Sesamoid Injury: Email Advice

Hi, Dr. Blake, 

My 12 year old daughter plays year-round soccer at a very highly competitive level. In early June after coming back from a tournament weekend, she complained of her foot being sore and not able to bend/flex her big toe very well. After asking her more questions, we find out that her foot had been slightly sore when she pushed in on the ball of her foot with her fingers for a couple months. However, now it was sore to walk and her flexion was limited. 

We took her to a podiatrist. MRI revealed inflammation and a bipartite sesamoid. He said it didn't appear fractured because of the clean lines. She was in a walking boot for 4 weeks with no pain. Then, she started wearing her custom orthotics in all shoes. We kept her out of soccer and pretty much all other running activity for another 2-3 weeks. She had little to no pain. We then slowly started her back into soccer wearing her orthotics in her cleats. She would only playing at 50 percent effort/time for a couple weeks and slowly increasing that keeping her discomfort level below a 3. After each practice and game she did an ice foot bath. We also were spica taping her foot all day at school and at practice in the evening and games. All the while she was doing foot strengthening and stretching exercises. A couple of weeks ago she was able to go at 100% effort with very low discomfort. We continued to ice bath after each practice and game, but because of the little amount of discomfort, we discontinued taping. Last week she mentioned it was getting a little sore with pressure again and this weekend at the end of her game she was in a higher level of pain than she had been in several weeks. 

Ugh! Will this ever go away and will she be able to be back playing regularly at her level of soccer? She's only 12 and the podiatrist doesn't do cortisone on children her age, which is fine. And, I don't want to resort to surgery. 

We are struggling with really knowing what her pain level is because she has a hard time determining when she has the "ok" kind of pain and when it's "time to pull back kind of pain". Her podiatrist told us/her that a low level discomfort is normal. 

Please help this mom who jumps to the conclusion that her child will never play soccer normally again! 

Dr Blake's comment:

     First of all, you are to be commended for the great and thoughtful course of action. Unfortunately, there can be many bumps along the way and you need to use the same common sense with each one of them. Children do have a hard time in general distinquishing good and bad pain, so typically parents must team with the coaches to pull the child when limping. I have found that bipartite sesamoids can fracture, but this does not sound like a fracture due to her good early return to soccer. This years advice though would be 100% spica taping while playing, removing any cleat under the sesamoid, making sure the orthotics have good arch support and great dancer's pads, and icing twice daily during the season. If you ever get an xray, please take some photos. Hope this helps some. Rich