“Your journey has moulded you for your greater good, and it was exactly what it needed to be. Don’t think that you’ve lost time. It took each and every situation you have encountered to bring you to the now. And now is right on time.”
So it will be two weeks tomorrow since my foot surgery, what a whirlwind of a fortnight. This is going to sound like stating the obvious but I just cannot wrap my head around how much it has taken out of me – I mean, I can do an Ironman and run 3 days later, but this surgery thing is in a whole different ball park! Even as a physio, I am constantly amazed at how exhausted I am and how little it takes to get fatigued or to swell up the foot…..but I am learning, often the hard way, and trying to be very patient with myself (doesn’t come easily!). I guess I figured that I was super fit going into the surgery and I had done so much “pre-hab” that I would just breeze through it – ah, close but no cigar! As promised, for the medical nerds out there I’ll go into the juicy details; if you’re not into it then feel free to let your eyes glaze over momentarily while you fast-forward past this section.
The fracture to the medial sesamoid happened 8 months ago; because of the difficulty in diagnosing this injury and because it was literally Christmas time there was a 2 week delay in getting the MRI results and a definitive diagnosis, then getting into a boot to offload the bone. Sesamoids are well known for being very difficult to treat and even with 8-12 weeks in a boot, your chances of it healing are statistically about 50%. This is mainly due to the location of the bone (under the forefoot so it gets your full body weight with every single step), and the poor blood flow to it – which is usually only one small artery for supplying all the nutrients needed for healing. Often when it fractures, you either break the artery or the swelling compresses it, further limiting the blood flow. I’m sure the delay in diagnosis would not have helped nor – I’m sure in retrospect – would me working 40 hours a week on my feet while in the boot; lesson learnt and I would never let a patient of mine do that. (Got to love the benefit of hindsight) So long story short, 4 months after this I had another MRI that showed no healing through the bone despite the mandatory time the boot, and I found myself sitting in the very swish office of a well-known sports surgeon in a big city far away from home.
He explained that we had a few options, and after a lengthy chat and a lot of questions from me, we both decided that the best shot I had at competing in Ironmans in the long term was to operate. He planned to do a bone graft from the hip and screw it into the sesamoid, but also do a dorsiflexion osteotomy of the 1st metatarsal at the same time, which would effectively offload the sesamoid and hopefully prevent me from having this problem again in the future.
So far so good, but here’s the kicker: it was fairly major surgery. Two hours under the knife, overnight stay in hospital, 10 days in a backslab, 6 weeks in a cast non-weight-bearing, then a further 6-8 weeks in a boot partial weight-bearing and a grand total of 9-12 months before I start a return-to-run program. Gulp. I asked him how long we could put off the surgery – I needed time to think! – and he gave me a couple of months. I needed every bit of that time to process how I was going to handle the situation (mentally and physically, not to mention the logistics of work etc) and to most importantly psychologically prepare myself so that I would be able to maintain good nutrition for healing and not revert to old habits throughout this challenging time.
Which brings us to the now, 13 days post-op.
The surgery itself did not go to plan in that when he got in there, the fractured bone literally “fell apart like an eggshell” and so he set about salvaging what he could of it. No bone graft was done but he re-attached the ligaments to the new smoothed out bone and the outcome should remain as favourable as if the bone graft was done. The osteotomy went well, and when the backslab came off it felt like unwrapping a present to see two relatively big but very neat incision scars and everything coming along well. Surgeon’s happy means I’m happy. He didn’t let me leave without a 15 minute lecture on training and not overdoing it, but then he does work exclusively with athletes so I am thinking I was not alone on the receiving end of that spiel! My next review is in 5 weeks to get an XRay done and hopefully we can remove the cast and get into a boot shortly after. I am allowed to do upper body weights and Pilates as long as I do not put my right foot on the ground, but nothing else. I will hopefully get back into swimming and deep water running, plus cycling in the boot on the turbo trainer, once the cast is removed.
