Sesamoid Injuries: Thoughts on Chronic Inflammation

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

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

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

Sesamoid Injuries

I have a lot of information to help you manage your sesamoid injury within the pages of this blog. Please go through the Labels/Index to find information. Here is a wonderful comment I just received. Rich

You’re a true gem of a human and doctor. My sesamoid pain began two months ago and it’s stopped me from doing my favorite activities like drumming and climbing. In only a few days of following your advice, I can already feel my foot healing. It’s motivating and giving me the confidence needed to overcome this. I’m surprised and grateful to find a doctor sharing so much knowledge freely and consistently for as long as you have. Thank you Dr. Blake and happy holidays.

Sesamoid Evaluation Tip: Check First Ray ROM

     In the photo above, I am evaluating the motion and position (kinematics) of the first metatarsal (called first ray) crucial in sesamoid injuries. Of course, when there is significant pain and/or swelling in the big toe joint, this examination may not be accurate. With the patient lying on their stomach, or standing on the other leg with the examined side having the knee bent and the leg resting on a chair, you first stabilize the 2nd metatarsal head. Then, you grab the first metatarsal head with your thumbs parallel. Keeping the 2nd metatarsal still, you move the first metatarsal up and down (typical motion around 10 mm total or 1 cm). With sesamoid injuries, you are looking for reasons that the first metatarsal is overloaded. You may find either less than 10 mm of excursion (called hypomobile first ray), or all of the motion below the plane of the 2nd metatarsal (called plantar flexed first ray). Both these conditions can lead to the sesamoid pain in activities due to overload, and both these conditions can be treated. You treat hypomobility with physical therapy or massage therapy to increase overall first ray range of motion. You treat plantar flexed first rays with some form of dancer's padding to load the other metatarsals. 

Crush Injury leading to Sesamoid Injury and CRPS

Dear Dr. Blake -

I am writing about a crush injury to my right foot 6 months ago (Aug 21 2018) when a large metal object fell from a top shelf onto my bare right foot  I’ve seen a variety of doctors and practitioners, but nothing I’ve learned has improved my condition, and I am in confusion and despair. I’ve read your blog during this time, and your recommendations always make more sense to me. I sent previous emails, but want to try one more time, because the end of my rope is near.

As a quick summary, the initial diagnosis was fractured 1st metatarsal. Second doctors found additional fracture to tibial sesamoid (also deformed), 2nd metatarsal (bottom), inflamed MTP joint, nerve sensitivity on top and bottom of foot.  

Pain has gotten worse rather than better.  Sesamoid/metatarsal area feels like shards of broken glass in my foot.  MTP joint is sensitive, and I keep my foot wrapped in sheepskin inside the boot for relief.
Dr. Blake's comment: That symptom would be intense nerve pain (neuropathic). 
During the day, pain increases the more active I am (light chores around house); better when I stay off it entirely.  During the night, pain can be worse, making it difficult to sleep. I’m still in boot, using wheelchair for total non-weightbearing, homebound from no driving.

Dec 2 MRI:

• Bones and joints:  No dislocation.  Moderate hallux valgus alignment with mild lateral subluxation of base of 1st proximal phalanx.
• Moderate 1st MTP osteoarthritis; severe sesamoid osteoarthritis. No joint effusions.
• Ligaments:  Lisfranc ligament intact.  No evidence of acute injury to collateral ligaments at MTP or IP joints.
• Tendons and muscles:  Mild edema/strain of the medial head of the abductor halluces muscle.  Mild muscle atrophy.
• Soft tissues:  Mild soft tissue swelling, greatest along 1st to 3rd MTP joints

Dr. Blake's comment: Your symptoms are of nerve pain secondary to the crush injury to an already arthritic big toe joint. 

Dec 18: 2 Cortisone injections, which caused extreme pain, fever, disorientation. No pain relief, but some reduction in inflammation.
Dr. Blake's comment: This is diagnostic as it only addresses inflammation. Since it did not work, the neuropathic pain must be addressed. 

Physical therapist has helped flexibility/strength in foot, ankle and leg. Electrical stim and light massage reduce pain temporarily, but sometimes nothing can be done because foot is too sensitive.

My two doctors recommended 2 different courses of action, both surgery. I resisted.

• Dr. 1:  Aggressive: remove both sesamoids, reconstruct MTP with pins, shave outside of bunion, all in one operation.
• Dr. 2:  Conservative: remove tibial sesasmoid.  If that doesn’t work, then remove 2nd sesamoid.  If that doesn’t work, reconstruct MTP joint.

Dr. Blake's comment: No surgery should be contemplated until neuropathic pain is recognized and addressed. The treatment is not easy, so as soon as you can have the neuropathic pain treated successfully the better. 

Jan 19:  Woken up by worst pain yet, like broken beer bottle jammed in my foot.  Decided surgery was necessary.

Dr. Blake's comment: Again, this is neuropathic pain, surgery has to wait for now, but could be avoided. 

Jan 24:  Went to yet another doctor for 2nd option on which approach to use; aggressive or conservative.  He temporarily put the breaks on, wanting more info.

• Increased nighttime pain may be related to L4, L5, SI nerve. I need to see ortho spine doc.
• X-rays show osteopenia in MTP area.  Bones may not have integrity to hold pins/screws, creating worse problem in future.  I need to see osteoporosis specialist.

