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Tuesday, November 10, 2015
Sesamoid Injury in Ballet Dancer: Email Advice
I noticed you helpfully answered a question regarding a young dancer a couple of weeks ago, and I'm hoping you can shed some light on my daughter's situation, as well.
My daughter is a 16-year-old classical ballet dancer at the pre-professional level. She dances 5 days a week, between 3 and 6.5 hours a day (depending upon the day). About half of this dance time is done en pointe. She is hypermobile with flexible pes planus (diagnosed around age 11 by a pediatric orthopedist), and has developed very strong feet and high arches through dance.
About four weeks ago she developed mild pain beneath her big toe on one foot, but kept dancing because it wasn't bothersome to her. One evening it suddenly reached a level where she could not dance on it. Through visits with a PT and to a orthopedist/foot & ankle specialist who treats dancers, and after a normal Xray, she was diagnosed with sesamoiditis. We placed a dancer's pad on an orthotic within a solid running shoe. After two weeks off and ultrasound therapy, she was beginning to make great progress--no pointe work and no jumping, but a gradual easing back in to barre and center exercises.
Last week she had a couple of great nights and was pain-free (still no pointe or jumping), taking things carefully during her classes. She was instructed that she could dance if the pain was below a 3, and she followed those instructions. That night she iced and elevated her foot preventively but did not have pain.
Apparently that was too much. The next morning, she woke up and had visible swelling and pain upon walking. It was like she was back to square one, or even square zero. We went back to the orthopedist, who confirmed her diagnosis but ordered an MRI just to be safe. She is now on crutches until she can walk without pain and will have the MRI at the end of the week.
Though I know it's impossible to predict the healing process, I wonder if you can recommend any practices or products beyond PT and ultrasound that might promote healing. She has numerous performances coming up, which we realize she will probably miss, and very important auditions for summer and year-round programs in January. Needless to say this is causing her a great deal of anxiety.
She has never been injured before, and there was no one event or accident (such as a hard landing) that triggered this pain. The only contributing factor may be walking about 2 miles from school after a switch in shoes--she had been wearing Birkenstocks in the warm weather, then switched to a less-supportive boot (with no orthotic, yipes!) about a week before the pain began.
Thank you for any light you can shed on this frustrating condition, and for your blog. I'm glad I found you!
Dr Blake's response:
I am happy to help. It sounds like you did everything right. Definitely from this point on when dancing she should have dancer's pads and some medial Hapad arch support, and when not dancing orthotics with dancer's pads. Keeping her dance shoes as stiff in the arch also helps. She should be icing for 10 minutes twice daily, and do the full 20 minute contrast bath as a deep flush every evening. Glad the xrays were negative, so we will see what the MRI shows. I would rather she in a walking boot with orthotic/dancer's pad, than non weightbearing, since no weight bearing always increases the swelling. She should be massaging the tissue 3 times daily to de sensitize the nerves that can get real protective, also adding to the pain. And, there is always more of that with the first injury a dancer's has, especially one that may interfere with career goals. Use arnica, biofreeze, etc to help with the massage. Of course, any bone injury needs bone strength, so make sure dietary or supplement she gets 1500 mg calcium and 1000 units of Vit D. Have her continue to do floor and barre exercises, figuring out what she can or can not do this week, testing weekly if she can add to the routines. Center work can do be done when she can walk comfortably and initially avoid jumps. Releves can be so much more stressful, than actual pointe work, thus barre workouts can help us know what she can or can not do. Since there can be a stress fracture, avoid ultrasound treatments with a passion right now. Hope this helps some. Rich