The things I have handled well include preparing work and home so that I can still be keeping my mind occupied – that is, running the business from home and still overseeing my junior staff treating my patients etc. That has been huge for me, because without running AND my work I go mad. Take away running – and Physio becomes my main crutch, excuse the pun. So the surgeon was happy to work with me on that one, I was upfront from the beginning and he has been brilliant with setting clear guidelines. As of next week I will go back to the clinic and see selected patients during half-days so that will be even better – the worst thing you can do in this situation is have only yourself to focus on! I was also lucky to have my closest friends around me throughout the whole process, as well as my husband’s family who I am closer to than my own. They all knew in advance that I would be in need of lots of laughs, some sense of “normality” and zero sympathy (I am NOT a good patient! Business as usual….well, as much as possible!). Anyone in my life that I thought would not be able to abide by those guidelines I haven’t spent much time with (yet). I need to make sure I have a strong support network around me and it has been worth its weight in gold; I would do the same for any of my friends. (Don’t be afraid to tell people what you need – your true friends will actually feel more comfortable as they will likely be upset seeing you so busted up as well! This was a lesson in life that took me a long time to learn but that has been invaluable). And of course, there has been plenty of baking coming from my kitchen (therapy for me and a great “thank you” gesture for said friends). Equally as important as anything else has been making sure I eat great quality food, regularly, and getting enough sleep – not as easy as it sounds with zero appetite after all that my body has been through. Of course, this is hard for me when I can’t train as the two remain inextricably linked for me (ironically I am healthiest food-wise when I am in full Ironman training mode), but having prepared mentally for it beforehand was very important. I have no intentions of gaining any weight during the next few months, but by the same token now is not the time to be depriving my body of any vital nutrients – the success of this surgery depends on it. My long-term running depends on it. And that, my friends, is non-negotiable!!
What I have found most challenging has been pacing myself – I am so used to going 100 miles an hour every waking moment of the day; obviously being in plaster non-weight bearing slows you down but having to stop and REST every hour or two is a HUGE ask for this little duck! The other complications couldn’t have really been predicted – I have low blood pressure normally (110/70) and a low resting HR (55) which I put down to being fit and possibly a bit of after-effects from the ED; but my body really struggled with the anaesthetic – the night after my BP went down to 70/40 and things got a bit hairy for a while there. But all is well now, onwards and upwards, time to rebuild this body!
Anyone wanting more info about sesamoids and stress fractures can head to this brilliant site:
and of course I am happy to answer any questions on this tricky topic or with coping with injuries.
Thanks for all the great information here. I sustained a sesamoid fracture 5 months ago squeezing my foot into a ski boot! Can you believe it. This has totally sidelined my triathlon activity and more than that impacted my whole psyche. Your practical and psychological advice has been most helpful as I try to see the light at the end of the tunnel. So far I am not pursuing surgery but trying all the usual – icing, calcium tabs, cut out insole and as little movement as possible. Any advice you can provide on physical therapy would be most helpful (seeing as that is your domain). Again, thanks for “putting it out there” in an excellent blog. I have three ironman events under my belt in the last few years. At 52 I have be in good shape and am feeling like an old man cripple these days due to the stupid sesamoid! David P
Hi David, so sorry to hear of your predicament. First and foremost, you need to get yourself into a boot or Aircast (walking cast) and commit to it for a solid 12-16 weeks. I know it sounds like a long time but it’s your only bet of healing it conservatively. I trialled 3 months in the boot and then re-did MRI’s and at that point I had zero signs of healing, so we went with the operative option and even then, only because I was lucky enough to have access to a phenomenal sports surgeon who had done the procedure many many times before. So that would be my second key point – get a medical team on your side that know how to deal with sesamoids, not a lot do….ask them, and if they haven’t treated any (successfully) then keep trying until you find one. Physios, sports physicians or surgeons can guide you. Lastly, if you haven’t already check out the website “Dr Blake’s Healing Sole” and have a read of the countless case studies on sesamoid fractures on there – it will give you insight into best practice and a lot of guidance as well. If you are in America you may be lucky enough to actually see Dr Blake as well. Good luck with it, let me know how you get on!
