The main blood supply to the sesamoids comes proximally (or from the arch) and plantarly (or from the bottom). Most of the sesamoid fractures do occur centrally where there is deceit blood supply. Right from the start of the injury, the bone swelling, which can cut off that circulation must be managed by creating a pain free environment: off weighting, icing, contrast bathing, elevation, etc.
Saturday, December 17, 2016
Friday, December 16, 2016
AASPM: American Academy of Podiatric Sports Medicine to find great podiatrists
I have attached a link to the prestigious organization near and dear to my heart. These are a group of fairly like minded sports podiatrists that care that you keep moving. You can go to the members section to find one near you (unless you are near the north pole!) Rich
Thursday, December 15, 2016
Neural Flossing the Peroneal or Tibial Nerves: Advanced Video with some Caution
I have always taught a very simple sciatic nerve flossing for nerve symptoms. These exercises (by Drs Abelson and Mylanos) are much more stressful to the nerves, but may be able to produce better results. Do any exercise once or twice, and initially avoid the head tilts. Also, initially sit with good support behind your back. Do once a day for several days, then gradually up the exercises to 3 times a day if you see results. Nerves are funny. Positives results mean that numbness gets less, but pain also gets less. Pretty much the nerve is coming back to normal sensation. Because the cause of the nerve symptoms can be a bulging disc in the back, any back symptoms which increase means you need to stop doing the exercise until you are evaluated. Some modification may be more appropriate. These exercise the peroneal nerve. The tibial nerve is done with the foot pointed and flexed back and forth, with the same knee and hip motions or positions. You just take out the foot inversion you see that stretch the peroneal nerve. When patients come in with nerve symptoms, I like gentle neural flossing, topical Neuro-Eze, warmth (not ice), and discovering what positions really make it act up (sitting, sleeping, lifting, etc.) Hope this helps. Rich
Monday, December 12, 2016
Sesamoid Pain and Need of Night Protection
Hi Dr Blake,
I'm hoping you may have some advice for me.
It appears that i have a lateral sesamoid fracture and according to the MRI possible Avascular Necrosis (the bone round with a central fracture was showing black). I don't have the images with me at this time, however the sesamoid still appears whole with a fracture line showing down the centre (my podiatrist described it as fragmented?). He also questioned whether my pain was coming from the avascular necrosis or whether it was A. a disruption of the fibrous connection between the fragmented sesamoid or B. from a tear in the flexor tendon and joint ligament.
Dr Blake's comment: That is alot of possible causes of pain, all plausible, but typically the the treatment right now is the same. As the soreness goes down, they can test the flexor better, and see if it is torn. You can typically tell if it is a complete tear, but the subtle partial tears are tricky. Fractures should coming from impact, where tears for a fall or more stressful non-weight bearing activities.
At first my dr. thought he would need to put me in a walking boot, however now the swelling has gone i seem to be able to walk ok (usually with pain under a 2) in my sneakers that have been altered (with a dancers pad and arch support) so he has left me in those for a week and asked me to check back in with him to see how i'm going. I did ask about bone stimulation and hot and cold baths at my appointment (as i'm quite desperate , as we all are, to get my foot well again), but he said at this stage it's probably not necessary just yet. We went with sneakers over moon boot because last week the pain was not bad at all.
Dr Blake's comment: It is all about timing, although with the threat of avn you definitely should push for a 9 month course of bone stim. The Exogen is a mere 20 minutes a day. Contrast bathing is also a no-brainer, since you have to keep the swelling lighting up the bone flushed out on a daily basis.
So far i do have confidence in my podiatrist, however i thought i'd get your opinion on a couple of things as i've been reading up on your blog and so far have found the info on sesamoids quite informative and interesting.
What i would like to know is (without seeing the mri), would you normally see how it goes before jumping into using bone stimulation and hot and cold baths or would you prescribe them straight away in order to get on top of the avascular necrosis?
Dr Blake's comment: Answered above. Great question.