Dr. Blake's comment: Localized osteopenia could indicate that the neuropathic pain has developed complex regional pain syndrome. I have many blog posts on this subject. 

I sit here befuddled, exhausted, and defeated. I truly hope that you can provide some clarity on what is happening, and how to best proceed.  Thank you for your time and commitment to healing.

Respectfully,

This is a foot that looks like CRPS Stage 2 (vascular stage)

Dr. Blake's comment: I wrote to the patient at this time that I was on vacation and my response was going to have to be delayed. 

Hello Dr. Blake.  I hope your vacation was rejuvenating!

You asked that I resend the email below after your return.  Here are a few updates as well.  Thank you so much for your generosity.

Pain Relief:

I got a medical marijuana card last week. A daytime tincture hybrid of THC/CBD keeps me alert while reducing pain.  The nighttime tincture is 100% Indica for sleep.  To my surprise, the daytime product has reduced my pain considerably, particularly around the tibial sesamoid.  I’m mainly feeling nerves, but in a lower pain range. 

The amount of pain I have right now is bearable, which makes me more resistant to surgery. It feels good to have the boot off.  I’m still putting all weight on my heel and outside of foot. Only a few steps here and there.  Doing exercises recommended by physical therapist.  Still in wheelchair most of time.

Doctor Opinions:

Here is the full array of opinions that have my head spinning.

Dr. A (podiatrist):  Recommends removal of both sesamoids, rebuilding of MTP joint, shave bunion bump. Should all be done all at once in order to maintain my gait, but also recognizes it will be a difficult recovery.

Dr. B (Dr. B's partner):  Recommends removal of tibial sesamoid only.  If that doesn’t work, then follow with 2nd sesamoid removal, followed by reconstruction of MPT.  More conservative approach, but possibility of 3 separate surgeries.

Dr. C (my chiropractor):  Advises against surgery because of complexity of foot, but if surgery is necessary, then do it all at once.  He recommended Dr. D for a second opinion.

Dr. D (third podiatrist):  Not rushing into surgery after reviewing the MRI.

#1 - He thinks the tibial sesamoid is not that deformed, and the pain/inflammation is likely severe osteoarthritis aggravated by the accident. He also thinks some nerve pain may be originating in my lower spine...L4, L5, S1. He asked for a workup from an ortho spine doc. If foot surgery is necessary, he recommends it all be done at once.
Dr. Blake's comment: This is my choice of direction, but CRPS has not been discussed?

#2 - He is concerned with osteopenia in the big toe joint, and not confident that pins would hold.  He wants a workup from an osteoporosis specialist, before he would consider surgery.

CNP (my primary provider):  She did not understand Dr. Haas’ concerns. 

#1 - She doesn’t agree lower spine should be an obstacle.  She ordered x-rays, and results were as expected. 

Mild degenerative disc disease at L4-L5 and L5-S1 with disc space
narrowing. Facet arthropathy is present throughout the lower lumbar
spine. No acute fracture or malalignment is seen. No evidence of
spondylolysis.

#2 - I had a bone density last March, and there is osteopenia everywhere. It's being treated with Vit D3 caps, and calcium through diet.  Marcie doesn’t see a problem with pins holding.

She said I’m between a rock and a hard place, but agrees with Dr. B; one bone at a time.
Dr. Blake's comment: In California we have pain specialists that are neurologists, physiatrist, or anesthesiologists who need to be consulted. Dr. D was right about the nerve part, but CRPS type 2 is nerve hypersensitivity from nerve injury. This has very specific treatments. 

Finally, my physical therapist): He has seen my ups and downs more than anyone. Most recent trend is down, so he can’t even do exercises with me, and we've cancelled appointments until this gets sorted out. He said it will be a difficult recovery, but he recommends the full surgery.
Dr. Blake's comment: The full surgery is only recommended by caring people who want desperately to help you. You can not blame, but if the pain is neuropathic, the surgery is going in the wrong direction. See if there is a neuro-physical therapist in your area. They have a national organization and are attuned to CRPS.

Me:  When feeling my foot prior to medical marijuana, I am resigned to surgery.  Feeling my foot right now, under the effects of medical marijuana, I don’t want surgery.  

Bottom Line:  where do I go from here?

Warm regards,

Common presentation of CRPS post injury

Dr. Blake's first response after vacation (3 weeks ago), but before the two photos above were seen. 

Just read through all the emails to get my brain working. Do you have any images you should send of xrays or MRIs? If you have surgery on your foot, you only want the tibial sesamoid removed for sure. More and more surgery at one time is less predictable, and more trauma to your body. You had a very bad accident, which everyone wants to help you with, but more surgery does not make sense right now.

Secondly, I treat patients every day with tibial sesamoid fractures, and no one hurts like this. The crush injury may have caused a complex regional pain syndrome to develop which behaves like this. If so, you need a sympathetic block in your back soon. So, please have a neurologist or pain specialist work you up for this to rule it out, but also to treat the pain. If you are having nerve pain from this, surgery may make you worse unfortunately. So, get away from the surgeons for a few weeks and focus on nerve pain and its treatment. Send me any images. Keep up with the cbd oil which works well for nerve pain in some/most patients. Rich

The Patient's response:
Hello Dr. Blake -

I’m writing because I’m stuck, and need to make a decision on treatment for my foot. Last night, I had another high pain episode. My physical and emotional reserves are depleted after 5 months since the injury. 

