(photo above pointing to the tibial sesamoid, the fibular sesamoid is the closest one to the second metatarsal)
Hello Dr. Blake,
I am writing today because in conducing online research about my injury, I came across your healing sole blog, and you offered your contact information so that folks might contact you with foot-related concerns. Thank you for extending yourself in this way. I could not find anything on your website about my particular injury, and so I thought I would write you. I have seen an orthopedic surgeon and a podiatrist, but I'd like to have another opinion. Also, I find it very difficult to get answers out of these doctors, as they only have a few minutes scheduled to talk to me.
I am a 29 year old female. I started dancing in college (modern and some ballet) about 8 years ago, and have continued on and off since then. I took some time off, but started taking classes about 3 - 4 days per week in July 2009. I am not a professional dancer, but have received scholarships for dancing at my studio, and have been involved in pre-professional training programs for modern dance. It is very important to me.
In about September 2009, I noticed some pain in the left ball of the foot. I stopped dancing for 1 week and it got better, so I resumed. However, the pain returned very gradually. I visited a sports medicine orthopedic doctor in February 2010 for a different concern (right ankle stability), and also mentioned the pain in the left ball of the foot. He diagnosed it as "sesamoiditis," and seemed confident of his diagnosis, so I declined an x-ray. I avoided jumps in dance classes as I had been since the onset of the pain, but I continued dancing. The pain very gradually became worse. At the end of May 2010 I decided to stop dancing and seek physical therapy, as the orthopedic doctor had said this was an option. After three sessions of physical therapy (involving ultrasound, iontophoresis, soft tissue mobilization, taping and home exercises), my foot was much worse - it was swollen and painful to walk. Prior to this, my main pain came from dancing, not walking. At the beginning of June 2010, I went to a different orthopedic surgeon and he took x-rays, diagnosing my injury as a non-union fracture of the fibular sesamoid. (A pre-injury x-ray from 2008 ruled out bipartite sesamoid.) I was in a walking boot for the month of June and non-weight bearing (on crutches) beginning in July. Upon recommendation from a friend and family doctor, I sought a second opinion from a podiatrist. The orthopedic surgeon said that if my bone wasn't healed by the end of August (after 8 weeks non-weight bearing), it would require surgical excision of the fibular sesamoid. The podiatrist has been more conservative in his treatment. On August 18, I began using a bone growth stimulator once a day for 30 minutes. It is the DonJoy Condensed Magnetic Field (CMF) stimulator. After my 4-week check-up on September 8th, the podiatrist added a twice daily contrast bath to my regimen, along with the bone growth stimulator. I will see him in another four weeks. I am still non-weight bearing, and I have been conscious to take calcium supplements, drink milk and eat yogurt this whole time.
http://www.youtube.com/user/drblakeshealingsole#p/a/u/2/rRt5hC24Afg for information on contrast bathing.
My concerns/questions are:
1) Is there anything else I should be doing to heal this bone (without surgery)?
2) I am a very patient person and would do anything to save my bone rather than have it surgically removed, as I fear it will compromise my dancing. However, is there a point at which we can be fairly certain that the bone won't heal, and I will have to resort to the surgery?
3) What risks would surgical removal of fibular sesamoid involve? Again, my main concern is with the function of my foot - I am very active and want to be able to dance for the rest of my life! I read on the Internet that removal of the sesamoid affects a persons balance and power, may lead to hallux varus as the tibular sesamoid loses its counterbalance, and may affect the tendons (adductor hallucis). My concern is that the doctors all tell me the surgery has no effect and I will be back to normal. I am a smart woman who has done her research and recognize that this isn't the case. Could you please provide me with an honest, realistic representation of what might happen over the course of my lifetime as a result of sesamoid excision?
4) Is arthroscopic surgery an option?
5) Are bone grafting or pinning options?
6) I have struggled to trust my doctors. What do I look for in a surgeon (if it comes to that)? Should I go with a podiatrist or an orthopedic surgeon?
7) When I get back to dancing, how can I avoid future injury to the fibular and tibular sesamoids? I realize that the impact is greater if both sesamoids are removed, and want to avoid that at all costs!
Dr. Blake, I apologize this is such a long email. I hope you are able to offer me some advice. Thank you for your help.
Dear Jenni, I will try to answer your questions in this blog posting. There are 2 sesamoid bones under each first metatarsal which make up the "ball of the foot". These sesamoid bones act like the knee cap in function: they protect the first metatarsal from direct pressure, and they separate the tendons from the joint axis increasing the lever arm of these tendons. Increased lever arm means increased power from these tendons which need, at times, to handle the force generated up to 5+ times body weight. The photo below shows these sesamoids sitting under the first metatarsal with the fibular (closest to the second metatarsal) having a fracture. In this example, you can clearly see how the fibular sesamoid looks irregular. The actual fracture occurred 10 months previous to this fracture.
On an aside, ultrasound is contra-indicated for stress fractures, probably why physical therapy aggravated the situation. Golden Rule of Foot: If ultrasound irritates the injured area, consider an underlying fracture may be present.
I will try now to answer your questions.
#1 Is there anything else you can do to heal the bone in an attempt to avoid surgery?
First of all, anything that you do now to help yourself avoid surgery, even if you need surgery, will help you post surgery immensely. This is a perfect time when the bone is sensitive to design perfect orthotic devices that protect them. These modifications in orthotic devices are a post in themselves, but most sports medicine podiatrists and physical therapists can design deceit orthotics for this problem. You may have a biomechanically challenging foot, with a very prominent first metatarsal and this could actually take the work of a biomechanical expert (hope this is not you). The goal of any othotic device for you, and athletic shoe ones are made first to wean you eventually from the boot, is to shift weight back onto the arch and onto the 2nd and 3rd metatarsals. Without a corrective orthotic device, at some point in each step, 100% of your body weight goes through the big toe joint and sesamoids. In the front of the orthotic device is a "dancer's pad", also called a reverse Morton's pad, and sometimes an additional metatarsal pad.
The bone stimulator for a nine month period is great, just do not stop it too early. If you are using the bone stimulator, best to be committed to it for 9 months. Remember, pain is going to be a poor guide on healing. As you continue non weight bearing, the area will get stiffer, weaker, more swollen, and with more bone and nerve sensitivity. You are in the easy stage of rehabilitation. It is getting you back on your feet gradually that the work begins. The doctor managing your care will need to balance the pain you have with a gradual increase in function. It can be a trade off to allow more function with some more pain initially. This is the same issues that have to be dealt with post operatively.
Learn to do spica taping to restrict big toe joint dorsiflexion with kinesiotape. The 3 photos show the placement of 1" kinesiotaping. It should be applied easy, not to pull the toe down, but to restrict the upward motion of the toe. It should not feel like it is tight or jerky on the toe. You can experiment with longer arms of the tape under the arch. The 1" tape is split in 2 for 1" to wrap around the toe. An upcoming post will show a video on this technique.
Stay strong with all those foot intrinsic muscles, but also you knees, hips, and core. The stronger you stay, the faster you heal, surgery or no surgery. The weaker you become, the more collapse of your arch into the ball of your foot, the more pressure on the sesamoids. You are in the Immobilization Phase, but you need to be blending the Restrengthening Phase into it. You need a smart physical therapist to begin restrengthening your body. Golden Rule of Foot: Begin Restrengthening the Injured Area even before you injure it.