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Monday, September 26, 2016

Sesamoid Injury: Email Advice

Hi Dr Blake,

I found your blog about 6 months back and read through much of the guidance you have provided for healing sesamoids. It was very helpful in terms of level-setting us on how long this type of injury can take to heal.  My (now) 11 year old daughter was diagnosed approximately 1 year ago via an MRI with a stress fracture in her left foot tibial sesamoid. She wore a boot for 4 months, going to PT weekly for massage and some range of motion exercises. We purchased an Exogen in November and used it consistently for 4 months. In January she transitioned out of the boot into running shoes, with a carbon fiber plate under a Type-3 (High Arches) orthotic from FootScientific. A second MRI in February showed that the stress fracture was not healed ("no significant change as compared to the prior MRI"). The MRI also showed "multiple small ganglion cysts arising from the plantar aspect of the second and third TMT joints." So we waited...no PE, no sports, other than some swimming.
Dr Blake's comment: The bone stimulator definitely clouds the picture since it will increase the bone metabolism for healing, making the stress fracture bone reaction seem unchanged. So, as long as you can keep the pain level between 0-2 you try to increase activity gradually at this point. I typically love the bone stimulator for 6-9 months, well after someone is back to full activity. 

In May, an office xray at our Pediatric Ortho showed partial healing. Finally some good news! We added ART massage to our regime. Our ART has found a lot of tension and stress in her hip/lower back area and feels like this could be contributing to the inflammation and pain that she still has. She would typically be pain free for 2-3 days after seeing the ART. So, we were encouraged. (Btw, when the stress fracture occurred she had just gone through a big growth spurt and with a fairly tall muscular build, had lost a lot of range of motion in her feet due we think to tight muscles and Achilles not keeping pace with bone growth.) So she did summer swim team, I held my breath every time she went off the blocks and this went fine - no increase in pain. We dropped PT at this point since she was doing ART and swimming 3x/week.

July rolls around and we decide that with school and her soccer season approaching it was time to test the foot a little bit. She went to a 3.5 day indoor volleyball camp, but with the restriction of no jumping/low impact activity only. (At this age, there isn't a lot of 'volleying' that goes on anyway.) This went fine and she was encouraged. So a couple of weeks later she tried some soccer - a half day workshop at an indoor soccer facility. She came home in tears convinced that she had reinjured the foot. That was 2 weeks ago. My hope was that it was sore and maybe inflamed, but hopefully not injured. The pain has lessened, but still higher than prior to trying the soccer.
Dr Blake's comment: I am so sorry for this problem. She is definitely in the Return to Activity Phase, although flareups are common, and some need 4-7 days of return to boot occasionally. I hope you have been icing after each practice, at least once a day, continuing to do a daily flush of the bone swelling with contrast bathing (minimum 3 evenings a week), and maximizing dancer's padding and cluffy wedges in the shoes she is participating in sports. 

https://youtu.be/GG-mSjtSwj8


Adding to all of this - is that she regularly has pain on the tops of both feet at the base of her toes and in the right sesamoid as well as the left. Even during the May/June months when ART seemed to be helping, within a few days, she would have pain. Some days sesamoids, but more often on the tops of her feet. Her pain level is not high, she tolerates it and doesn't complain with regular activities unless she is on her feet for a long period. So, I'd say 2-3 levels.
Dr Blake's comment: This whole immobilization and body compensations process makes other areas hurt. This is why no limping is allowed in Return to Activity Phase. Also, this is why you ice and contrast bath, get some arch supports, and sometimes tape. You could try the contrasts and suppport the foot taping to see how that works.

https://youtu.be/41Or2rdpxbY


Prior to all this happening, she had a lot of ankle pain and we put her in a stabilizer running shoe which helped significantly with that pain. So this has been about a 2.5 year journey so far, trying to understand why at such a young age she has persistent ankle/foot pain and how to address. I kind of feel like her stride/gait may be completely out of whack after all this - she favors her feet in different ways on different days and that moves the pain around? But I have no real evidence of this - watching her stride there is nothing obvious to the untrained eye.
Dr Blake's comment: Tell her that it is the sesamoid pain we want to avoid, and protect with dancer's pads, and the other pain we need her to work through. Unless the pain is consistent, you almost have to ignore it. Her nervous system is on such high alert for any pain whatsoever, that pain is now magnified. Children always have a problem differentiating between good and bad pain, and in this scenario, any pain can seem bad, which triggers inflammation and compensatory gait and muscle activities. Some physical therapists are just wonderful in this world. 