It is very generous of you to provide your expertise, and i cannot imagine how busy you are. While understanding that, I also need to make a decision soon about surgery. I’ve been putting it off for months, and my foot is only worse. 

Is it possible to talk by phone/Skype, or do you have enough info to make a recommendation in writing?  I am so happy to make a contribution to your blog or pay you outright for your time. I just don’t know where else to turn. 

With respect,

Dr. Blake's next response:

I just reviewed the foot MRI. The Spine MRI is out of my expertise. The fibular sesamoid is out of its normal position, probably from the bunion or possibly a ligament tear. It will probably have to be removed. There is some arthritis in the joint, which could be part of the pain. I will have to read your original email to put it all together tomorrow. There is a lot of swelling around the tibial sesamoid which also probably hurts. The L4 nerve root is problematic and this goes to the big toe. Lucky you!!. I will think more on it tomorrow. Rich

Image under the big toe joint showing the fibular sesamoid out of its normal alignment

Another image of the same thing

Arrow points to intense fluid under a normal appearing tibial sesamoid, the fluid seems to be why she is hurting

This is another image of the intense inflammation under the tibial sesamoid in the subcutaneous fat, the tibial sesamoid looks arthritic, but it does not looked fractured or needing to be removed.

Here is the comparison more normal fibular sesamoid and fat pad

The arrow is on the flexor hallucis longus showing intense inflammation above near the fibular sesamoid. I wonder with the injury if the ligament connecting the 2 sesamoids was not torn. This would explain why the fibular sesamoid in the earlier images looked way out of place.
 

This image points to the gap between the tibial and fibular sesamoids possibly created by a tear of the ligament.

The architecture of the tibial sesamoid does not look injured, but you can see the swelling below in the soft tissue which will hurt on pressure

This image shows the mild wear and tear of the joint itself, osteoarthritis, that could be stirred up in the injury and resulting demineralization process going on

Another view of some mild wear and tear.

Thank you, Dr Blake. This is important information.

I’ve been regulating pain with medical marijuana (mm), and also using the Curable app. Both are helping a lot with calming down my nervous system, reducing discoloration and swelling. Mm is supposed to be good for nerve repair. Reading that I probably need surgery has released a flood of anxiety, and I’ll focus on that now. 

You are most kind.


Dr. Blake's comment: Yes, if you need surgery due to the fibular sesamoid out of alignment, that can wait and you may avoid it. Get the CRPS evaluated. Sounds like you are already calming your nervous system. On your recommendation, I introduced the Curable app for nerve pain in a recent blog post. It definitely looks promising. Keep me in the loop.

Transitioning from one restriction to less restriction: Email Advice

Hi there Dr. Blake,

 I found your blog while looking for the best way to transition out of a walking boot back to my shoe.  I fractured my Medial sesamoid in my Right foot in March while on the elliptical due to high arches and over-pronation.  Started as a stress fracture which I thought was a soft tissue injury so I treated it that way.  Rest, Ice, NSAID’s, elevation.  No improvement after 2 weeks, so I went to our podiatrist here and she found my fractured sesamoid (my what?).

Into the boot, I went for 8 weeks with icing 3 times a day, NSAID ointment for topical use and elevation at night.  Things looked great at follow-up so back into my shoe.  2 weeks later, it was swollen, red and angry again.  Back into the boot and a knee scooter for non-weight bearing for 2 months.  At follow-up, the x-rays showed the bone was knitting with remodeling on the bottom of the bone. 

   There has been general discomfort in the MTP joint for a month, just achiness and occasional tingling in the sesamoid area.  This is Sept. 11 so 5 months out and I will have the knee scooter until the 21^st.   I’m concerned about just going into the boot or my shoe and re-breaking it again.  I do not want to have it surgically removed. 

   If you have any suggestions or anything, I’m open to trying it.  Thank you for your time!

Sincerely,

Dr. Blake's comment: Thank you for the email. Improper transitions, like our US sprinters dropping the baton in the Olympics, can be devastating. You have done a lot to help the sesamoid heal in the last 4 months so I will assume it is healing just fine. Sesamoids are very sensitive as they heal, and with high arches and overpronation, you are going to be putting a lot of stress on a sensitive bone for a while. So, the question is how to minimize that stress on the bone. My blog is full of information on the following: dancer's padding, Hoka One One Shoes for rocker, avoid toe bend in general, spica taping initially to help stop toe bend, get some Dr. Jills Dancer's pads for even sandals as they come in 1/4 inch size, while you are waiting for a good pair of orthotics to be made, use the dancer's padding in an anklizer boot. You may need to use crutches initially also since you have been using a knee scooter and putting no weight down. That typically makes the joint more swollen and sensitive as you begin weight bearing. Contrast bathes nightly should help reduce the inflammation. I would get Neuro-Eze from Amazon and rub in nonpainfully for 3 minutes three times a day. You also need to strengthen your foot again with metatarsal doming, single leg balancing, heel raises. I have a post explaining how to build a well or depression to float the sesamoid while still doing exercises.

I hope this helps. Rich
PS. Why no Exogen Bone stim? 

Sesamoid Injury: Email Advice

Hi Dr. Blake,

     I woke up to a swollen and painful foot in the big toe junction area at the end of February this year. Got misdiagnosed at an ortho as gout, then a strain, then a sprain as my blood work was clear of autoimmune signs and PT for the strain/sprain was helping, but slowly and then progress would recede. 

