 weeks. Whatever happens, as you begin to wean out of the boot, you can not have more pain. Hopefully the boot has brought the pain level between 0-2 while you are walking in it. 

Now that you know my story I have a couple of questions. I read on your blog, when used properly, cortisone pills can sometimes help inflammation and pain. This was great to hear and we shall see how they work for me on an individual basis. My main question is this: do sesamoid fractures usually heal and will I ever be pain free again? I am having a very hard time physically and emotionally due to the fact that I am so young and am normally very active. I miss working out and I have not read the best recovery stories about this injury. I want to avoid surgery if possible and my podiatrist is on the same page. I like that is seems you have the same ideas about surgery. I am really just looking for some words of encouragement from an outside source or any positive feedback that you have gotten or seen from a sesamoid fracture recovery. 

I thank you so much for taking the time to read my email and for creating a blog that allows for me to further research what I am going through.

Sincerely, Michael

Hope you will be back running soon!! 

Dr Blake's comment: Sesamoid Fractures are very tricky, but sound principles and patience can get most patients through without surgery. All guidelines to treatment are close approximations/generalizations. You can still heal even if you are an exception. What are the most important points for you right now? 

A) Listen to your body and do not accept more pain as you go from stage to stage.
B) Bones need Calcium and Vitamin D3 to heal, make sure your diet is good.
C) Swelling is your enemy, even deep swelling in the bone which you can not see, it cuts off healing circulation, so icing and contrast bathing daily is extremely important.
D) Typically at 3 months post injury you are getting out of the cast, and 6 months after the injury you are beginning a walk run program, so go slow with each stage.
E) Your podiatrist can begin making an off weight bearing orthotic device now, or modify your present ones, so when you begin to wean out of the cast, you are protected.
F) Avoid all anti-inflammatory meds after you finish the cortisone pills, since many slow bone healing.
G) Even with the boot, you should be riding a stationary bike, swimming, and other core activities that do not put stress on the sesamoid, or force bending the big toe joint. 
H) Ask the podiatrist if you are a candidate for a bone stimulator.
I) Ask if a baseline MRI can be taken, in case you need one in 6 months to check on healing.
J) Learn spica taping and how to make dancer's pads (also called Reverse Morton's).
K) Find out when you should start re-strengthening your foot (met doming, single leg balancing with a hole for the sesamoid, inversion/eversion therabands, etc). 

I hope this all helps Rich

Sesamoid Injury: Email Advice

Hi Dr. Blake,

Your blog is the best resource I've found for sesamoid injuries. Thank you for giving me hope.

This has been a frustrating injury. I am a female runner, 29 years old, and I went to a podiatrist after feeling some pain in my left foot during plank and downward dog in Pilates.  After an initial mis-diagnosis, via an x-ray he found that I'd fractured one of my sesamoid bones. I went a month without running, but the pain didn't go away. I was even beginning to feel it when I walked up the stairs at work.

I decided to seek a second opinion, and went to see an orthopedic surgeon who specialized in feet and ankles.  He did more x-rays, and advised me that my fracture was worse. He then gave me an air cast (walking boot), and advised me to see him in 4 weeks.

After 4 weeks in the walking boot, I went back to the doctor, and he advised me to try walking without the boot.  After 3 days I was limping, and was in pain.  This was so frustrating because the entire time I was in the boot, I was pain free.

Dr Blake's comment: With sesamoid fractures, you need 3 months in a removable cast, followed by a 2-6 week gradual wean out process keeping the pain level between 0-2. There is normally no skipping corners with this tricky injury. 

I put the boot back on, and called the doctor.  His assistant advised me to leave the boot on for another 4 weeks, and to then see him again.

It was durning the second 4 weeks in the boot that I found your blog.  I was concerned that we couldn't really see the bones in the x-ray, and couldn't tell how I was actually doing. On the follow-up appointment with the doctor, I requested an MRI as you'd suggested in your blog, and had an MRI the following week.

