Insights On Rehabbing A Fractured Sesamoid With A Long First Metatarsal

An active 56-year-old patient contacted me one year after feeling a pop in the foot while squatting during some home repairs. The immediate discomfort was not great and he quickly forgot about it and learned to favor that foot slightly and not squat, thinking it would work itself out. As the weeks and months progressed, so did the discomfort. He never had any discoloration, obvious swelling or point tenderness. The range of motion was good.
 

Six months after the injury, an X-ray revealed a fractured lateral sesamoid. The patient’s podiatrist said the pieces of the sesamoid had moved too far apart to knit back together and gave him a steroid injection for the tendon. The patient also wore a cut-out dancer's pad under his insoles to relieve pressure around the sesamoids. The patient started an ice massage three to five times a day. The plan has been to let things calm down, then get custom orthotics to replace the dancer's pad. The podiatrist mentioned surgical sesamoid removal as a possibility if things didn't improve.

By nine months, the patient says the foot was feeling much better and he was able to routinely hike four to eight miles again, with pain levels in the 0-2 range. He stopped icing. He then got a new pair of cycling shoes and did one ride without the relief pad. The next day he noticed slight discomfort had come back and it continued to get worse over the next two weeks, so he resumed icing. A new X-ray at 10 months showed the sesamoid remained in a state of nonunion and he got another steroid injection. As with the first injection, it took about two weeks before he sensed improvement. 

Is the steroid injection simply masking symptoms? Yes. I would stop steroid injections, as patients can hurt other things when the pain is masked. Long-acting cortisone shots work for nine months. With two injections in this patient’s system, he has seven more months of the shots doing something for pain, so it will be May 2019 before they are out of his system. If his symptoms are still good in May, then he will probably be fine. 

At this point, is there any hope that the sesamoid pieces will heal back together? If not, can the patient have an active lifestyle (backpacking, mountain biking) with a fractured sesamoid? The last two X-ray views show very round edges to the junction, which means it was probably a bipartite sesamoid that broke. This means it will never go back. This patient just wants the injury to stabilize and stop hurting.

How concerned should this patient be about the degradation of cartilage on the metatarsal head caused by the rough, fractured edges of the sesamoid? I am not sure. We don't remove the sesamoid for fear of this being a problem. When we remove sesamoids, it is due to the disability the whole problem produces. It can be hard to know exactly what triggers pain in some patients. Sesamoid removals occur in so few patients who break their sesamoids, and some heal with a lot of irregularity. I advise yearly checks on the condition by the treating doctor if only to refurbish orthotics and occasionally take X-rays. 

What symptoms would indicate avascular necrosis in this patient? Is avascular necrosis still a risk one year after injury? There is not much of a risk here. A full examination with MRI and CT scan would be required. This patient should have bone stimulation for nine months if there are any signs of avascular necrosis.

Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2018/11/fractured-sesamoid-with-long-first.html . It is reprinted with permission from the author.