     Second opinion sought after an MRI I demanded revealed sesamoiditis and it was recommended I try to take it easy. An experienced podiatrist took X-rays and found a fractured lateral sesamoid, and indications of tendon tears in the area. Proceeded with red laser therapy weekly, non-weight-bearing and a dancers pad. Pain level kept lowering. 

     5 weeks ago 2nd ultrasound showed no change in the amount of swelling. Was placed in a cam walker boot. I feel this helps walking, but can be painful when sitting or laying. This boot was an attempt to stabilize my forefoot (high arches, flexible forefoot). Swelling is an issue bc I seem to have the family Raynaud's Syndrome. Every time I try to ice, even for just a few moments I  experience incredible pain. Even tried going 10 seconds and then into warm water for 30. 

     I just want to make sure we aren’t missing something in our diagnosis/treatment. And the swelling greatly concerns me. I’ve been doing self-massage to try to get the swelling down daily and taking a load of turmeric as the prescription anti-inflammatory was having adverse effects on my digestive tract after 1.5 months. Also had tried a steroid pack at week three with the ortho doctor. Had no effect but I was still on my feet. 

     Your input would be GREATLY appreciated!!!

Dr. Blake's comment: Sorry for the long road, but it sounds like you are finally in the Immobilization phase of rehabilitation (Phase 1) to allow this to heal. Typically strains do not cause swelling, so I am going to discount that diagnosis. A sprain would be related to a fall, trip, stumble, so what brought this on? If you did not have an acute incident that could have sprained the tissue, I am assuming that is also incorrect. Sesamoiditis vs stress reaction vs stress fracture of one of the sesamoids is the highest possibility and they all look essentially the same on MRI, and you have to treat them the same. A fractured sesamoid looks a lot different. These injuries are caused by walking too much, dancing too much, etc, especially if the winter brought some silent Vitamin D deficiency. With this type of injury, you go into a removable boot/cam walker and get the pain to 0-2 as quickly as you can. You can walk for bone mineralization with these injuries. Sometimes you have to stay in the boot 3-4 months, but other times you can wean into a Hoka One One shoe or Chrome Bike shoe (or something similar) with the embedded cleat even after one month. All based on achieving the 0-2 pain level consistently. 
     If you go to YouTube and type drblakeshealingsole sesamoid in the search area, you should come to all my videos on sesamoid injuries. The typical treatment has to include: contrast bathing (important for the painful swelling trapped in the sesamoid), dancer's padding and cluffy wedges (important to off weight the sesamoid slightly), an Exogen bone stimulator if it is actually broken (fractured), and non-painful massage and range of motion for nerve hypersensitivity. You can use lukewarm water with Epsom salts for 30 minutes with toe range of motion for the circulation because of the Raynaud's instead of the contrast bathing. Look at google for foods that produce inflammation, like peppers. Consider physical therapy to strengthen your foot and as an anti-inflammatory measure with all their wonderful equipment. See my post on making a sesamoid well for doing protected weight-bearing exercises like single leg balancing or achilles stretching without putting too much pressure on the sesamoids themselves. I hope this helps. Rich

Sesamoid Injury in Soccer Player

Dear Dr. Blake,

I came across your website while researching my son’s injury.  I wanted to reach out to you to ask for your opinion on his injury.  I have mailed you a copy of his MRI and CT for your review.  I am so grateful for the information on your blog and would really appreciate it if you could take a look at his MRI and CT when they arrive at your office.

Dr. Blake's comment: Will do. 

My son, Ben (13 years old), is a very competitive soccer player.  He plays soccer on average 5-6 days a week.  During a game this past Spring (March 11th), he felt pain in his left foot.  He did not suffer any direct trauma to his foot but thinks the pain started when he planted with his left foot and went to cut right.  After the game, it was hard bearing any weight in his left foot.  We thought that perhaps he had turf toe (he was playing on turf, but wearing hard spiked soccer cleats) and had him rest for a few days.  When it appeared that he wasn’t improving, I took him to see a podiatrist on March 15th (4 days after the injury).

Dr. Blake's comment: One of the culprits is the cleat right under the sesamoid pushing up hard. Please consider removing it as part of the treatment. 

Find the Cleat right under the Sesamoid to remove or file down

The podiatrist’s X-ray showed that the medial Sesamoid was in 2 pieces.  He was not sure if it was a bipartite sesamoid that was inflamed or a fracture.  He recommended an AmnioFix injection, saying that if it was sesamoiditis is would help speed healing and it could do the same for a fracture.  I was not familiar with AmnioFix, but at the time I felt that if it could give Ben a better chance at healing, we should do it.  Looking back on it, I am upset at myself for going through the injection because it caused Ben an intense amount of pain and swelling for about 3-4 days and with the information that we found out later, I wonder if it made things worse (edema causing poor blood flow which impacted the development of AVN?) The podiatrist put him in a walking boot after the injection. I purchased a dancer’s pad for him to wear with the boot.

Dr. Blake's comment: I am not doing any of the regenerative medical treatments, like PRP or Stem Cell, or AmnioFix. I have always thought AmnioFix as a skin substitute, or collagen former that would be helpful in achilles tears or plantar fascial tears or diabetic ulcers. I, therefore, have no idea why it was put into your son. Sorry. It is hard to get info on it but it should be degraded by now. The acute inflammation should not cause any long-term AVN problems. 