Also, though walking is fine most of the time I seem to keep re-injuring my big toe/sesamoid (to where i can't bear to walk the next day) - not from walking, but from sleeping! I seem to catapult myself from side to side all night using my injured foot and am waking 3 or 4 times in pain. It seems i do this once a week and the next day i literally can't walk at all from the pain. I even tried out the moon boot with my altered orthotic (i have one on hand) and it was just as painful as the sneaker only more annoying. I did this to myself again on Saturday night and by sunday afternoon i was at a level 9 in pain. This morning (monday) it was still painful and i limped a bit, but now as it's the afternoon i seem to be back to about a 3 (though my whole toe bone still feels tender). Have you come across this before? Is there any type of protection - support or taping that you could suggest i wear at night on my injured foot to minimise any damage i may do unconsciously? I generally try to sleep with a wooly sock on my injured foot as a subconscious reminder and elevate it on a pillow, but it doesn't always work. My feeling is that without these episodes of re-injury during sleep, i would be doing quite well pain wise and probably be on the road to recovery.
Dr Blake's comment: I would definitely recommend a ulcer guard for sleeping. This should protect you. The 2 links below can be bought or shown to the podiatrist for consultation and correct sizing. He or she may have another ulcer protector that they like.
Just for a bit of general info:
- It's been 2 weeks since i first realised i had the fracture after experiencing enough pain to go to a podiatrist. The podiatrist thinks my injury is older than 2 weeks (i think i can trace it back to a year ago when i sprained my foot/ankle and the GP i saw didn't think i needed an xray so i just waited til it felt a bit better then continued on - though i was hobbling around for the first 2 months of the year and it in general has been pretty delicate since - mainly just burning in my arches and ball of foot when jumping or exercising and me being very cautious about rolling it outwards).
- This time when i injured it, it happened the very day i returned to doing some jumping exercises after i'd taken 2 months off (self imposed) from jumping due to what i thought was turf toe - brought on from my catapulting myself from my mattress in the middle of the night).
- I have seen my naturopath and gotten all the right supplements to help both bone growth and circulation and will be returning to some swimming and light (non weight bearing exercises) this week.
The only problem to sort now seems to be the nightly gymnastics that are hindering any recovery attempts.
Sorry for the long email for only 2 actual questions!
Any help is appreciated.
Cheers,
p.s. i'm 35 and my past history is gymnastics (though that was 20 years ago so i'm sure it's not a fracture from that far back, though who knows - i've injured this exact foot/leg many times over the years).
Dr Blake's comment: I hope the above was helpful. Let me know if I can help more. Happy Holidays!! Rich
Saturday, December 10, 2016
Skin and Subcutaneous Fat Atrophy Post Cortisone Shot: Typically a Reversible Complication
Every now and again, a cortisone shot can cause skin and subQ atrophy. I noticeable indent is noted at the site of the injection. I was just asked in an email if this was reversible, and I have always seen it almost completely reverse itself. I have told my patients around 9 months, and this article says 6 months to 2 years.
See the post shot discoloration on the right foot
My Book on Sale!! Secrets to Keep Moving: A Guide from a Podiatrist
I am happy to announce that Barnes and Noble is selling my book or eBook at a reduced cost this Christmas!! I also need desperately for people to buy the book or eBook and write a kind review for Barnes and Noble, Amazon, and other book retailers. The book is very unique because of its non-surgical orientation. I sure hope it helps some people. Rich
Heel Pain: Adjusting the Removable Boot
Sometimes I am very proud of myself. This nice lady tore her plantar fascia and was prescribed a walking boot for 3 months. When she came in with the boot, and since her heel was swollen, she was still hurting about at a level 8 out of 10. Here I am using two 1/4 inch pads of adhesive felt from Moore Medical to fashion an off weight bearing pad for her heel on my work bench. With the instructions to land full foot, not heel strike, the pain decreased to the healing 0-2 pain level. She has a lot to do with the inflammation over the next 6 weeks with icing and contrast bathing also.
You can see the heel is floated with the weight on the 1/2 inch front pad.
