Possible Sesamoid AVN: Email Advice

Hi Dr. Blake,

     I have been reading your blog for the last month and viewed several of your videos which has spurred a few questions. 

     My 14 year old daughter was diagnosed with AVN in the left tibial sesamoid (this means avascular necrosis or dying bone secondary to poor blood supply).  A bit of background; she is a competitive Irish dancer and sadly due to this injury just had to sit out on the World Championships.  Last fall she dealt with some sesamoiditis in the right foot which we treated and it resolved.  Both feet have bipartite sesamoids (naturally occurring sesamoids in 2 pieces), we know from X-rays.  The left foot started aching in late November and then was really bad in early January after she started back from Christmas break.  She went into a boot 1/15 for 3 weeks at the time the DPM was treating as sesamoiditis, when she started to work out of the boot in wk 4 the pain was the same so we had an MRI on 2/11 and the AVN was noted.
Dr Blake's comment: You can get an idea of AVN from MRI, but CT Scan denoting bone fragmentation is the best test, just more radiation.

   The DPM immediately tried to arrange for a bone stimulator and she wanted her immobilized again.  We also sought a second opinion from a pediatric orthopedic because teachers and family felt it was important.  She understood by the time we saw the orthopedic that Worlds was out, and we saw the MRI pic ourselves (clearly it was not normal to our untrained eyes).  She asked him what she needed to do to heal.  He said a cast for 3 wks non-weight bearing, then a boot for another 2 wks non-weight bearing and start an Exogen unit.  She was allowed to start weight-bearing last Thursday but we were traveling for Worlds so I had her continue with a scooter.  She is now walking in the boot and is not having pain.  In addition, she has seen a chiropractor during this time who has done some ART (Active Release Technique) for her left calf and arch and right hip and foot since it was getting the brunt with the crutches.  We were supposed to go back to the orthopedic this week, but knew he would not do any X-rays or MRI yet so I called and she is to start PT this week.  The PT can release her from the boot, and she’ll go into a carbon fiber plate and at some point back to activity.  She is chomping at the bit to get back, but very concerned she do it correctly so she doesn’t re-injure it.  My questions are:

1.      When should we expect to re-do an MRI to know if the AVN is turning around?  And why do you say, as did the orthopedic, MRIs, X-rays are delayed in showing healing?

Dr Blake's comment: The earliest for a new MRI is 5/11/15 or 3 months from the first. I personally like to wait as long as possible while following symptoms as I move the patient from non weight bearing to weight bearing with boot to weight bearing without boot to return to activity. The Exogen bone stimulator is a 9 month course, so you want typically 6 months before an MRI or CT scan is done. Do you have that patience? Most not, so use the 3 month rule for some idea of healing. X-rays only reflect the amount of calcium in an area. If that area is healing, the water content of the area dramatically increases bringing in nutrients, like calcium, making the area appear to have less calcium, thus poor healing, when actually there is more calcium with healing. It is just a percentage reader. You can increase calcium for healing, but with the increase water, the area looks like it has avascular necrosis or at least is not healing. 

2.      What % of your young patients heal from AVN?  Should we expect it will re-occur due to her intense foot pounding activity?

Dr Blake's comment: Young patients rarely have AVN problems due to their great bone metabolism. Unless you do not create a pain free environment (0-2 pain levels) as you progress her back to full dance, unless she has some dietary issues negatively influencing healing, unless you can not control the swelling with icing and contrasts, or forget to use the Exogen, she should do just fine. 

3.      We plan to have her use dancer pads when she goes back, though it will be difficult and change how her dance shoes fit.  Should we also do the spica taping, though I’m afraid it will impair her range of motion for dancing and possibly mess something else up? 

Dr Blake's comment: You have to just try. I love dancer's padding and spica taping for this problem. Remember every day she has had restricted mobility it takes two days to get that mobility/activity back. So, it is important to calculate for her the injury date to return to activity date starting date. If that takes 100 days, it will take 200 days from that point to get everything back. You go slow, conservative, and it typically does fine. With some tears for sure. 

4.      What type of shoe should she be wearing outside of dance?  Is barefoot walking bad?

Dr Blake's comment: Barefoot is the worse for the next year. You want a stylish shoe that she wants to wear, that has room for a dancer's pad, and allows for 0-2 pain levels. 

5.      How do we get her foot mechanics evaluated to see if she needs to learn different walking/running mechanics outside of dance to help minimize added stress?

Dr Blake's comment: I used to treat the entire SF Ballet. It took me a few years to really understand that what they did outside of class had a big influence on the pain during class. So, typically with sesamoid injuries, you are not just adding dancer's pads and arch supports to her dancing shoes, but all shoes and activities need to be evaluated. When you are talking about someone who is at the level of World Competitions, you need top sports medicine advice on all her shoes and activities. 

6.      Have you had any of your patients do dry needling for sesamoid/tendon issues?

Dr Blake's comment: I love dry needling for circulation and nerve hypersensitivity. If you can get it, do it twice weekly. Does it help more than contrast baths nightly, I am not sure. But, if you do both, and add the Exogen bone stimulator, you are doing your best to heal this. 

7.      In your opinion, when could she start riding a stationary bike?  She has not only lost lots of muscle in her calf but her hamstring and quad as well with the extended inactivity.

Dr Blake's comment: OMG, she should do this the day she injured herself for up to an hour daily. You can lower the seat of the bike a little, and place your weight of pedal in your arch. I hope this advice helps her. Rich

I do like the DPM we have seen though she does not see lots of high level athletes and the orthopedic is good too but we are rushed in and out - it’s difficult to get questions asked and answered.  So thank you so much for your blog and sharing your experience.

Kind regards,