I decided to take him to see a Foot and Ankle Orthopedist the following week.  He thought that the distal fragment of the medial sesamoid “looked funny” so he ordered an MRI.  I have enclosed the MRI.  The MRI showed edema, sclerosis, and avascular necrosis of the distal fractured portion of the medial sesamoid.  I’m wondering if the swelling/inflammation from the AmnioFix injection caused the AVN or made it worse.  Can AVN happen so quickly-9 days passed from the date of injury to the day the MRI was taken? Could he have had this injury “brewing” for a while (he never complained of foot pain)? The doctor told Ben to wear the boot and dancer’s pad for the next month and return for a follow-up.  I asked the doctor if an Exogen Bone Stimulator was a good idea and he said that it was okay to use and gave us an order for the machine.  He has been using it daily for 20 minutes since March 29th.

Dr. Blake's comment: Please talk to the Exogen rep for me about the age restriction. I know the bone has to be skeletally mature, but not aware of recent studies on age. Did see some studies that 13 was the earliest including in the Exogen study. It is hard to imagine in a child that some short-term swelling will lead to AVN. I have not seen it. I have seen AVN occur when a year has passed and the inflammation was never under control due to inadequate treatments.

We returned to the orthopedist on April 23 for a follow-up.  He did a CT scan in his office and said that “the bone did not fragment, but still showed AVN” and Ben could transition into an orthotic as soon as possible and if he felt good, he didn’t need to return to his office for any follow-up.  He didn’t indicate that Ben should be restricted in any way or need physical therapy.  Because of what I read on your website, I thought that 6 weeks was a little premature to be out of the boot, especially with AVN.  

Dr. Blake's comment: Yes, first of all, you need the boot to achieve the 0-2 pain level? Sometimes you need an orthotic or dancer's padding to accomplish that. If I can good pain wise, and I have good 0-2 pain control, I will begin weaning from the boot and orthotic to shoe and orthotic at 10 weeks. As long as the pain does not go higher. Keep him in the foot for at least 4 more weeks. 
     If we are worried about AVN, then contrast bathing twice daily, Exogen bone stim if good for his age, and weight bearing as long as we keep the pain between 0-2. Also, bone health should be important with proper Vit D, Calcium, protein, perhaps asking a nutritionist if there are diet changes to make to ensure stronger bone. 

I was disappointed to have Ben discharged from his care without any type of follow-up or plan for returning to play.  Instead, I decided to follow your recommendations of 12 weeks in the boot with dancer’s pad, daily bone stim,  and daily contrast baths.  I’ve had him on Vitamin D3, calcium, and magnesium since the beginning of the injury.  Ben has also been doing body weight exercises and using the rowing machine while wearing the boot.  

Dr. Blake's comment: Great, what pain level are we having?  

Ben reached the 12-week mark on June 3rd and his been weaning out of the boot and into a Hoka shoe with the orthotics.  The orthotic had to be a very low profile in order to eventually fit into a soccer shoe. The orthotic has a carbon fiber plate with the metatarsal cutout and dancer’s pad for the left foot.  The right orthotic does not have the carbon fiber plate or dancer’s pad (only has the metatarsal cutout). Ben has very high arches which probably contributed to his injury (along with wearing hard spiked cleats on turf and perhaps overtraining).  This past week, Ben says he feels good and has no pain with walking.  He says he gets a little bit of pain if he puts a lot of pressure on his left foot to “test the orthotic”.  He has some pain with palpation of the area to the side of the medial sesamoid (along the base of the big toe)-he describes it as “tingling pain”.  He has not done any running or jumping.

Dr. Blake's comment: Wow, this sounds wonderful. You are doing a super job. All of those symptoms fit in the 0-2 range. Palpable pain can be normal well after a person is back running with full activity due to some nerve hypersensitivity. Massage the area for 2 minutes twice daily with the palm of your hand. The massage is for desensitization and cannot be painful. 

Thank you for taking the time to read this and look at Ben’s scans.  I want to make sure that we haven’t missed anything and if there is anything else we should be doing.  Do the orthotics that he has sound appropriate for his injury/needs? Should I also be spica taping him? Continue with bone stim and contrast baths? Any recommendations that you have on how to progress his activity from here would be greatly appreciated.  He is tolerating the orthotics and can walk about 1 mile without pain.  

Dr. Blake's comment: Definitely needs another pair for normal athletic shoes that can have more bulk (more padding, more dancer's protection, more arch?) As he begins to increase activity (longer walks, then walk-run program) experiment how spica taping and cluffy wedges feel. Check about the bone stim for his age. Contrast bathing until a new MRI 6 months after the first one, or we have stopped worrying about AVN (bone death). 

How do we know if the bone has healed and no longer has AVN?  I’ve read that it can take up to a year for a bone with AVN to come back. Is it safe for him to play soccer before we have proof that the bone is okay?  It has been extremely difficult for him to sit out the last 3 months and the competitive nature of his team/league makes it difficult to come back after a prolonged injury.  However, I’d rather be safe than sorry.