Here is the roll of 1/4 adhesive felt I was using. If you don't want to wait, use other materials, like shoe inserts, and try to create the same float idea. You too can be as brillant as I was this day. LOL
Thursday, December 8, 2016
Cortisone Helps the Pain from a Neuroma But Not the Numbness: Email Response
I had a cortisone injection a month ago in my neuroma and am super happy that the pain is gone and I can walk several miles in my wide toes shoes with arch supports in :) however I still have toe numbness which I thought meant that the neuroma wasn't quite better since that was my early symptom, before I realized there was an issue with my foot -- the Dr.'s office told me this is normal and additional injections would only cause more numbness -- I would like to understand why this is and they were unable to explain it in a way that made sense to me. thanks
Dr Blake's response:
Thank you so much for the question. Any abnormal pressure on the nerve from the bones and swelling can cause numbness, pain, or a combo. In your case, the pressure of walking, and maybe some other cause of nerve tension (low back) is causing the numbness, with the pain from the swelling pushing against the nerve. All the cortisone did was to shrink down the swelling, so we know that caused the pain. But, the pressure against the nerve is still there, thus the numbness remains. Hope this helps. Part of your treatment should be metatarsal supports behind the nerve to take some pressure off the nerve, a look at the low back or other sources of nerve irritation, an understanding of what stresses out the sciatic nerve and how to avoid it, and perhaps the numbness will slowly get better. Rich
Sunday, December 4, 2016
Navicular Pain: Email Advice
Hi there Dr. Blake!
Searching around the internet I came across your blog and I'm hoping you can help me?
I have been suffering from pain of the navicular bone and all around the navicular bone. As you can see from the photos, it sticks waaay out, although X-rays have come back "normal"??
Dr Blake's comment: I did not receive the attachment with the photos, but an MRI should be done to look at the 3 dimensions of the injury.
The attacks began in August (it is now early Dec) and are becoming increasingly frequent. These attacks begin as twinges in the medial area of my left foot, the area then burns and on occasion swells. The attacks are leaving me hobbled and unable to weight-bear.
This doesn't work for me as I am an active primary school teacher, I don't even have a chair at my desk, that's how little I sit! I'm losing work time and this needs to be fixed.
Dr Blake's comment: The problem could be an accessory navicular, and also nerve pain from the back or ankle in the tarsal tunnel. Some patients just have a large navicular than interferes with the posterior tibial tendon and causes tendinitis. Other than an MRI, you want to treat the area with taping, orthotics, and shoes for great support, and icing right now for 10-15 minutes three times a day for the inflammation.
I have seen a podiatrist and chiropodist who have said that my left leg is slightly longer than the right, which has caused my left foot to flatten and is tearing my posterior tibial tendon. The attacks seem to come on out of nowhere, no rhyme nor reason which is what confuses me. If I had such an issue, wouldn't the pain be constant?
Dr Blake's comment: The neuropathic pain, arising from the nerves, typically behaves like this. The cause can be the pronation, which stretches the nerve as it comes around the ankle. Nerves hate to be stretched. Thus, trying to figure out the right amount of support, whether the nerve can take any compression from the tape, and if there is low back involvement.
And where did it come from all of a sudden? I have orthotics coming in mid-December but am worried that they won't help the situation as I have been wearing drug store arch supports and supportive shoes and I still had an attack after a week or two. I'm so worried I may not be able to exercise anymore!! Please help!!! What can I do to properly diagnose and fix this??? I'm hoping to get in to see an orthopaedic surgeon next. But that could take months!!!
Dr Blake's comment: I sure hope a custom device made for you will be better than store bought!! Did the doc who made them thus what was going on, what the role of the orthotics, if they can be adjusted, etc etc. Definitely keep me in the loop. Rich
Thank you in advance,
Caroline Jordan Injured Foot Exercise Videos
I have just got finished reviewing several of this four part series videos. I am totally loving Caroline. I hope you will also. Remember, many of the exercises whether you are injured or not, may be too difficult. But, go slow, listen to your body, and if she says to do 10, start with 2 and work up. You should never have pain during. If any exercise, Caroline's or mine, flares you up, ice several times a day until you are back to normal before restarting if it feels okay. Enjoy.
Sunday, November 27, 2016
Saturday, November 26, 2016
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.
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.
Friday, November 25, 2016
Sesamoid Injury: Email Advice
This is an email from a patient struggling with pain from a sesamoid fracture. We have had a few correspondences to help some.
I am attaching here the picture of the footwear I'm wearing these days.
Dr Blake's comment: The patient has a post operative stiff soled shoe with an ace wrap and Dr Jills Sesamoid pads.
1) The post -op shoe which I got last week , I wear with a sesamoid pad made by
combining the Dr.Jill's pad and a pad cut out from felt .On top of that I tie a
bandage and then wear the shoe. Is this the right way of wearing these things?
Or the stiff shoe has to be worn on its own?
