I treat many sesamoid fractures under the first metatarsal head with a small percentage needing surgical excision. There are so many parts to this injury that make treatment challenging. We will review making the diagnosis, immobilization phase duration, and mechanics that commonly need to be addressed. Since the injury is at the plantar surface of the foot, these can be much more painful than normal. Even though I want to focus on mechanics to allow healing (Immobilization Phase), we must focus on mechanics throughout the Re-Strengthening and Return to Activity Phases also. The patients can hurt well after the fracture has healed, suggesting to them perhaps the fracture hasn’t healed or that AVN has set in, and overall this will slow down the rehabilitation process.
Let’s start today with my top rules for healing, that has become my office handout, and maybe yours. I have re-worked this several times, so I might as well give you both versions.
The top 10 initial treatments for sesamoid fractures are:
- Exogen bone stimulator for six to nine months
- Removable boot for three months to create a consistently pain-free (0-2 pain level) healing environment.
- Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths twice on non-work days.
- During the initial three months of immobilization, orthotic devices should be developed that off-weight the sesamoids.
- Learn how to use 1/8” adhesive felt (Amazon has) to make dancer’s pads for the boot and for post-boot activities.
- Learn how to spica tape for post-boot action
- When you are not wearing the CAM walker, avoid going barefoot.
- Do cardio, core, and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep strong and keep fit!!
- Since we are dealing with bone metabolism, make sure your calcium and vitamin D intake is good, and get nutritional counseling if you think that there might be a bone density issue.
- Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The period of weaning out the boot can take anywhere from two to six weeks, and no added soreness is allowed.
The Above 10 pointers are pretty solid. I use Exogen for the bone, since electric bone stimulators will not work if there is no gap between the fragments which there may not be. What do I tell my patients who come in with various periods of mis-diagnosis, various disabilities, various pain levels, and of course various levels of frustration..
- They almost always heal.
- Even with normal healing, they can take up to two years, so patience is a virtue here (some fast and some slow, and all patients want to be the fast ones).
- Healing, and feeling better, is based on many factors that can be unknown when the patient first exhibits symptoms.
- MRIs and CT scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
- Follow-up MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.
- The MRI can possibly show that you are not dealing with a sesamoid fracture at all, but something else (like bursitis, ligament tears, arthritis), and prevent treating the wrong diagnosis (self-pay MRIs are around $1000 in the San Francisco Bay area).
- Since we are dealing with bone, we must look at diet, vitamin D3 levels, calcium/zinc/magnesium, and bone density.
- Treatment of sesamoid injuries flows through three phases that are normally overlapping—immobilization, re-strengthening, and return to activity.
- When the patient is in the immobilization phase, the treatment visits should be geared toward the return to activity phase with visits dedicated to shoes, orthotics, strengthening, and cardio.
- Oftentimes, treatment mistakes involve having the patient in the wrong phase for example, return to activity when they should be in the immobilization phase).
- One of the crucial aspects of treatment that can be hard to design is protected, weight-bearing inserts and shoes.
- As treatment starts, the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc.) that maintains 0-2 pain level.
- The initial goal is to create this pain-free environment for three months by whatever means it takes.
- Non-weight-bearing (via crutches or a rollabout walker) activity increases swelling, so some protected weight bearing is crucial. Every step pushes fluid out of your foot.
- The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed.
- If you are basing treatment on X-rays alone, you may be way off base.
- Do not let the joint freeze up (frozen toe syndrome) with routine pain-free range of motion or mobilization techniques. Go to YouTube and type “drblakeshealingsole Self Mobilization.”
- Start strengthening the minute you get injured (or at least after you read this), even if it takes some modification for pain. Go to YouTube and type “drblakeshealingsole foot and ankle strengthening playlist.” Keep the joint/foot flexible and strong.
- Patients with sesamoid injuries are prone to setbacks, so do not get discouraged.
- If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using it. Some insurance companies require a three-month wait to document delayed healing, some not. Self-pay for an Exogen Bone Stimulator is around $1000.
After you soak all this in, next week I will talk about diagnosis ins and outs, and the local and global biomechanics affecting the sesamoid.
