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When There Is Avascular Necrosis Of The Fibular Sesamoid In A Patient With Significant Spinal Issues

I recently received an online inquiry about a 38-year-old female with pain in her left hallux upon extension. She is a chemistry professor, a professional belly dancer and participates in Thai kickboxing daily. Late in 2019, she began to notice the hallux pain, but kept training and taped the site as the pain was not severe at the time. After the onset of the COVID-19 pandemic, she began running more due to the closure of her gym. Unfortunately, this increased her pain and caused her to decrease her activity. 

She saw a podiatrist and received a diagnosis of avascular necrosis of the fibular sesamoid, which was identified on magnetic resonance imaging (MRI) in June of 2020 and confirmed on single-photon emission computed tomography (SPECT-CT) in early July. Plain film radiographs did not reveal any fracture or degeneration. Both the MRI and CT showed localized soft tissue inflammation and edema, but no tears.

The patient was in an immobilizing boot for six weeks and had a bone stimulator that she wore for three hours daily for almost three months. She receives manual therapy from a physical therapist, does toe yoga and tries to go on walks or short hikes in a Hoka One One Bondi 6 shoe. The patient did have a reduction in pain from zero to two on the visual analog scale so she attempted to increase her activity. However, she still experiences pain and swelling when she does this. Needless to say, she is very frustrated.

The patient also relates a history of mild to moderate scoliosis, which causes her back pain, especially due to her decreased activity level. Her sports medicine doctor has brought up the idea of spine surgery as a result. Otherwise, her fitness routine has kept her degenerative disc disease, disc herniations, stenosis and facet joint arthritis in check. Unfortunately, this recent change in routine coupled with the necessity of resting her foot and performing seated exercises is not compatible with her back issues. 

Her inquiry to me revolved around the best course of action to return to her previous types and levels of activity as soon as possible. From afar, my thoughts are that she should switch out of the boot for her back and into some bike shoes with embedded cleats. This will provide evenness in function and weight between the two sides. Her physical therapist should be able to help with a program to keep her back loose and strong as she goes through her foot rehabilitation.

I am also curious when she will get a follow-up MRI. I usually wait six months in these cases but if possible, every three months might help her and her team to see some light at the end of the tunnel in regard to healing of the avascular necrosis.

There is also some information missing from her inquiry, specifically about anything footwear/orthotic wise other than her Hoka shoes. Interestingly, there could be consideration of a myriad of options including orthotics, dancer’s padding on the orthotic and separate Cluffy Wedges, varus cants, spica taping, carbon plates with first ray cutouts, etc. It would be helpful to see a coronal MRI view of the injured sesamoid, both T1- and T2-weighted views, to see the avascular necrosis. Lastly, non-steroidal anti-inflammatory drugs (NSAIDs) are not indicated due to bone healing issues but the patient may benefit from contrast baths for deep bone flush and circulation every evening.  

Dr. Blake is in practice at the Center for Sports Medicine, which is affiliated with St. Francis Memorial Hospital in San Francisco. He is a past president of the American Academy of Podiatric Sports Medicine. Dr. Blake is the author of the recently published book, “The Inverted Orthotic Technique: A Process Of Foot Stabilization For Pronated Feet,” which is available at

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

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