On another follow-up appointment the next week, upon reading the MRI, the doctor advised me that the bone had healed, but that it had then necrotized.  Looking at the bone on the MRI, it was darker than the other bones.  What didn't make sense to me was that the bone would heal, and then just die.

Dr Blake's comment: That is typically a mis-read. The bone is inflamed for months and months even after healing, which makes it look darker on T1 images (bone is white), and whiter on T2 images (bone is dark). 

I read in another part of your blog that bone growth can be misdiagnosed as necrosis on an MRI.  Do you think this could be the case?   Should I have a CT scan done?  What is the difference between an MRI and a CT scan?

Dr Blake's comment: CT scan shows only bone anatomy in 3D, and MRI is great for showing soft tissue and fluid within the bone. I would just wait a minimum of 3 months for a followup MRI to see if these bone changes look better. MRI changes are much more predictable for this injury. 
I've been in the boot for 2 1/2 months now, and still feel tenderness and some pain if I land wrong on my foot. 

Dr Blake's comment: The key line is "if I land wrong". The sesamoid is going to be tender, especially if you land wrong, for months and months. This is not a sign of poor healing. This is the time to be designing a shoe insert that you are going to be wearing to off weight the sesamoid post cast. It is essential to weaning successfully off the cast. You place that insert in the boot also while you continue to wear the boot. 

 The doctor is suggesting surgery to remove the bone, but that makes me very nervous.

Dr Blake's comment: Average sesamoid surgery, which is done rarely BTW, is over 1 year after injury. Fight hard to save the sesamoid. It is important.

  I have a copy of my MRI, and am seeking a second opinion before considering going under the knife. My mom had a sesamoid removed, and said that she still has pain from the surgery after many years.  I'm not ruling surgey out, but I don't believe it will only have a 2 month recovery time that the doctor is suggesting.  If the bone is actually dead, I want to make the best decision that will lead to a pain free and active life.

Dr Blake's comment: I would be happy to look at the MRI, but any elective surgery should get a 2nd opinion. Look at the AAPSM website for a fellow or member near you. These are sports minded podiatrists that typically share my anti-surgery zeal unless proven it is needed. Email me with your city and perhaps I can narrow your search. I hope this helps. Thanks for all your kind words. I think you you need to investigate icing, contrast bathing, orthotics, taping, bone stimulators, dancer's pads, etc. Rich

Thanks for all your help.  Your blog is wonderful, and has really helped me understand what is happening with my foot.

Take care,

Lisfrancs and Sesamoid Injury: Email Advice

Hi Dr. Blake,

First let me say what an incredible resource your blog has been for me - and how grateful I am that you take the time to advise and treat patients simply because you believe everyone has the right to heal. So thank you.

As for me, I've seen far too many doctors - who all have very different opinions (and seemingly different levels of commitment to my healing). I'm desperately seeking a treatment plan - and some patience with the many questions that I have. 

Now here's my story...

I'm 30 years old and live in New York City. Back in late MARCH, I tripped up (yes UP) the stairs -- and injured my toe/foot. I seemed to only have pain in my big toe (top of my foot) - in the phalange and metatarsal. The first podiatrist I saw didn't catch anything in the x-ray, and believed it was a stress fracture. After 3 weeks of it not seeming to get any better, he still gave me his blessing to go on my 2 week Europe trip. I should have listened to instinct...but alas. I went, wrapped my foot, threw it in a hiking boot, grabbed a cane, and went on my way. The trip was great - but by the last day I couldn't stand. And my foot was purple.

Came home beginning of May - switched doctors. Got an MRI (and another x ray) - and it was confirmed that I have a fractured tibial sesamoid, as well as a lisfranc ligament sprain. The doctor seemed to pay little regard to the lisfranc injury - saying that a sprain isn't serious. 

