Fractured Sesamoid Bone - Sesamoidectomy?

[Augie]

Hi all,

Desperately looking for personal experience/advice for the predicament that I am in. 9 month ago I fractured my big toe and medial sesamoid kicking a cabinet. I know this was stupid but it was a moment of frustration while waiting on the results of the biopsy to see if my spine tumor (which was removed shortly after) was cancerous or not. I have seen 3 different orthopedic surgeons, 1 podiatrist and done countless sessions of PT over this issue and we always come back to the same issue. I spent 1 month on a knee scooter, 3 months in a walking boot and tried doing a ultrasound bone stimulator for 90 days but saw no noticeable changes or decrease in pain... only seemed to only make things worse. My current ortho has done many NFL athletes foot surgeries as well as my best friends ankle surgery. He initially advised against doing surgery, he even had me do an EMG nerve study which showed I do have some tarsal tunnel syndrome in my left foot. But due to my constant pain around the big toe joint and sesamoid consuming my days and not being able to mitigate the pain which is normally between a 5/10 and a 9/10 he is recommending that we do a sesamoidectomy and a tarsal tunnel release. I am able to walk very limitedly and can do some toe/calf raises with minimal to moderate pain, but it makes my life miserable and depressing not being able to hike, golf, hunt or even just go do things with my fiancé without needing accommodations. Being 29 years old and not able to walk much is devastating for me and I can't even sleep with a blanket laying on my foot without pain. I have seen several reddit posts where they are recommending people not to due the surgery and they have spent 3+ years trying to heal with mixed success. Meanwhile I have seen several posts from people who have gotten the surgery and never regretted doing so as well as people who wish they never did the surgery.

My MRI results were as follows:

1. Subacute fracture of the left great toe proximal phalanx at the distal medial margin extending to the IP joint without displacement or adjacent ligament/tendon abnormalities.

2. Left great toe medial sesamoid edema with possible occult nondisplaced fracture, less likely bipartite with adjacent mild edema of the medial great toe metatarsal plantar head with no other elements to suggest turf toe.

My ortho who has done several CT scans on my foot has said that my medial sesamoid still shows some slight separation, but his concerns are that the bone itself is "moth eaten" looking somewhat hollow with little density. He ultimately says to do what I want to do based on how much pain I'm willing to tolerate.

Ultimately I'm looking for someone to express their personal stories and choices made with their sesamoid fracture to help me in my decision making process. Thank you!

 

[wildwilderness]

Sorry no personal experience or medical opinion- but I hope you get it figured out.

from a life perspective I would most likely do the surgery. You are too young to put up with chronic pain. Life is short so the sooner it is fixed the better. Worst case scenario if it worse after the surgery could you amputate?

I did have an acquaintance with a bad foot/ankle with chronic pain end up amputating. A prosthetic was made and he was able to walk again without pain. Said it was totally worth it.

 

[Loper]

That sounds miserable.

I don’t have any experience or advice for this but I hope you figure it out and heal up soon.

Everything good with the spine tumor?

 

[yfarm]

Have a similar anecdote, trimming one of my dogs toes got to close to the quick and he yanked his foot hard away. For the next week he refused to put weight on the foot, took to local vet said everything was fine,just wait for it to heal, no xray. Went on for a month, touch the toe sleeping at night or when outside and would just howl in pain. Took him to the ISU Vet School, diagnosed with an avulsion fracture very similar to your #1, they made a splint,wrapped it, gave meds and away I go. Was ok for about 4 days and worsened, removed splint and pressure from the splint caused skin ulceration.Took everything off and allowed skin to heal. Kept limping not using the foot and took him to the U of IL Vet School, amputated toe, three days later the dog was running like the wind. Has your #1 fx healed completely?

 

[Theringworm]

Not sure where you are located but Dr Robert Anderson is probably the best foot and ankle surgeon in the country. I think he is currently with OrthoCarolina after being in Wisconsin forever. If feasible, I would try and get a second opinion from him.