( I thought it was too hard to be worn without padding)
Dr Blake's comment: This is very good as long as you are achieving the 0-2 pain level consistently, and you are able to increase your weight bearing for mineralization. If not you would have to go to a removable boot, like the anklizer.
2) I also wear the Crocs Clogs ,with cushioning and sometimes the bandage as
well ,find this quite comfortable.
Dr Blake's comment: I am so happy you found a shoe/clog that gives good relief, and can rotate with the post op shoe. This will allow the stresses to be variable with each shoe. That is typically very good for overall healing.
I am quite confused about the PT and the strengthening exercises which are
recommended . I feel that some exercises which involve flexing of the toes
forward and backward will not let the bone unite,is it so? What exercises and
PT is one supposed to do ?
Dr Blake's comment: When you are trying to heal the sesamoid, you want to avoid bending the toe forcefully upwards. Typically, I will have the patient do metatarsal doming, flat footed balancing with a sesamoid protection (a hole of the sesamoid in the middle of 4 books), and posterior tibial and peroneus longus theraband (resistance bands). These strengthening exercises can be found on the blog.
The calf muscles of my left leg (fracture in left foot) has really become loose,
can it become firm again or is it permanent atrophy? How does one make
them firm again ?
Dr Blake's comment: The flat footed balancing will start getting them strong as you build up to 2 minutes. You can do weight bearing squats with the well for the sesamoid, you can do 2 positional theraband calf strengthening (just without having the band push hard on the sesamoids. These can be found on the blog also.
There are days when walking does not cause pain and then there are days the
pain is too much and even travels upwards to the leg. Why is it so?
Dr Blake's comment: It is always a good sign when there are good days, and hopefully the periods of good days will last longer and longer. However, the area can get inflamed from what you did yesterday, and not bother you until today. Typically, it is limping from you protecting the area that can give you shooting pains which are muscular. But if it feels neurological, it can be that you are picking on the sciatic nerve. Definitely try not to limp, and you should be going gentle calf, quad, and hamstring stretches twice daily. For the calf stretches, try using a towel to pull you foot towards you without pushing on the sesamoids.
How much should one walk or stand?
Dr Blake's comment: You are trying to both re-strengthen your feet, and return to normal activity. These are two distinct phases of rehabilitation that we are always trying to blend together. Based on your circumstances, you try to increase both activities gradually, sometimes breaking the activity into small sections. So, a runner must do a walk run program first before they can run without stopping. I love 2-3 fifteen minute walks daily, no limping, 0-2 pain level, and gradually weekly bounce it up by 5-10 minutes. It is based on how you feel. The standing is actually sometimes harder, but the dancer's padding helps, or the soft Crocs. When you stand, try to get your weight even from front to back, and right foot to left foot. Get off your foot when you can, ice when you have irritated it.
Will life ever get back to normal ? If yes ,then how long will it take?( I've been
like this 10 months)
Dr Blake's comment: No guarantees, but are you making progress. Are you somewhat better than where you were 3 months ago? I find for these situations making benchmarks can be psychologically beneficial. Spend a day making 5 functional levels of what you can do now? This is what we will look at each month. These benchmarks may include: the duration of a walk before pain, the time standing before pain, the number of weekly bad days, etc. The progress may be slow with one of these 5, but significant in another. At least look at this for 3 months, and report back based on those benchmarks. Good luck again, and thank you for the donation to the blog. Rich
Thank you
PS Here is the ordering sites for my new book (and it's ebook version).
The Patient then replied to my comments.
Thank you so much for helping me! I cannot express how relieved I am to hear that there is still hope for my sesamoids, even after 8 months of pain. It really made my day, as I’ve been rather pessimistic after the visit at the orthopedist.
Attached are some of the MRI images showing the sesamoids in addition to the x-ray of the right foot. It was a bit difficult to pick images showing bone marrow edema, since I’m not sure about what I’m looking at (no doctor has explained it to me, I’ve only been told that the MRI is showing bone marrow edema).
Dr Blake's comment: You sent a beautiful image of the bone marrow edema in the tibial sesamoid.
- Dancer’s pad/other orthotics: I’ve been using a dancer’s pad (home-made of felt) for only a a couple of weeks because I discovered your blog only recently. Before that, I used the blue sole into the post-operative shoe I’ve got (images of both attached in the first mail), but this sole only seems to provide some arch support, it doesn’t protect the sesamoid specifically. Right now I’m trying to wear the blue soles combined with a dancers pad in Hoka (One One) shoes because this feels most comfortable. Before I’ve been thinking that the Hoka shoes haven’t got soles stiff enough, but perhaps they are acceptable? Especially since you recommended rocker bottom shoes. I can also mention that I will have somewhat more customized soles made soon.
