Sesamoid Fracture in Dancer: Email Advice

Hi Dr. Blake,

My daughter is 11 years old.  She's been a dancer for 6 years, 4 years competitively.  This year, she enrolled in a more intense program that includes, per week: 5 hours of ballet + 9 hours of other classes (strength and stretch, hip hop, tap, Lyrical, Acro, competitive dance routing practice).  This year also involved a new studio with new floors.

A few days after an intense weekend of dance "turns" with an out of town choreographer, she said the ball of her foot hurt.  Then next day, she was walking on the side of her foot.

So, that evening we took her to a podiatrist (orthopedic surgeon).  He felt her foot, took x-rays, one of the injured (right) foot which showed a separation of the sesamoid bone.  He then took an x-ray of the left foot to compare it against the right one to see if it might be a bipartite sesamoid.  The left foot was normal.  This was on a Tuesday.  He said he wanted an MRI done on the affected foot because .  He asked her if she wanted a hard shoe they had on hand and told her that crutches would be useful.  He also told us that our daughter might never dance again.

Dr Blake's comment: There is no place for this comment in that situation!! I apologize from the rest of the medical profession. 

It wasn't until 11 days later that our daughter had her MRI and 14 days after this initial consultation that we got the MRI results.  Also, since the 6th day of her pain, she has had no pain.

Dr Blake's comment: Good starting taking such a short time to get in pain free. Now, you have to keep it between 0-2 pain as you gradually work her back. 

MRI RESULTS

Osseous structures and articulations:

There is a linear low signal extending transversely through the medial/tibial sesamoid at the first MTP join (sagittal images 4 and axial series 7 image 15).  There is mild adjacent bone edema.  This has the MRI appearance of a subacute or chronic sesamoid fracture.  There is no significant separation of the fragments.  There is also a mild edema involving the lateral sesamoid at the first MTP joint.  There is a small first MTP joint effusion.  The other regional bones and joints are normal.  The Lisfranc ligament complex is normal.  The MTP joint plantar plates are intact including the great toe plantar plate complex.

Muscles & Tendons:

The regional muscles and tendons are normal.  The visualized portions of the planar fascia are normal.

Miscellaneous:

The regional neurovascular structures are unremarkable.  No regional soft tissue masses.

The day we got the MRI results (I went to pick them up in addition to the results sent to the initial doctor), I decided the take my daughter to a pediatric orthopedic surgeon.  This doctor did not see the MRI images (due to insufficient time between the time I gave them the CD and the time of our appointment - minute apart) but he read the report noted above.  He took x-rays as well.

He could not conclude that there was a stress fracture, a fracture-fracture, sesamoiditis...).  He put her in a long walking boot and told her she didn't need crutches.  He also sent us to get carbon fiber shoe inserts for when she eventually transitions into shoes.  He scheduled an appointment in 3 weeks to take more x-rays to see what changes have occurred, if any.

Dr Blake's comment: So the MRI showed stress to the sesamoids with bone reaction (edema). You have to treat it as a small stress fracture (worse case scenario), even though it could be a bone bruise with sesamoiditis. Conservative protocol would be to immobilize with the walking boot for 6-8 weeks, and then take 6-8 weeks weaning from the boot into normal shoes (hopefully with orthotics and dancer's pads). Since it is a removable boot, she should do contrast bathing (see other posts)daily to flush out the deep swelling in the bone and in the joint. 

So, I have questions...

1) What is a chronic sesamoid fracture?

Dr Blake's comment: As a sesamoid heals, it can look like your daughters for a long time, with some swelling (healing response). It is about timing. A chronic sesamoid fracture would be at least a year old or so. A subacute stress fracture signifies that the acute phase is over, or never happened. It can look like that between 6-9 months or so, so just after a bone bruise that never broke. This is what I hope she has. 

2) Do you think based on the MRI report that she has a stress fracture, a subacute fracture, a chronic sesamoid fracture?  Are MRIs 100% conclusive?

Dr Blake's comment: Based on what you have said, she either has a small stress fracture (which can get worse if not protected) or just a bone bruise (sesamoiditis). She is not in the subacute or chronic stages yet. 

3) Is there any way that she could really have bipartite sesamoid with sesamoiditis?  (Wishful thinking, as this seems the least problematic.)

Dr Blake's comment: This happens all the time, so why not now.

4) Is it correct that our daughter wasn't put in a cast (totally immobilized)?  That she does't need crutches with her boot?  Is this the right course of action for any sesamoid issue?

Dr Blake's comment: No matter what any one says, you and your daughter need to do what it takes to create that 0-2 pain level. If that is not happening within the boot, someone has to build an accommodation or orthotic in the boot to create that. You definitely want to weight bear if you can create that pain free environment. Non weight bearing typically causes more pain, swelling, hypersensitivity, and bone demineralization. You use crutches initially if you can not obtain a 0-2 pain level without them. 

5) How long will the healing take?

Dr Blake's comment: So much depends on how fast she goes through the stages of normal rehabilitation. She needs to be pain free in the removable boot for minimum 2 weeks, then it is a minimum 2 weeks to go from boot to no boot (into shoes with dancer's pads minimally). Then 2 weeks to increase walking to all day, with floor bar all along this course. Then slowly 2-6 weeks getting back into shape with no increase in pain, etc. 

6) Is the fact that she's had no pain after the 6th day a good sign? GREAT!!!!!

7) Do children heal quicker than adults? 

Dr Blake's comment: Definitely, but have a poorer sense of good and bad pain, which can be a major issue. 

8) Do you think my daughter will dance again?

Dr Blake's comment: Yes, silly goose!!! I love that saying. Your job is to be her ombudsman, her protector, and make sure she is keeping this pain free, without walking on the outside of her foot, as she moves from this point on. 

9) Are there any questions I should ask the doctor?

Dr Blake's comment: Who will make her orthotics and dancer's pads? Can she go to physical therapy to help safely progress her through the rehabilitation? Can her pain and function progess allow her to avoid xrays (basically can she avoid xrays if they really do not show much and she is improving). 

Thank you, in advance, for your response. You are Welcome!! Good luck!!