I hope following these 5 articles that sesamoid sufferers can be treated with higher sophistication. Let’s follow a common flow of mechanical changes from Day 1 treatment of a patient that just injured their foot you believe is a sesamoid injury. I can only discuss the common flow of treatment, there are so many variations to work through.
- First Visit: Patient placed into CAM walker with a 1/2 inch accommodation of adhesive felt to off load the sesamoid. Recommend that the patient have bike shoes with embedded cleats or Hoka rocker shoes (or both) for transitioning out of the cast and orthotic dispense visit. And of course, if you use a CAM walker on one foot, you need to use a big Hoka or an EvenUp on the other foot to keep the spine fairly level. If a patient has such bad back pain that the thought of a CAM walker gives them pain, I have had good luck starting with the bike shoes with embedded cleats with some dancer’s padding (aka Reverse Morton’s extension).
- Second Visit: As the patient remains in the boot for 3 months, functional orthotic devices are ordered with inversion for any heel valgus (may simply be forefoot varus balancing) and rearfoot post with no motion, dancer’s padding, standard arch, and metatarsal padding. You want these ready about one month prior to coming out of the cast.
- Third Visit: Orthotic Dispense day. If the timing is not yet 3 months, the patient can replace the accommodative padding in the CAM walker with their new orthotic devices. It is advisable to have them walk around with the orthotic devices with their shoes as well, while in the office. This is also a very important time to begin or improve their foot and lower extremity strength. At 3 months, you will typically be leaving the Immobilization Phase and entering the Re-Strengthening Phase. Each evening they should have 5 or more exercises to do so that they can progress.
- Fourth Visit: Typically at 3 months, as each visit is normally a month apart, you begin to wean from the boot. There will be a one month or less transition from boot to shoes full time adding 30 minutes daily to standing and walking time. There should not be an increase in pain during this transition. For most patients, two weeks is enough. The patient should know the skill of spica taping and applying Cluffy wedges if the pain is more than 0-2. These skills can be utilized even while in the removable boot.
Typically the patient will continue to use an Exogen bone stimulator (electric stimulators are great when you
have a fracture gap to close) for 9 months total.
The deep swelling the patients have from their injury, especially edema within the bone, is best treated with
nightly contrast baths.
Using a 10 minute ice pack right after any flares and for several days minimizes the chance
of a significant set back.
- Fifth Visit: Assuming that you have managed to wean them from their removable boots while maintaining 0-2 pain levels, they are ready to begin to get back to their activity. It is ideal to spend 1-2 months in this Return to Activity Phase gradually adding increased stress to the tissue. Runners do well in some form of Walk/Run 10 step program to get back to 30 minutes of straight running. Any activity can be started with a less stressful activity and gradual change. Here you may use a PT to help.
- Sixth Visit: This can be the final check, although I personally prefer 3 month followups until they are back to full activity. 20% of patients will not be perfect at this point. To keep their pain levels down, they have to accept some disability. This is the time to experiment with PT, different orthotic designs, make sure that they are doing icing/contrast bathes each day, and repeat the MRI (however this may be the first one also). It is a time to experiment with another month of temporary immobilization (4 hours daily in a CAM walker, spica taping, figuring out which Hoka MetaRocker is the best for them). The patient did their job at controlling pain at 0-2, but increased activity is not allowed as it would increase the pain. This is a perfect time to re-assess their mechanics, and perhaps make new orthotic devices with more pronation control or just more softness in the design at the ball of the foot area. When you made their first orthotic device, you only had some basic information, and not a good assessment of gait, their sport of choice, vast array of shoes to select, etc. It is common that they need one or two different styles of orthotic devices at this time.