Dr Blake's comment: You are creating a good healing environment to spend the next 3 months in while you increase your weight bearing. There are no surprises in the MRI suggesting difficulty in healing, and that makes sense based on the history of where you are at right now. There is nothing all-important except creating that 0-2 pain level, and increasing your weight bearing. Everyone will be different in the stiffness needed, rocker needed, cushion needed, off weight bearing needed, and arch support needed. And what combo works well in one shoe, may not do the trick in another shoe. Experimentation to create that 0-2 pain level is crucial.
- About the pain: As I mentioned, I find it quite difficult to find an acceptable pain range. Still, I think I am in the 0-2 pain range most of the time and have been for about 1,5 month (after getting that post-operative shoe). However, I feel very constrained by how little I can do when staying in the 0-2 range. Luckily, I can still work because I have a sedentary job, but that’s about it. To be honest, I don’t really have a plan for staying in the 0-2 range other than not walking too much on the foot (which is perhaps a bad plan in the long run).
Dr Blake's comment: Make sure you read the post on good versus bad pain. It is almost a new month and December should be 10% more active than November, with the same for January, and so on. Each month you need to do a little bit more, and ice after you walk, try short walks twice daily, experiment with arch massage, get an anklizer boot that rolls more for increasing your walks,etc.
- I began doing contrast baths about two days ago
Dr Blake's comment: I love the daily contrast bathing, with twice daily (especially after exercise) icing for 10-15 minutes.
- I will have my vitamin D level checked the next time I have an appointment with my doctor (which is in about a week).
Dr Blake's comment: Great, it will be good to know how if your overall bone health needs some work.
I have also scheduled an appointment with a physical therapist next week, because this was what the orthopedist recommended. But I’m still not sure how that can help me right now, considering that I feel quite immobilized for the time being.
Dr Blake's comment: You are in the Re-Strengthening Phase of your rehabilitation. You should be learning safe lower extremity exercises without putting too much pressure on the sesamoid. Remember, if they ask you to do something that hurts, do not do it as politely as you can. Get the calf tension stretched and massaged out would also be great, along with arch massage to make your foot more pliable. Alot to do!!
This also leads me to what you said about the different aspects of treatment – e.g. dancer’s padding and orthotics, but also activity modification and foot strengthening. I guess I’ve been doing quite a lot of activity modification for the last months – namely going from being active to being inactive. However, since I get very restless from not being able to do much physical activity, I’ve done a lot of exercises at home (e.g. push-ups on the knees), focusing on not doing anything that puts weight on the left foot. Maybe the physical therapist can help me find even more appropriate alternative exercises?
Dr Blake's comment: Perfect!!
I’m not entirely sure about what you mean with foot strenghtening, although I can understand why it might be needed. After I began the contrast baths, I’ve tried to wriggle my great toe in a non-painful manner when in the warm water – and I’m quite shocked to see how stiff and difficult to move it has become! Therefore, I would really appreciate more advice on the different aspects of treatment – especially foot strengthening. If you have the time to do that in separate posts, as you mentioned, that would be really great.
Dr Blake's comment: Since you are seeing a PT, ask them to make sure you know how to do metatarsal doming, posterior tibial and peroneus longus resistance bands, flat foot balancing with the sesamoid in a well between 4 books, same for the 2 positional calf stretches, and self mobilization for a stiff big toe joint. I have made posts on all of these.
Finally, having read about sesamoid fractures in medical journals, it worries me a bit that avascular necrosis is said to be a potential complication of sesamoid fractures. When having a sesamoid fracture for months (and potentially 1-2 years, in my case), do I run a risk of avascular necrosis? Is the risk higher the longer one has a sesamoid fracture?
Dr Blake's comment: Yes, and yes. You need to focus now on the opposite of avascular necrosis which is re-vascularization with contrast bathing daily, bone stimulation daily, creating that 0-2 pain level so the inflammation stays in control.
Again, thank you so much for helping me! I’m looking forward to your next post. If you need other MRI images than the ones I sent, just let me know and I will try to pick some better images.
