Recent Fibular Sesamoid Removal: Email Advice

I had a fibular sesamoidectomy 4 weeks ago and I am still having a ton of pain in the big toe joint. It is actually worse than before the surgery. My surgeon never taught me how to properly tape the area and I was wondering what the best way to support the toe was. Also what exercises could I be doing to help the area. I still don't have full range of motion.

Thank you for your help.

Dr Blake's Response:

     You are in the 3 month zone of the surgeon's responsibility before they release their patients back to people like me who will rehabilitate. Everything I discuss has to be discussed and agreed upon by your surgeon who has ultimate responsibility and first hand knowledge. My primary goal here will be to give your some normal guidelines on what happens and can be done. 

     After you leave the hospital or surgical center, you will have bandages and stitches and post op shoes/boots, and crutches. These will all be in part of your life until 2 or 3 weeks when the wound has healed and your stitches can come out. The joint is sore, swollen, very limited range of motion, and basically non functional at this point. The next 10-12 weeks you have to reverse all the swelling accumulation with icing twice daily, NSAIDs, contrast bathing each evening, and 2-3 times per week physical therapy. This is where you are at right now. Your goal the next 8-10 weeks is to reduce swelling, but get strong. 

     So, during this next 8-10 weeks, use crutches, removable boots, post op shoes, big tennis shoes and orthotics, whatever it takes to minimize the day to day irritation that will keep aggravating the swelling. You want 2 months from now to be in a great position to re-strengthen the foot and leg. The Immobilization Phase (now for you) lasts typically 3 months, and the Restrengthening Phase until your 1 year Anniversary. Don't let the inflammation linger into the 4th month by pushing it too much now. 

     The physical therapist goal in seeing you is to reduce inflammation, gradually increase range of motion, gradually teach you how to strengthen your whole lower extremity progressively, sometimes design dancer's pads and/or orthotics, make recommendations to the surgeon on your progress and changes in treatment, etc. 

After the 12th week post operatively, typically the swelling is down, the range of motion is better, and the Restrengthening and Return to Activity Phases are gradually blended. Some activities will take you 1 full year to get back to like cutting hard in basketball, whereas running with off weighting orthotic devices can be started at 3-6 months. Depends on the force needed for the activity. 

     It is important to understand about scar tissue maturation. At 9 months, the scar tissue produced by the surgery will begin to thin, and cause less interference with normal motion. By 12 months, the scar tissue is typically no longer a problem restricting motion and causing pain. Some activities require this normal scar maturation process to occur before they are comfortable. 

     So, in my practice, you would have the stitches removed, you would have little to no pain because you would be using crutches, removable boots, etc, whatever is needed, you would be icing 2 times a day, contrast bathing once daily, you would be going to PT 2-3 times weekly, you would have a healthy diet, you would be getting soft based orthotics (like Hannafords) to protect the joint, using dancer's pads (1/8th adhesive felt from mooremedical.com),  you would use spica taping when you feel you need it, you would be using the Blaine Scar Kit for twice daily massage, and the physical therapist would definitely have you on the stationary bike (arch on the pedal), swimming/running in place in the pool, taking NSAIDs orally or topically, doing Hallux Limitus Self Mob if allowed twice daily, walking progressively more and more, not trying to manually increase normal joint motion, and using intelligent activity modification principles. Memorize my post on Good vs Bad Pain. 

     I sure hope this helps some. Rich 

Post Sesamoid Removal Problems: Email Advice

Hi, Dr. Blake,

Your blog has been a WEALTH of knowledge for me this past year... I had a chronic foot injury that went undiagnosed (properly, at least) until March 2013. At that time, my expert ortho surgeon and I decided that my medial sesamoid would be removed, as it was fractured/fragmented. I also needed my bunion repaired and hammertoe (second toe) fused to allow a plantar plate tear to heal. The surgery took place in April 2013, and it is now Nov 2013.

 I have had MANY ups and downs since then. I've done everything I can to heal the right away--PT, acupuncture, swimming, orthotics, TENS machine, etc. I just had a follow-up visit last week, and I'm just disappointed with my progress... I seem to have "decent" and "bad" cycles of pain, and have been in a fairly bad one for the past few weeks. Prior to that, I thought I was turning a corner and started doing some more "challenging" activities like some light hikes in the woods and testing out some jumping activities, but always with orthotics on and atop thick Pilates mats! 
Dr Blake's comment: Flareups are very difficult to take during the 2 year rehabilitation course you are on, but you must get through them. Sounds like you are doing everything well. Do your orthotic devices protect the sesamoid area well? Develop a short Immobilization routine you do as soon as a flare strikes----typically removable boot and icing in some form. Remember, flareups are normal, normally not a sign of anything dangerous, and just means you misread what you thought you could do safely. I seem to be an expert at that scenario. 

I was doing great, I thought, but as of a couple of weeks ago, the remaining sesamoid region in the left foot started to bother me a bit. My ortho is quite positive it is NOT fractured--everything has healed VERY well on X-rays (screw in big toe is still in place and looks normal), but he said I could get a CT scan just to set my mind at ease... I'm not having a ton of swelling--I actually have not since surgery, but I DO have pain...
Dr Blake's comment: There is no indication of fracture, but the demineralization process from disuse can make the bones more sensitive. Motion of a still healing joint cause cause swelling in that joint. In the big toe joint, the swelling drapes over the sesamoids causing sesamoid pain when the sesamoids are fine. I hope these are part of your problem---fixed by walking, good diet, and icing/contrast bathing. 