Thanks for the great advice and speedy reply. I was a bit disappointed in trying the generic cam walker early on as it provided no pressure relief on the Sesamoid. I will research the aircast. Agree Dr.Blake’s blog is a great resource. Thanks so much.
For complex fractures (which includes sesamoids) we will only fit patients in the Aircast boots – much more expensive but they actually lock the joints into correct position. If you’re still not offloaded enough you can also put a basic arch support orthotic (with or without the sesamoid cut-out depending on symptoms) into the boot. Remember that the fracture has been there for a while now and the nerves will be quite sensitive, so it may take some time (a few weeks or more) of being super diligent in the boot for the pain to settle. I would then organise an MRI for a few months’ time to review where the healing is up to. In the meantime it may be worth researching (very good) surgeons in your area – some will take a few months to get into anyway so if you know you have an appointment waiting should you need it, it can make the psychological side of things slightly easier to cope with! The good news is I competed in another Ironman 2 months ago…..you will get back, it will happen, but it does take a lot of time and patience 🙂
Congrats on the Ironman . . . .what a remarkable comeback and gives me hope. The Aircast is on order with Amazon. I get it tomorrow. Thanks for your encouragement!
Hey Ana. I simply cannot thank you enough for making these posts about the sesamoid injury. It has literally brought me to tears to learn that there is a cure for this injury just when I though all hope was lost after walking 6 years on a fractured foot. Today I will have yet another talk with a surgeon on my injury, he sounds like the first doctor who actually knows something about this injury, it’s scary to say but I have met with so many doctors who are unfamiliar to this injury and one was even going to operate my calf to fix it.. Anyway you are absolutely right about looking for the right team. If it turns out my doctor doesn’t seem like a good fit I wanted to ask you where did you get your surgery? I think you mentioned it somewhere, but I can’t find the post anywhere. Once again, thanks for the inspiration and motivation your posts give us who still battle fractures sesamoids. Rakel
Hi, I am Australian and had my surgery done by an amazing surgeon based at the Wesley Hospital in Brisbane called Dr Ben Forster. I would travel as far as you need to to get someone who specialises in athletes and feet – that is your best chance of getting back to full function, especially after having it for so long. My surgeon gave my foot somewhat of a “facelift” at the same time, changing the arch height to take pressure off the sesamoid. Much longer recovery time but my function since has been amazing and so worth it. Good luck!
Hi Ana. I wanted to ask you a question… I have talked to the clinic where Ben Forster works at to try to get information on a possible quote of the surgery I am wanting to do but they won’t give a concrete answer until I visit their clinic.I live in Norway (half way around the world). Just for orientation I wanted to ask what your surgery cost? I know you said your case was a little different with the face lift. The doctors in Scandinavia won’t do bone crafts on sesamoids, they think it’s too risky and heroic to even try. I have read about some successful surgeries abroad. The doctor I visited just a few minutes ago actually, thinks the best chance for me is to take away my whole later sesamoid. My tibial sesamoid is a quite small in size so I am afraid if I am left with just one, then that bone might not be able to handle all the weight alone. So my questions are:
1. What was the approximate cost of the surgery itself
2. Do you know if the doctor had done those kind of surgeries in the past and their success rates?
3. What is your opinion on orthodics that decrease the weigh on sesamoids? Both re and post surgery. Eg dancers pad (different doctors here have all different opinions..) personally for me they don’t help.
4. What is the state of your foot right now?
I am torn between taking the easy way out with the risks and possible consequences in mind of just taking the bone out, or taking the long and expensive way to have a bone craft done. I have read of success stories on sesamoidectomy and athletes returning to high intensity level sports so I have some hope. You can reply on email@example.com or here. I would truly appreciate that. Have a nice day and happy running!
I have it too! Did you get yours fixed? I agree, many doctors knows to little.