Best,
Wednesday, November 23, 2016
Sesamoid Injury: Email Advice
Thank you for all the helpful information on your blog, especially what you have written about sesamoid injuries. I have also begun reading your book, which I find very helpful and educative. Yet I need to ask you some questions about my specific “sesamoid case”, and I do hope you have the time to answer them as I am clueless on what to do from here.
I am a 27-year-old woman, and I have been struggling with pain in my left foot for about 8 months. It began in the end of March 2016 and I cannot recall having hurt my foot in any way. After the pain began in March, I didn’t pay it much attention because I just thought it was the same kind of pain I have experienced before. I stopped jogging for a while and tried to wear better shoes, but the pain kept increasing. It was highly affected by the level of activity – I could be almost pain-free when I awoke in the morning, but during the day the pain would increase, even after short walks. I have tried to think about possible causes, but cannot think of any, other than that I have a high-arched foot.
Dr Blake's comment: High Arched feet are a curse on shoe buying and both heel and ball of the foot pain. Too much pressure is put normally in these areas leading to injury without apparent cause.
Dr Blake's comment: High Arched feet are a curse on shoe buying and both heel and ball of the foot pain. Too much pressure is put normally in these areas leading to injury without apparent cause.
Since the pain didn’t go away, I went to see my GP in June. She sent me to x-ray, which showed both of my sesamoids to be split or bi-partite – I was told that this might indicate stress fractures, but they could also be naturally occurring. Nevertheless, my doctor recommended me to wear stiff-soled shoes for about 4 weeks to see if the pain would subside.
Dr Blake's comment: This was good initial advice.
6 weeks later the pain was even worse, and I had trouble walking short distances. I went back to see my doctor in the beginning of September, and then she sent me to MRI, which showed the same split in both of the sesamoids in the left foot, in addition to bone marrow edema. My doctor interpreted this to confirm the diagnosis of sesamoid stress fracture, and not naturally occurring bi-partite sesamoids. She then referred me to an orthopedic specialist, and I was told to use an even more stiff-soled shoe (which is actually a post-operative shoe, as I had trouble finding a shoe with soles stiff enough) while waiting for the appointment with the orthopedist. She also recommended me to be even more conservative with weight-bearing. I used crutches for some time (about 3 weeks), and the pain got better – but only when not putting much weight on the foot. When I tried to walk a bit further than walking around in my apartment, the pain got worse and was about the same as before. Lately I have also begun experiencing the same kind of pain in my right foot. However, x-ray of this foot was normal, although I was told it cannot be ruled out that I might be developing a stress fracture in this foot as well unless an MRI is taken (which has not been done).
Dr Blake's comment: Hopefully, you are making dancer's padding for both sides to help the left and protect the right. You can get the 1/8 inch adhesive felt at www.mooremedical.com and design your own.
Dr Blake's comment: Hopefully, you are making dancer's padding for both sides to help the left and protect the right. You can get the 1/8 inch adhesive felt at www.mooremedical.com and design your own.
A couple of days ago, I finally had the appointment with the orthopedist. However, this was far more confusing than helpful for me. In contrast to what my doctor had recommended, he told me not to wear a stiff-soled shoe. Rather, he recommended orthotic soles to relieve pressure on the sesamoids (I haven’t had these made, yet), in addition to seeing a physical therapist. He said my gait was wrong due to being in pain for several months (which I admit is true). However, what confused me the most was that he said he found it very unlikely that my sesamoids would ever heal. My immediate reaction to this was of course that I thought my foot would never be ok again. I asked him repeatedly what he meant, but didn’t get a clear explanation. Having thought about it afterwards – and having read about different sesamoid injuries myself – I think he might have been unsure as to if I have an actual sesamoid fracture. In my understanding, the treatment he has recommended indicates that he might think I have sesamoiditis rather than sesamoid fractures, and that the non-union of my sesamoids might be naturally occurring. However, he never expressed explicitly his view on diagnosis to me. Further, when I asked about how I should “treat” my injury in a practical sense – e.g. should I walk for more than a few minutes on the foot even though it hurts; should I use crutches; can I drive in spite of the pain; and so on – I got no or very vague replies. These questions have important practical implications for me, and I feel I have no one else to ask.