 

[Blackcow]

I fractured a sesamoid in my left foot in 2009. I was guiding a late elk hunt, day 2 of a 7 day hunt. Holy crap it hurt. I had my wife meet me halfway with my schnees sheep hunters that have like no flex, but if I owned ski boots I probably would have had her bring those. Here’s where I f’d up. I just thought it was a bad bruise. It would feel better overnight, and then of course the 1st time your big toe flexes the pain was right back. I hunted and guided on that sob the next spring, all the fall seasons of 2010, and archery hunted all Jan of 2011 on it. Formed the habit of curling my big toe down to take some pressure off to walk. As you know, steps and especially kneeling on it was just a hot poker.
February or march I went to the doc, who sent me and my X-rays to a podiatrist. Ended up one had fractured and healed. Like a marble broke, and you super glued it back together but not quite right. He didn’t even mention surgery, just said it was healed close enough that it was sesamoiditis at this point and that a cortisone shot and immobilization for a couple weeks should do it and he was right. Took about 2 month for it to feel about normal. Still gets tender if I catch a rock or something just right. Oh, that cortisone shot! It immediately felt better, but he said wait until
tomorrow, it’s gonna hurt. Sure as shit, the next day it burned and ached about as bad as anything I’ve ever felt, and then poof. Just went away.
All that to say, if I were you I’d have the surgery. Or chop my foot off, before I’d ever go through it again. Ended up with plantar fasciitis is my other foot for the last 3-4 months before I went in because I was walking so differently and putting as much weight on it as I could. You’re young and life’s too short to deal chronic inflammation and pain. If there’s a way out, take it.

 

[elephantrider]

It sounds like this is making your life miserable, and dramatically reducing your quality of life and overall health. I would not put too much stock into what Reddit has to say on these things as each patient is a slightly different set of circumstances and different surgeons performing the surgery. You are weighing the pain you are currently in vs. the chances for a good surgical outcome. Your surgeon should be able to give you the odds on how likely a good outcome is for someone of your age and condition. The fact that he took a wait and see approach to surgery is a good sign instead of the 'beaver' type surgeon that always want to dive in and proverbially build a dam right away.

 

[ztc92]

I’m very sorry to hear about your injury and subsequent struggles. Sesamoid injuries can be very tricky, as can tarsal tunnel syndrome. I’ve cared for a few patients with both of these problems in my time doing sports medicine as a family physician. I generally agree with what your orthopedist has told you but here are a few thoughts:

- Have you done much with a skilled PT who focuses on the foot to build up the strength and stability of intrinsic foot muscles and supporting structures like ligaments? If not, I really see no downside to this and if you opt not to get surgery it will likely help you compensate for the Sesamoid and tarsal tunnel pain even if it doesn’t fix them.

- Have you considered finding a sports doc with training in ultrasound guided injections? This would be my next step if I was in your position. I personally would have a skilled sports doc (or orthopedist) do a DIAGNOSTIC injection, first of the tarsal tunnel and the of the Sesamoid. That would mean numbing medicine only, no steroid or other “treatments”. The goal is to see which location is the real source of your pain (or is it actually both?). Once you’ve found the pain generator, pursue treatment for it and ignore the other diagnoses if they aren’t causing you pain, since none of them REQUIRE surgery if they heal on their own.

- I think any time there is confusion of its u clear how to proceed, a second opinion with an expert is a great idea. I second this suggestion.

Feel free to PM me if you’d like help finding sports docs or experts in your area, I know the medical system can feel like a labyrinth at times…

Best of luck!

Edit: Forgot to add that once a diagnostic injection (hopefully) locates the pain generator, you can next consider a therapeutic injection to treat that spot. If it’s the Sesamoid, sometimes a steroid injection can help with residual inflammation (though this can impair healing of a fracture, so there’s certainly a risk/benefit discussion to be had). If it’s the tarsal tunnel, an injection can sometimes give the nerve “room to breathe” and calm down any inflammation that may be making symptoms worse. Tarsal tunnel syndrome is similar to carpal tunnel syndrome in the wrist. Surgery is generally a last resort but usually is very effective.