Dr. Blake's comment: It can take one or two years to know that a devitalized bone has revitalized (I know big words for me). Typically, we first follow the symptoms, as long as we are doing the above bone stim, contrasts, bone health, weight bearing. If the symptoms and disability (inability to play soccer) are stalled at 6 months, a CT scan and another MRI are ordered. The signs of AVN are bone fragmentation and no marrow signal from the bone. This is getting the buggy before the horse right now. 

Thank you for taking the time to read this long message!  I so appreciate it.  The information from your blog has been so helpful!

Dr. Blake's comment: Thank you. Sounds like you are doing wonderfully. Look forward to seeing the images. Good Luck. Rich

The Patient's mother responded: 

Dr. Blake,

Thank you so much for your recommendations.  Looking forward to hearing your thoughts on Ben’s films.

I spoke to the Exogen rep about the age limitations on the bone stimulator and he said that studies have not been done on children, but it has been used in kids Ben’s age without any negative effects (that we know of).

Side View of the Tibial Sesamoid with 2 fragments looking nonfractured and smooth edges, but the distal fragment (closest to the toe on the left side) looking sclerotic (sign of AVN) brighter white than other fragment.

Take care!

Dr. Blake's review of the images sent: CT, and MRI. Selected images presented. 

                                                               Again the tibial sesamoid on the left side looking more sclerotic in its distal or bigger fragment, but the two pieces look typically bi-partite (round, smooth edges). The trauma appears only to the distal fragment.

These are side by side comparison of the tibial sesamoid in T2 MRI where the normal bone is dark and inflammation shows up as white, and T1 where normal bone is white. See this distal fragment does not change consistency. This is very unlike a new injury where trauma to a bone would make it white on T2. Possible AVN? Probable old AVN! MRI after 6 months of Exogen, contrasts, weight bearing will be conclusive. Long wait I know. 

 Here the arrow above points to a medial collateral ligament irregularity. Also, note the tremendous swelling on the whole joint. This points to a Turf Toe injury which is acute (3 months old). Taping of the joint crucial to allow healing. This could be a reason to do surgery to sew up the ligament or consider PRP or prolotherapy. However, no joint instability has been found, so again I would wait for the followup MRI. I would do even if the joint is doing well.

 These 3 CT scan reconstructions are conclusive to me. The 2 fragments have the classic appearance of a bipartite sesamoid, round, different sizes, smooth edges at the junction. The distal fragment with the possible AVN looks healthy, nonfragmented, just like the uninjured fibular sesamoid. Good sign!!

Sesamoid Injury: Email Advice

Hello Dr. Blake,

 I am a 26-year-old female from Windsor, Ontario, Canada. 

I am struggling with a fibular sesamoid injury which occurred in January 2018. I read your posts regarding sesamoid injuries on your blog and found them very helpful! 

I've had two x-rays, a bone scan, and an MRI so far and unfortunately, I have not been able to get a clear answer from the health care professionals here in Windsor. The radiology reports from both of the x-rays and the MRI indicated no fracture or focal bone lesion, however, I have gone to see three podiatrists who all claim that there is a fibular sesamoid fracture. The report from the MRI (which I finally had in May 2018) stated that there was lateral sesamoid bone marrow edema and the conclusion was sesamoiditis. One of the radiologists also thought there might be a "crack in my big toe." 

Dr. Blake's comment: Sesamoiditis with bone edema can be the same treatment and injury as a stress fracture. You can not see a small stress fracture, but it causes bone edema as your body attempts healing. So, they can look the same, and we are really forced to treat the possible fracture because that has long-term complications like the need for surgery that we want to avoid. 

I admit I did not stay off of my foot when I was originally injured in January since the diagnosis was unclear. I am very active and do a lot of walking at work (sometimes wearing heels). However, despite staying off of my foot for the past month I am still in a lot of pain and have not seen improvement. I am also struggling with circulation issues (despite trying contrast baths). I am wondering if there is underlying etiology that may have been missed. 

Dr. Blake's comment: For bone health and tissue strength, along with swelling reduction, weight bearing to tolerance is crucial. Yes, you can not push through pain, but rest (getting off your feet for an extended time, does not help either. 

Due to our healthcare system in Canada, I am not able to get in to see a specialist until September 2018. I was wondering if you would be so kind to have a look at my MRI or x-rays and give me your clinical opinion? I could mail or e-mail them to you and I would be happy to pay you for your time as well! Please let me know if this would be okay with you. 

Dr. Blake's comment: Yes, please mail a disc to Dr. Rich Blake 900 Hyde Street, San Francisco, California, 94109. No charge for this. Contact my friend Dr. Shannon Frizzell at OOLAB (Ontario Orthotic Lab) in Hamilton, Ontario to see how you can get a good orthotic to protect the sesamoid. 

Thank-you for providing such thorough and detailed information on your blog. It has helped me immensely so far! 

Thank-you for your time, 

Sesamoid Fracture in a Young Athlete: Email Advice

Dear Dr. Blake,

     I want to thank you for all of the time and love you have put into your blog. It is by far the most comprehensive and detailed source of sesamoid injuries that I have been able to find. I was wondering if I could ask a few questions about my daughter because I would like to know if we are on the right healing path.

Dr. Blake's comment: Thank you for your kind remarks. I will be happy to answer them in hopes of giving you some guidance. 

     First, to give you some background, my daughter is a 9-year-old soccer player. She was diagnosed over a year ago with Sever’s disease, and despite our efforts to cushion her heels, the pain was quite severe. However, she continued activity and playing soccer through the pain, and tended to compensate for the pain by running on her toes.