          Dr Blake' s comment: A Lisfranc injury is one of the most severe foot injuries I treat, 
          with a high  percentage needing surgery.  

Now here's where things get even more complicated. I was heading to Los Angeles for a gig a few days later. The doctor advised me to non weight bear for 3 weeks (in a remove-able walking boot), use a dancers pad, then see another doctor (doctor #3).

I continued to have swelling - but iced and did contrast baths daily. Saw an ortho in Los Angeles - who perhaps due to my desire to be as conservative as possible - decided to keep me non-weightbearing for 8 weeks. The last thing I wanted was to look back and wish I would have committed to more time. He also thought that the bone might be dying, and thought that when I'm back in NYC I should have a CT scan (or bone scan?)

So now...I'm back in NYC. Saw a new Ortho (doc #4). He said that I should start putting weight on it, and to stay in the boot until my next appointment -- in 4 weeks. And he said no CT scan.

Unfortunately I had no advice on how to wean off the crutches - it was implied that it would easy to just start walking. Not really the case for me. So...I started weightbearing while still using the crutches for a few days, then went down to one crutch, and now to a cane. I seem to be doing pretty well -- except that I keep getting a shooting pain in my ankle every time I step a certain way (which isn't that often - but when it happens it HURTS). Been happening now for the last 4 days. The sesamoid, however, seems to be ok. Still a little swollen - but doesn't seem to have very much pain at the fracture site. 

Also my whole body seems pretty out of whack (my hips have a very strange turn out right now...).

          Dr Blake's comment: Typically this out of whack feeling is part of any cast regimen.
           It is helped greatly by using an EvenUp on the side without the cast, 
           and never going to one crutch. It should be 2 
          crutches or no crutches, since one crutch and sometimes canes
          throw your back and pelvic into strange tilts. 

So now that you know my story, I have so many questions...

1. My big toe still feels so strange. Like it weighs 5 pounds. Which is how it felt when I first injured it (why I assumed I broke my toe). I can barely bend it down - and can't bend it up at all. Is this normal? The pain/stiffness/heaviness goes from the joint of my big toe down to the middle of my foot. Often times I have strange twitching there as well...

          Dr Blake's comment: For what I know, this is all normal for your injury and
          being in a cast and non weight bearing for a while. You are gradually
          progressing from the Immobilization Phase of Rehab to 
          the Re-Strengthening Phase. During this phase you need a lot
          of physical therapy guidance to work on the remaining swelling,
          and increase range of motion, strength, flexiblity, and balance. There is a
          lot of hard work ahead.  

2. At this point, should I be forcing my toe to bend? Or is it all still healing that it should still be immobilized most of the time?

          Dr Blake's comment: For these injuries, you never push the toe bending
          part of rehab. You let that 
          come naturally. It is always fun to measure the range of motion 
          with each stage if you have a therapist  you will be working with. 
          Typically you come out of the cast with almost no motion in the motion, you  
          start doing some of the self mobilization movements on my blog
          under Self Mob for Hallux Limitus. You can 20-30 degrees as you 
          begin to walk normally, and another 20 degrees as you begin to run. 
           Keep the joint pain free when you are working on it, you never 
          know if more healing is still going on it there.  

3. What about ankle exercises? Could that also interfere with the healing of the sesamoid/toe? Any physical therapy for the rest of my body? Or should I still wait...

          Dr Blake's comment: Core and other lower extremity strengthening that does
          not hurt the injury can normally be started right after the injury.
          There is benefit to riding a stationary bike with one foot and 
          no tension when you foot is in the boot. There are so many core, hip,
          knee, and ankle movements that you should be doing right now,
          and that is why a PT or Personal Trainer can help. The stronger the 
          core, the normal you are lifted off the foot, and the faster
          the rehabilitation goes.  

4. This lisfranc sprain - is this really something that should be so swept under the rug? I finally researched it and it sounds like it could be a big deal. How do I find out if the sprain has healed? 