Dr Blake's comment: Golden Rule of Foot: Sesamoid Fractures Rarely Never Heal. I find that they can take awhile, but they heal. Even if you are stiff soling it, trying to transfer to the arch and off the big toe joint is a great idea.
Some background information:
- I’m living in a European country with a public health care system (which I’m grateful for), so that I’m not suffering large financial expenses due to my foot pain – however, this also means that I have to wait quite a long time before seeing any specialists, as my type of foot problem is not prioritized
- When I was pregnant in 2015, I gained about 55 pounds (but I am normal-weight now)
- Although I am definitely not an athlete, I enjoy physical activity and used to engage in some form of physical activity (including jogging/running, lifting weights) about 3-4 times a week before the pain began
- I have experienced pain in both of my feet a couple of times before, but the last time was about 4 years ago and lasted only 3-4 weeks when I stopped running/jogging for a period and made sure to wear good shoes
- I don’t take any pain killers now and haven’t at any point since I’m skeptical about using such medication
- Although I didn’t think about it at the time (but I have after reading your blog), I think my intake of vitamin D and calcium was far below the recommended levels prior to the pain debuted – yet I think I am too young to have any osteoporosis-issues although I haven’t had a bone density scan.
Dr Blake's comment: There is an epidemic of Vitamin D deficiency leading to stress fractures, so it only takes a couple of months of low Vitamin D3 to cause a stress fracture. At least see if you can get the Vitamin D level measured and see where you are and what the range of normal is. I love my athletes to be in the middle of the range, around 50-55.
So now I feel lost and confused. Here are my questions, and I will be extremely grateful if you could answer any of them:
1. It is my understanding that the correct treatment depends (in part, at least) on the correct diagnosis. Can you please help me get a second opinion? Do I have sesamoid stress fractures in my foot or not?
Dr Blake's comment: It looks like from the 2 x-rays that I saw that you do have a stress fracture. I was not able to look at the MRI images for some reason. If you can send 2 or 3 images like the x-rays showing the supposed bone edema, that would be great. When there is any doubt however, we must treat it like a fracture, which you are.
2. Could it be that I have naturally occurring bi-partite sesamoids in my left foot, but whole sesamoids in my right foot, and would that indicate that I have sesamoiditis rather than stress fracture?
Dr Blake's comment: Sure, but sesamoiditis does not hurt like this. The history is one of a fracture.
3. Is it true that my injury will never heal, and in that case, what is the point of treatment from here? Can some form of healing occur even though the sesamoids stay non-unioned, or is the goal treatment that the sesamoids must be united again?
Dr Blake's comment: Some sesamoid fractures do not heal, but the majority do. I am sure that with poor treatment, and mis-diagnoses, your need for surgery goes way up. This is why you emailed in the first place. How can we do inter-galactic (you could be an alien LOL) or at least inter-national consulting?
4. What would you advise me to do from here? Should I continue wearing a stiff-soled shoe, even though the orthopedist told me not to? Should I be wearing another shoe than the one I have now? Can physical therapy help me, and if so, how?
Dr Blake's comment: This will take some Q & A. The first thing you need to do is develop a program that you maintain 0-2 pain level? Are you there with your present situation?
5. What should I do about my right foot? The pain is not as bad as in the left foot, but I definitely feel it. Is MRI indicated? If I indeed have a stress fracture in that foot too, how can both of my feet heal?
Dr Blake's comment: It is okay to get at least an x-ray on that side, and make sure you are designing dancer's padding for both sides, and some arch support for both sides, and ice pack both sides for 10 minutes twice a day. For the left, if there is bone edema, you should do contrast bathes each evening.
6. I really want to avoid surgery if I can, but: Am I a candidate for surgery, and if so, what kind of surgery would that be?
Dr Blake's comment: In my practice, it takes at least one or even two more MRIs to get a feel that surgery is needed. Each MRI is 6 months apart, and there are treatments of contrast bathing, bone health issues, orthotics, dancer's padding, activity modification, foot strengthening, etc. I am happy in separate posts to address each aspect for you.
7. I feel that walking even very short distances is too painful, but how much can or should I walk or even do anything at all? It is really difficult for me to know when there is too much pain (i.e. pain level exceeding 3), so can you please elaborate on how to find that “acceptable pain range”? I’m not afraid of the pain, but I’m afraid of making it worse (and beyond repair) if I try to do too much stuff.