 Part of my pain is related to my tendency to produce EXCESSIVE internal scar tissue when I've had a traumatic injury or surgery. When I fractured my right tibial plateau back in 1998, it took years to feel "normal" again, and I've had flare-ups. THIS is worse, though, as it's my forefoot and taking more pressure than even my knee! ;) At any rate, my ortho is very knowledgable about folks who are prone to excessive scarring (it's definitely genetic for me, though my scars LOOK fine externally!), but there's not much more he can do. My main fears right now are: 1) that I HAVE fractured the other sesamoid and 2) that I'll never feel less pain due to this excessive scarring... I really cannot bear it if I have to wear a CAM boot AGAIN for most of a year to see if yet another fracture will heal. I am praying it's just scarring/bruising/sesamoiditis, b/c at least I can "manage" that somehow... It's hard to know at this point what is "new" and what is just related to my body continuing to "rehab" from the surgery! I know I had rather extensive procedures done, but I guess I had hoped to be in a better place by nearly 8 months out. My doc said it could take my foot up to 2 years to calm down. Any suggestions at this point? Hoping to hear from him today re: ordering me a CT scan! I really don't want to have a totally sesamoid-less foot, but I can't really fathom going through my entire life worrying I've damaged the remaining little bone! ;) Help! Thanks in advance! 

Dr Blake's comment: First of all, you need to put yourself back in the Immobilization Phase with a Removable Boot with Accommodation, an EvenUp for the other side, and 3 times a day ice pack, until the symptoms of this flare calm down. For flareups, you really should be prepared to do this on a regular basis as soon as possible since it calms things down so much quicker. 
     Scar tissue maturation, when the external and internal scar thins out and gets in the way much less, always occurs from 9 months to a year. This will give you a better, less scarred, big toe joint, but will not even start until late Jan 2014 and end early May. You have over 2 months before that process begins, so I would be kind to your joint between now and May 2014. I would immobilize with flares, work on joint range of motion, work on foot strengthening, weight bear only with protection, increase your cardio (biking, swimming, etc) without jumping!!
     What has the PT said about your range of motion? How is your foot strength? How is your bone strength? You always get transient demineralization with casts making the other sesamoid and foot prone to stress fractures, so you must be getting your calcium and Vit D3 and know where you are at bone wise. 
     Get the CT scan and let me know what it says. Begin your own self mobilization as the video shows below. Have the PT measure you so we can have a starting point. This is very important if you are worried about internal scarring. 

Post Sesamoid Surgery: Email Advice

I am a Detective and in an office setting most days but of course have to be 'fit for duty' with the ability to run, chase and fight at a moments notice. I had a sesamoid bone removed 072913 (i broke it in two after chasing a bad guy in May 2012 and the doctor let me walk around it until 07/2013) and have been home since.

 I had one post surgery visit and he said "start putting weight on your heel" so I did that. 6 weeks later I went for my second post surgery visit and I cant bend my toes without pain, there is a burning sensation on the top of my big toe and at the bottom of my incision scar is a "lump" that is very painful. I think it is scar tissue and when I touch it, it is very sensitive. I still can not put my weight on this area therefore I am walking on the outside of my foot (according to my tennis shoes) and not putting any weight on the inside ball of my foot because of the pain.

 Last week I was released to "light duty" with restrictions of no more than 15 min walking or standing an hour.... is this normal?
Dr Blake's comment: This sounds like the surgeon's mantra: "To cut is to cure". Surgery is really just the start (normally a good start) towards being well again. This is the hope of every patient when they go to surgery. And with sesamoid surgeries, this is what you should expect. It is hard to know what is going on right now. Are you just more painful than most, or is this a complication? You really have to create a pain free environment with a removable boot, orthotics, dancer's pads, stiff sole shoes, etc. Whatever it takes, and with whatever combination it takes. You are the surgeon's responsibility so have a heart to heart conversation. You should be icing twice daily with 10 minute ice pack, and doing a 20 minute contrast bath each evening. Read my posts on sesamoid fractures which talk about how to protect the sesamoid. 

Should I get a second opinion because I don't feel my surgeon "cares" now that I am back to work and I am in pain still. I have began to take my hydrocodones at evening time again and my foot is so sore on the top (tarsals) I think because I am walking wrong.

Dr Blake's comment: You really need to talk to the surgeon. Say you need advice because you think you have more pain then you should. Find if he/she believes physical therapy would help you. Physical therapists see you typically after the stitches come out, and you are ready to get the joint calmed down, un swollen, and moving again. Ask the surgeon if the Blaine scar kit is appropriate. Ask if an agent like Neuro-Eze would help reduce the pain and allow you to massage the injured area. Pain free self massage is always good to a painful area. Tells the brain to not be so hyper about it. 

What do I do? Should I be home letting this heal properly? Should I anticipate additional surgery to eliminate this pain? Is this amount of pain normal?

Dr Blake's comment: This could be where a second opinion comes in. Not to transfer care, because that would be hard to advise from afar, but just to say yes or no to some of these questions. Second surgeries are rare post sesamoidectomies, but secondary problems because you are not doing a good post operative program are not uncommon. Good luck, and please keep me in the loop. 

Thanks for your reply and assistance.

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.