Dr. Blake's comment: I hope now you understand how bad limping is. A child may not be able to describe the pain and use good judgment on what not to do, so I have to tell parents and coaches that as soon as they see limping, the child has to be pulled from the game or practice. 

    Flash forward to 8 weeks ago, she woke up in the morning with a very sore big toe after a week of heavier than normal activity. After x-rays and a referral to an orthopedic surgeon, she was diagnosed with a stress fracture of the fibular (lateral) sesamoid. The doctor’s recommendation was to get her in more supportive shoes, Superfeet insoles, and rest (no running, jumping, barefoot walking). After a week or two of this, and scouring the internet for advice, we added dancer’s pads and toe taping to the regimen. Additionally, we have been having her supplement extra calcium, vitamin D, and magnesium. With all of these modifications, her pain level was down to a 1 by her judgment.
Dr. Blake's comment: I would have put her in a removable boot, but I am glad you got the pain to 0-2 range for healing. The issue now is to keep an active child in this for the next 3 months to guarantee good bone strength. With a stress fracture, there is no visible gap of the fragments, which is an MRI diagnosis. This is very hard, but possible, to diagnosis on x-ray. I hope we are talking about the same thing. 

     At her 4-week check-up, slight healing could be seen on the x-ray, however, her pain had not changed.

Dr. Blake's comment: You can not follow the progress on xray, which the healing shown lags up to 2 months from where it is. You can also not follow the progress on palpation, because the bone will remain sore to touch months after it has healed. I had a 16-year-old, who was back running 10 miles a day 5 days a week tell me the bone we still just as painful for another 18 months on palpation. You immobilize the pull of the toe bend, you off weight the area, for 3 months on average, and then you gradually increase activity again. During the 3 months, you work on both nerve hypersensitivity with nonpainful massage 2-3 times a day and inflammation part of the healing process with contrast bathing and icing. 

     The doctor’s advice was to continue as we were and come back in 4 more weeks. During the 7^th week, she noted a small improvement in pain. At the 8-week check-up, the fracture looked only very slightly better than at 4 weeks. The doctor’s advice was to continue for yet another 4 weeks or go non-weight-bearing in a hard cast. He recommended to just continue as we were as he is not a fan of casting a child in this case.

Dr. Blake's comment: So if you are following it by x-ray, you are going to be misled. Sounds like it is a fracture, although without an MRI it could be a bipartite sesamoid that is bruised. Your doctor sounds like he/she has good wisdom. What are you doing gauge the pain? Remember, palpation is not a useful tool. The improvement in swelling would be a good indicator. I think going the 3 months in the boot keeping the pain level to 0-2 is just fine. If she is walking in the boot for 2 weeks with a 0-2 pain level, she can start the 2-6 week course of weaning out of the boot into a shoe, orthotic, dancer's pad, spica taping, and cluffy wedge. The initial goal is to keep the pain between 0-2 and wean out of the boot. The goal is not to have it look better on x-ray or feel better when you push on it. 

So, given all of this information, I would like to ask a few questions:

1. How often is this injury seen in a child so young? I have read that the sesamoid bones ossify around this age, could that have something to do with her becoming symptomatic? Do children usually go on to complete healing, or are we looking at a lifetime of issues? Dr. Blake's comment: It is rare for kids this early, but I have found if they are wearing cleats with long spikes right under the sesamoid it can get beat up. Some people have really prominent first metatarsals plantarly (on the bottom of the foot) and are prone. Kids are just are vulnerable as adults to bone health issues, so evaluation of any dietary issues could lead to bone density issues. Therefore, it is possible for many reasons. As I am treating a patient, I like to look for 3 possible causes of any injury besides bad luck (called the Rule of 3). For sesamoids, this can be bone abnormalities, bone health issues, cleat placement or shoe bend issues, biomechanics of how she runs, etc. 
2. Since she is able to currently keep her pain level below a 1 as long as she is in her shoes, would you say that it is ok to keep her like that? Or would you recommend switching to a boot or cast? Dr. Blake's comment: I am sorry but I thought she was in a boot. Definitely stay away from the hard cast, so hard to rehab from. I would definitely spend 4-6 hours in a boot and orthotics for the next 6 weeks if she has not been wearing a boot. I would forget about more x-rays if you take a photo of any of the images seen them my way. I prefer an MRI if possible to make sure we are dealing with the correct diagnosis. I have had some patients where we thought fracture, only to have the MRI show soft tissue bruise or bursitis. 
3. I’ve read your advice for contrast bathing. Is this primarily recommended to help with pain and swelling (which she does not have), or will it also promote healing? Dr. Blake's comment: Yes, probably the best thing you can do if she is getting the right calcium and Vitamin D are daily contrast baths. It is a wonderful flush of the deep swelling that sits in the bone and makes it hurt longer than necessary. The deep swelling can actually cut off the circulation to the sesamoids and stop healing. So, contrast away!!
4. Our doctor said that he didn’t think a bone stimulator is recommended for a child her age, and also suggested that insurance would not pay for it. Do you think it is ok? How would I go about getting one, or access to one, without insurance? Dr. Blake's comment: Yes, exogen is for skeletally mature individuals 18 or over. Sorry, this not an option.
5. After having taken 8 weeks off already, what would be a reasonable time-frame to expect that she could be back on the soccer field? Dr. Blake's comment: The normal would be 3 months of some form of immobilization maintaining 0-2 pain, then 2-6 weeks weaning out of the boot maintaining 0-2, then a walk-run program of which she can do in her cleats building up to 30 minutes of straight running, then sport specific drills from the coach like cutting, pivoting, etc which usually is progressive in terms of the demands on the tissue. So, 3 months is the fastest from now. During this time, based on symptoms, she may need different cleats, different orthotics, better evaluation of her biomechanics,  getting an MRI, so you see what it takes to keep her in the 0-2 range. When you do it smart and progressive in terms of loads, you avoid re-flares which are so frustrating for everyone. Hope this helps some. Rich

Thank you very much for taking the time to read this and for answering my questions.

