#878 Is it possible to run with a sesamoid fracture non-union? - DOC

#878 Is it possible to run with a sesamoid fracture non-union?

Is it possible to run if you have a sesamoid fracture non-union? That is a great question and that is what we’re talking about today on the Doc On The Run Podcast.



I got a great question from a runner who has a sesamoid fracture that has turned into a non-union. The sesamoid bones are just two tiny little bones under the big toe joint. So, I am not going to draw any pictures because it does not really matter that much about the anatomy. If you have one, you already know what I am talking about.

They are very small. They are about the size of kidney beans and they are basically the equivalent of your kneecap. Your kneecap is actually a type of sesamoid bone. It is just really a big one. The sesamoids under your big toe joint, they are a lot smaller. But when you break one of the sesamoids and you have two pieces of bone that do not heal back together and become one bone again, that is what we call a non-union. It did not unite, it did not get back together. It is not going to get back together.

In her case, she actually used a bone stimulator. Did a whole bunch of stuff for over a year and then the doctor looked at it, looked at the X-ray and said you have a non-union and the doctor said we should take it out. So, this patient called me for a second opinion, and she wanted to know my thoughts on surgery since she is a runner.

Well, one thing to think about, those two little bones are embedded within a tendon and they are sitting in the tendon together. If you take one of them out, the tendon is then going to have more tension on one side or another and your big toe can then drift one way or the other. You can get a bunion, or you get a thing called Hallux Varus which looks sort of like your foot looks like a monkey’s hand. Your big toe sticks over like a thumb like that.

It is a bad thing. So, one of the unhappiest patients ever treated had Hallux Varus, I did not cause it, but she had a sesamoidectomy. It was removed surgically and the toe drifted way over and she could not put on shoes or anything else. I had to do a very creative surgery to fix it and she was happy afterward. But I will tell you, she gave me a lot of heartache. I was very worried about her because she was super unhappy and understandably so. So, you do not want that problem for sure.

All that instability is a problem and one of the things that this patient told me, she said the doctor said, “Oh, it is no big deal. We do this all the time” and I said “Really? Then just ask the doctor, are you going to guarantee that my toe is going to stay straight and I can run?” Because they would turn white if you actually ask them that question out loud, because they cannot guarantee that. They can only guarantee that you are going to get a bill  and a scar. That is it. So, the question though, can I run on a non-union, it is an important one because again, this doctor looked at her and said it is non-union, it is not healing, it has been a year, it is not going to heal. You now have a bunch of scar tissue between those two pieces of bone.

Very interesting point. I said, “Have you tried running? She said, “Yes.” As a matter of fact, today when I am recording, this is a Tuesday. She said, “Yeah, I ran today. I ran yesterday. I ran Sunday and I had run on Friday. So, did my first run on Friday, then I ran on Sunday, Monday and Tuesday and had no pain.” And she said, “Granted, they were short runs. She hadn’t run in a long time.” So, she ran about two and a half miles, she had no pain at all.

So, the question is, you do not have any pain at all, is it really a problem or is it not a problem and I said, “Look, maybe it is not a problem at all. You just have to stop and think what is the risk?” So, if you get a non-union, there is a simple way, believe it or not, the doctors classify non-unions. Is it a painful non-union or is it a not painful non-union. And if it is not a painful non-union, so what?

There is a thing that happens in the sesamoids, it is actually called a bipartite sesamoid. It is a naturally occurring thing where it looks like you have two pieces of bone, and they are two separate pieces of bone but they never united as you are growing as a baby. Instead of them coming together and forming one solid bone, they just stay separate, but they are not loose, they not just sitting in there rolling around or anything.

They are connected with a whole bunch of soft tissue, like a ligament and so in effect, when you get a non-union, you have a bunch of scar tissue between the two pieces of bones that functions as a ligament. Like the sort of ligament that exists between a bipartite sesamoid those two pieces, and if that doesn’t hurt, it is not a problem. A lot of people have that, and you might see it on your own X-ray. If you are getting an X-ray for a bunion or a different problem, you might see that and the doctor might point it out sort of in passing, but never considers it to be a problem.

If you think about it, if you get to that place where you actually do have a non-union, but It is not painful and it is solid, because you have really been protecting and keeping it still and trying to get it to heal, and it is stable enough that it is not going to hurt when you run, then in that case, yes, you could run. Her question though, was like, “What is the real risk if I run” and I said, “Well, look, you just had a doctor who said to take it out. That is the worst thing.”

If you think about a diabetic foot infection, what is the worst possible thing? You have to cut off the leg. So, anything less than that is better. And in my mind, anything less than removing the sesamoid is better. If you do not have any pain at all, and you do not have swelling, and you have explained that to the doctor, and you told them you started to run, I think it would be crazy to do surgery to take it out just because it might get worse later.

You do not want to just run and ignore it and get necrosis or a problem with the sesamoids. So, you have to talk to your doctor about it. But that is the way that I thought about it and explained it to this particular runner.

If you liked this episode, please like it, please subscribe. Make sure you talk to your doctor before you go run and I’ll see you in the next training.