Dr Blake's comment: If you can not walk in the 0-2 pain range, you need to use inserts for dancer's padding and arch support, shoes with rocker bottom, removable boots, etc. You can not just go outside the 0-2 range and expect to heal (less predictable).
8. Finally, my husband and I are considering having more children, but we have postponed it due to my foot problems. From a podiatric point of view, would a pregnancy be ill-advised (e.g. in terms of weight gain, hormonal changes, etc)? If we should continue postponing it, when can I be well enough to manage a pregnancy?
Dr Blake's comment: Pregnancy will change the demands needed to maintain a 0-2 pain level, but should not be a reason not to have children. Of course, what do guys know about such matters!! I just think you can deal with it during that time.
I have attached MRI- and x-ray images, in addition to pictures of the last stiff-soled shoe I used together with a sole I put into it in order to relieve the pressure on the sesamoids.
Dr Blake's comment: I could not get the MRI images to open. Please just send 2-3 images of the sesamoids where the bone should be dark from at least 2 angles. I sure hope this helps you some. Rich
Thank you in advance, and I really hope you can help me!
Best wishes,
Thank you so much for helping me! I cannot express how relieved I am to hear that there is still hope for my sesamoids, even after 8 months of pain. It really made my day, as I’ve been rather pessimistic after the visit at the orthopedist.
Attached are some of the MRI images showing the sesamoids in addition to the x-ray of the right foot. It was a bit difficult to pick images showing bone marrow edema, since I’m not sure about what I’m looking at (no doctor has explained it to me, I’ve only been told that the MRI is showing bone marrow edema).
Addressing your other questions:
- Dancer’s pad/other orthotics: I’ve been using a dancer’s pad (home-made of felt) for only a a couple of weeks because I discovered your blog only recently. Before that, I used the blue sole into the post-operative shoe I’ve got (images of both attached in the first mail), but this sole only seems to provide some arch support, it doesn’t protect the sesamoid specifically. Right now I’m trying to wear the blue soles combined with a dancers pad in Hoka (One One) shoes because this feels most comfortable. Before I’ve been thinking that the Hoka shoes haven’t got soles stiff enough, but perhaps they are acceptable? Especially since you recommended rocker bottom shoes. I can also mention that I will have somewhat more customized soles made soon.
- About the pain: As I mentioned, I find it quite difficult to find an acceptable pain range. Still, I think I am in the 0-2 pain range most of the time and have been for about 1,5 month (after getting that post-operative shoe). However, I feel very constrained by how little I can do when staying in the 0-2 range. Luckily, I can still work because I have a sedentary job, but that’s about it. To be honest, I don’t really have a plan for staying in the 0-2 range other than not walking too much on the foot (which is perhaps a bad plan in the long run).
- I began doing contrast baths about two days ago
- I will have my vitamin D level checked the next time I have an appointment with my doctor (which is in about a week).
I have also scheduled an appointment with a physical therapist next week, because this was what the orthopedist recommended. But I’m still not sure how that can help me right now, considering that I feel quite immobilized for the time being.
This also leads me to what you said about the different aspects of treatment – e.g. dancer’s padding and orthotics, but also activity modification and foot strengthening. I guess I’ve been doing quite a lot of activity modification for the last months – namely going from being active to being inactive. However, since I get very restless from not being able to do much physical activity, I’ve done a lot of exercises at home (e.g. push-ups on the knees), focusing on not doing anything that puts weight on the left foot. Maybe the physical therapist can help me find even more appropriate alternative exercises?
I’m not entirely sure about what you mean with foot strenghtening, although I can understand why it might be needed. After I began the contrast baths, I’ve tried to wriggle my great toe in a non-painful manner when in the warm water – and I’m quite shocked to see how stiff and difficult to move it has become! Therefore, I would really appreciate more advice on the different aspects of treatment – especially foot strengthening. If you have the time to do that in separate posts, as you mentioned, that would be really great.
Finally, having read about sesamoid fractures in medical journals, it worries me a bit that avascular necrosis is said to be a potential complication of sesamoid fractures. When having a sesamoid fracture for months (and potentially 1-2 years, in my case), do I run a risk of avascular necrosis? Is the risk higher the longer one has a sesamoid fracture?
Again, thank you so much for helping me! I’m looking forward to your next post. If you need other MRI images than the ones I sent, just let me know and I will try to pick some better images.
Best,
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