Recovering From A Sesamoid Fracture: Keys To Facilitating A Return To Shoes After Wearing A Walking Boot

When and how should patients go about transitioning from a walking boot back to a shoe after injury? A patient contacted me after fracturing his right medial sesamoid in March while he was using an elliptical runner. His podiatrist told him the sesamoid fracture may have been caused by high arches and overpronation. The injury started as a stress fracture but the patient thought it was a soft tissue injury so he treated it as such with rest, ice, non-steroidal anti-inflammatory drugs (NSAIDs) and elevation. 

After seeing no improvement after two weeks, the patient went to a podiatrist who diagnosed a fractured sesamoid. The patient then started wearing a walking boot for eight weeks with icing three times a day, using a topical NSAID ointment and elevating the affected foot at night. Things looked great at the follow-up appointment so he started wearing shoes again. Two weeks later, his foot was swollen, red and angry again. He went back into the boot and utilized a knee scooter for non-weightbearing for two months. At follow-up, the X-rays showed remodeling on the bottom of the bone.   

The patient now says he has had general discomfort in the metatarsophalangeal joint (MPJ) for a month, noting achiness and occasional tingling in the sesamoid area. He is concerned about just going into the boot or the shoe, and re-breaking the sesamoid again. 

Improper transitions back to shoes, like a sprinter dropping the baton in the Olympics, can be devastating. This patient has done a lot to help the sesamoid heal in the last four months so I will assume it is healing just fine. However, sesamoids are very sensitive as they heal. With this patient having high arches and overpronation, he is going to be putting a lot of stress on a sensitive bone for a while.

As far as how to minimize that stress on the bone, I suggest the following. Encourage the patient to avoid toe bend in general and have him (or her) use Spica taping initially to help stop toe bend. Get some Dr. Jill’s Dancer's Pads (they come in ¼-inch sizes). While the patient is waiting for a good pair of orthotics, have the patient use the dancer's padding in an Anklizer walker boot (Bird and Cronin). The patient also may need to use crutches initially since he has been using a knee scooter and putting no weight down. That typically makes the joint more swollen and sensitive as one begins weightbearing. 

Nightly contrast baths should help reduce the inflammation. I would get Neuro-Eze (Foot Express) from Amazon and rub that in for three minutes three times a day. The patient also needs to strengthen the foot again with metatarsal doming, single leg balancing and heel raises.

Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2018/09/transitioning-from-one-restriction-to.html . It is reprinted with permission from the author.