When A Patient Has Persistent Pain After A Fibular Sesamoid Fracture

I was recently presented with the opportunity to advise online on a case of persistent pain after fibular sesamoid fracture. Evaluation and treatment techniques for these injuries can vary, even among podiatrists. Accordingly, let me share this patient’s experience and my responses to her inquiries in hopes of inspiring discussion and thoughtfulness about our own algorithms.

The patient struggled after receiving what she characterized as “conflicting medical advice” about a diagnosed sesamoid fracture. The initial injury occurred while the patient kicking herself multiple times during a dream to the point of bleeding in the foot. She experienced pain with ambulation and bore weight on her heel to tolerance. Two weeks after the injury, the patient presented for evaluation and was diagnosed via X-ray. After a few weeks in a soft cast and flat therapeutic shoe, she continued to have significant pain. The patient proceeded to use a CAM boot with a sesamoid cutout for three weeks and then shifted to a thick sneaker with a sesamoid cutout pain-free. She used arnica cream, contrast baths and gentle massage with success.

Although she relates her X-rays continued to show a fracture line, a follow-up MRI suggested the fracture was healed six months post-injury. The patient relates much improvement overall but is unable to walk comfortably without the sesamoid cutout in her shoe. Otherwise, she experiences pain and swelling along with a “frozen,” immobile great toe.

She expressed frustration about conflicting advice between her physician (who advised her to continue to use the sesamoid cutout) and her physical therapist, who advised her to begin barefoot activity. The patient also shared that her latest MRI report revealed a plantar plate tear in the area of the injury.

I noted that the X-rays can be unreliable in assessing the true healing status of the injury and that I tend to order MRI every six months to monitor healing if necessary.

In general, I will watch patients monthly and gradually increase activity and toe bend while they work on strength. I will advise patients to keep the area protected and keep inflammation under control.

In my clinical experience, I have found that barefoot pressure to an injured sesamoid can be sore for several years, even if the patient is back to marathon running. Therefore, I discourage barefoot walking as far as its use as an assessment of healing. I do share that a patient can try to walk barefoot after he or she has been out of their boot for three months. At this point, the patient may add daily pain-free massage, icing and contrast baths to control inflammation. If this is tolerable and no pain or swelling results, the patient may continue to progress.

Unfortunately, the initial treatment is to “freeze up” the joint. Now we have to unfreeze it with pain-free stretching, walking and physical therapy when available. I stress avoiding barefoot activity as a rule for several years. Given the additional finding of the plantar plate tear, this adds complexity in this particular case. In similar cases, I recommend spica taping.

I recommended that this patient consult with her physician further regarding the plantar plate portion of the injury. It would be helpful to know the level of healing and if she may need surgery to repair it. This would help guide the patient and the physical therapist as far as how aggressive one can be with joint and scar manipulation. Full knowledge of, and confidence in, the treatment plan is important.

After I was given a chance to learn more about the circumstances of the injury and see the MRI report, this patient may have actually sustained a plantar plate tear with bruising of the sesamoids. In cases such as this, the physician may consider fluoroscopic evaluation with dye injection to the joint to see if the dye extrudes, suggesting the tear is still present. Another option is the use of carbon graphite plates, such as those used in the shoes for “turf toe,” as the patient progresses in footwear. This may also help advise physical therapy as to the parameters of treatment, especially if surgical repair is needed.

Careful measurement of great toe range of motion over the next three months will be important as is strengthening of the long and short flexors and extensors over the next six months. These cases can be complex so careful evaluation and management are key for the patient to make a full recovery.

Dr. Blake is in practice at the Center for Sports Medicine affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine.

Editor’s note: This blog originally appeared at www.drblakeshealingsole.com. It is adapted with permission from the author.