Treating A Possible Case Of Avascular Necrosis Of A Sesamoid Bone

A 24-year-old patient recently contacted me after a diagnosis of avascular necrosis of a sesamoid bone that has been causing increasing pain since last August. He says at the beginning the pain was like small cramp when he was walking but had gotten worse. He does not remember having a bad jump or a fall, does not smoke and does not drink much alcohol. The patient is not a runner but does do low-impact exercises.

The patient got an X-ray and magnetic resonance image (MRI) and his doctor in France concluded it was a "contusion" of a sesamoid bone. The patient received some insoles to wear in his shoes but says they did not make any real difference, and the pain continued to increase. 

Finally, the patient saw a doctor in the United States who diagnosed avascular necrosis after taking a new X-ray and MRI that showed more cyst in the bone. His doctor wants him to wear a walking boot for six weeks to try to ease the pain.

The patient is frustrated that the doctor never talks about healing the bone and only about relieving the pain. He is feeling pessimistic about the condition and that this condition will ruin his future hopes with exercise.

Six to nine months of the Exogen bone stimulator (Bioventus) along with some weightbearing with orthotics and dancer's pads can turn this around. I believe one can only diagnose avascular necrosis with a computed tomography (CT) scan. If the bone has fragmented, one should definitely consider surgical removal. 

In this case, clinicians should also determine if there is any problem with the patient’s bone density or if there is a vitamin D deficiency. Physicians might advise vegetarian or vegan patients to get a dietitian consultation.

The patient also asks if he should stop all working out. Patients with avascular necrosis need circulation, leg strength, cardio, and weightbearing. A patient such as this should test his workouts to see what does and does not bother him. Simply putting the pedal of a bike on the arch can offload the area enough to help reduce or minimize pain while exercising.