Sincerely,

Sesamoid Patient and Performer!!

People of all walks of life get sesamoid issues. This patient is many months from wearing her removable boot, but still has some symptoms. She also is the lead singer in a popular band, so this shoe should work. It is more of a flatform than traditional heel and she combines it with a 1/4 inch felt dancer's pad. This is why I can see 100 patients with the same injury and never be bored. The sesamoid are associated with interesting people!!!

Hi Dr. Blake and hope this email finds you doing well!

Thought you might get a kick out of seeing my latest "sesamoid friendly high heel shoe" for my singing on stage with my band:
*Note:  Only to be worn with 1/4" FELT Sesamoid Pad!    ;-)
    Is it helpful to use Exogen for as long as possible?  I recall reading 9-months treatment but am wondering if longer is helpful??    Thanks again!  

Sesamoid and Sciatica? Email Response

Hello Blake, I have read many of your blog posts about sesamoiditis and have tried my best to apply them to my injury. After a long period of issues I have decided to reach out for you personally for help.

I am (was) a high school runner and this injury occurred during December of my junior year (nearly a year ago as I am now a senior.) I had been running 50-65 miles per week during my cross country season with no big Issues. Only this lingering upper hamstring/piriformis issue that would appear when sitting for long periods. A deep, stabby type pain in my upper hamstring/piriformis. This is important later. In early December I had been having issues with numb/burning/tingly toes on my run. Along with plantar fasciitis type issues. I had attributed these issues to new shoes I was trying out, but I am now guessing these issues were pre-cursors to my sesamoid issue.

Dr Blake's comment: The upper thigh, heel pain, and toe numbness could be a sign of sciatic nerve irritation. 

One day I was running when I suddenly got a piercing pain in the ball of my foot. I hobbled home and rested. I have to this day not run because of the injury. In the following weeks, a lot of inflammation and dull aching was common. Still having no idea what it was. I stayed off of it as much as possible and did some icing.

At one point I went to my massage therapist and she mentioned my right leg was basically twisted out side ways. My hamstring/piriformis/hip were all screwed up. This led me to (and I still) believe that due to those issues changing my gait, I was putting excess pressure on different bones in my foot; causing the sesamoiditis. This theory may or may not be true. She worked on me and said it was better than before, but still not good. I didn't touch it after that.

I got x-rays in January that showed no issues with my foot. Inflammation and occasional ache remained, but the ache was less frequent than before. In April I got more X-rays. This time with different angles at a foot specialist. This revealed inflammation in one of my sesamoid bones. They gave me a foot pad to offload the bone and claimed it would heal itself soon. At this point the inflammation was still there and the bone didn't ache as much as before. I never wore the foot pad due finding it to be uncomfortable, now I know this was probably dumb. I went around in flip flops and barefoot all summer and the inflammation remained. I specifically remember it would ache when I woke up.

I found your website in September/October and have been applying some of your recommendation since. I wear the foot pad at all times around the house and have a similar set up in all my shoes. I ice multiple times a day and every couple days I do the contrast bath. There is rarely ever any pain, so I would put it in the 0-2 range. Maybe slight pain every couple weeks, most likely after I do something stupid to it. I also supplement with some calcium/vitamin d/magnesium to be safe. My question is: What else can I be doing for this injury? I feel the bone is healed, but some inflammation remains, but I feel the bone has been just about healed for a long time. The inflammation has been the real issue that refuses to go away. I can't wear certain shoes because my right foot is bigger than my left, I don't dare to run on it, etc. It has been almost a year and while I have made much progress from where I was 6-12 months ago, I am still sick of this inflammation. What can I add in to help? Am I doing anything wrong?

Dr Blake's comment: I would definitely see a neurologist or physiatrist to rule out sciatic nerve irritation versus piriformis syndrome. This could be causing some hypersensitivity along the L4 nerve root distribution. See my video on this. 

https://youtu.be/E0E60NpOSHg

Here is my issue with the upper hamstring/piriformis. It still gives me the deep stabbing pain when I sit in certain positions or for too long. I am wondering if you think there is any connection with this? Could my gait theory be correct? I have since begun hamstring strengthening exercises (specifically for my issue, which I believe may be a high hamstring tendinopathy injury) to try fix this issue as all the stretching/massaging in the world did not seem to fix it. I have been doing these for a couple weeks. Do you have any experience with this?

Dr Blake's comment: The pain syndrome seems to point to the sciatic nerve. Also, nerves hurt sitting or sitting or resting, and tendons with activity. So, that would be my next investigation. Good luck . Rich

Thank you for your time.