          Dr Blake's comment: Lisfranc Injuries are big deals. You need to wait 3
          months from your first MRI  to get a repeat MRI to document healing.
          I treat all Lisfranc Sprains very seriously with a 2 year 
          committment to orthotic devices, arch taping, and a gradual progressive
          re-strengthening program on all the important intrinsic and extrinsic
          muscles/tendons that support the arch.  

The middle of my foot definitely hurts right now - but I assume a lot of it has to do with the fact that I'm putting weight on it for the first time in 8 weeks. I also have a boney bump in the middle of my foot - under the big toe. The doctor assumed it was from the boot. Does that sound right to you - or could it have something to do with this lisfranc thing?

          Dr Blake's comment: Lisfranc's Injuries hurt in the middle of the foot. If you
          are weight bearing, get a orthotic ASAP to stabilize that area and learn to
          tape your arch (I have arch taping videos on this 
          blog). I am not sure what the boney bump is. You could send me
          a photo of you pointing it out, and
          another of the same spot on MRI.  

5. Does walking in the walking boot for 4 weeks after being non weightbearing for 8 (and in a hiking boot for 4 weeks before that) seem like the right treatment course?

          Dr Blake's comment: Yes, but 16 weeks of immobilization means 32
          weeks minimum more to get your foot healthy again. Go slow, go gentle,
          but persist. You are still in the hands of the docs for 
          direction, but PTs and Personal Trainers and Athletic Trainers
          should have the most prominent role in your recovery now.  

6. My left foot has also been hurting quite a bit - since it's been doing most of the work the last couple of months. Is there an insert/insole you can recommend to help this? Mostly the middle of my foot. What about Superfeet?

          Dr Blake's comment: When you get custom made functional foot orthotics from
          a sports podiatrist, they are always made in pairs. Consider seeing Drs Karen
          Langone, Dr Robert Conenello, and Dr 
          David Davidson in New York. You can also see the AAPSM website
          for all the New York 
          members. I am typically safe recommending from that list.  

7. I've been using the bone stimulator twice a day on my sesamoid - which is why I haven't been taping. Should I be taping and just removing it daily?

          Dr Blake's comment: The bone stimulator has a 3 inch penetration. You can aim
          the beam from the top of your foot where you do not have tape, and it 
          will still work. That way you can tape also. This is  at least my understanding
          of the Exogen bone stimulator, but check with the local rep. 

8. I'm not 100% sold on this ortho I'm seeing in NYC. He's just so rushed - in and out in 5 minutes. Do you know a doc (ortho or DPM) here that you would recommend? I had been recommended someone at the hospital for special surgery - but unfortunately they don't take my insurance (GHI/Emblem)

          Dr Blake's comment: See my recommendations above. Even if they are a distance,
          it is worth it. They can refer you to a local PT to do the lion's share of the work.  

9. Would it be possible for me to send you my MRI from beginning of May? I would love to know your thoughts.

          Dr Blake's comment: Yes, Dr Rich Blake, 900 Hyde Street, San Francisco, 
          CA, 94109.  

Thank you so much for taking the time. As I mentioned, I generally need to be on my feet all day (although this last one in LA was thankfully pretty low key). I'm so anxious for my foot to feel normal again, but I'm also committed to recovery and can be as patient as I need to be. However, I just need to feel like I'm doing what's "right". And with so many different doctors over the last few months (all with very different opinions) - I'm left fairly confused and rather discouraged. 

Any thoughts/advice would be so greatly appreciated. 

MANY THANKS,

Jill (name changed)

          Sorry one last question!! 

          I've been using 1/4" adhesive felt applied directly to my foot for the dancers pad. Is this correct for use in             a boot? 
          Dr Blake's comment: See if you can place as an insert in the boot. Somewhere in my blog
          I have an example of this. Get working on your orthotics ASAP and then just
          place that in the boot. I sure hope this 
          helps you. 

          Thanks!!!