We see our Dr. next week and should get a read on how the fracture looks. But I have had a hard time getting him to look at the big picture. I am considering a running expert, or maybe even a chiropractor at this point... We also have a prescription for a gait/running analysis from PT that we haven't done because she isn't supposed to run...
Dr Blake's comment: You are definitely thinking along the same lines as I, although I tend to work more with PTs knowledgeable in biomechanics. 

I know I crammed a lot of info into this note, but if you have any guidance on what to ask next, what to try, etc., it would help us greatly to have that input. Her soccer season started this week, but she has not gone. Sitting out PE again is really going to be hard for her as she starts middle school.
Dr Blake's comment: As long as she has some inserts and sesamoid padding to off weight the fracture, she should start on a walk run program. It takes a minimum of one month to get up to thirty minutes of running straight, but at this stage, it is better than an xray to tell us where she is at. I sure hope this helps. Rich

https://youtu.be/o8Iky7Dc_jY


Thank You!

And the patient response 7 weeks later.

Hi Dr. Blake, 

I'm following up on your August 6, blog post to my email. It has taken me a while to reply, partly because of the craziness of school starting, but also because things took a little bit of an unexpected turn with my daughter's recovery. At our 8/11 appointment, our Dr. was pleased with the xrays - he didn't go as far as to say the fracture was healed, but ordered custom orthotics and told us that if her pain levels were improved after several weeks of wearing them to start to gradually ramp her activity. She has high arches, so his objective was to take some of the pressure off the ball of her foot and base of her toes and add some extra support with a met pad (at least that is what I can make out in the prescription).

We had the orthotics made and she has had them for 1 month tomorrow. They have helped significantly with her pain, especially the pain she had been consistently having at the base of her 2-4th metatarsals. Some occasional pain in the sesamoids, but usually easily correlated to a day or activity where she "did more." So to me this is goodness and orthotics doing the job. So far, so good. She is doing PE at school daily, sitting out high impact activity and playing some volleyball 2x/week (no jumping).

In the meantime, our ART therapist had noticed tightness in her left hip and concern that those muscles weren't 'engaging.' Various range of motion tests he did also illustrated that her right hip did not have the same range of motion as the left. So we decided to see a chiropractor who my husband has used with success. Based on his xrays, her bottom four vertebrae are 40 degrees off center and her right hip is out of alignment. He wants to see her 2-3x/week for 6-8 weeks. Our ART is more of the opinion that this should be addressed muscularly vs. skeletal. She was in a boot for 4 months at a time when she was growing (wondering now if that was the best approach).
Dr. Blake's comment: The curve in the spine should be treated by an MD specializing in scoliosis. He/She will direct the right PT and chiro. 

Our Dr. also gave us a prescription for PT for 'Gait Training" and progression to running. I'm a little uncertain of the best next steps. I'm not a big fan of chiropractic care, and from what I've read its not often recommended for patients under 13. I'm planning to call our Pediatrician tomorrow and get the x-rays transferred to him for his opinion on the overall situation. My inclination is to start with PT, but things seem a lot more serious now that her back/hip are involved. Any guidance you might have is greatly appreciated!

Thanks!
Dawn

P.S. Wrt dances padding - do you still recommend it in the ortho? We haven't been using it since the orthotic was custom made to her foot and there truthfully isn't a lot of extra room in the shoe.

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  2. Hi, I'm so pleased to have found your blog and I'm wondering if you might give me some advice. I am looking for a second opinion on treatment for a fractured sesamoid (the one on the outside of my foot).

    Here's the story: I trained for a marathon all summer and the week before hit my pinky toe on the leg of the bed and broke it. I stopped running for 2 months to let it heal and then started back up a couple weeks ago. My foot felt good but I did have a little discomfort in the ball of my foot by my big toe and figured maybe I was overcompensating unintentionally and stressing it a little.

    Last Monday night I woke in the middle of the night to severe pain in the outside bottom of my foot when I flexed my toe. The next day I was limping a little and everyday the pain got worse and it was harder to walk. On Thursday night the pain was almost unbearable even when lying down. I went to my doctor and they did an xray and only saw the fracture in my toe. He perscribed me pain meds and suggested I ice it and rest it. I wasn't satisfied so I made an appt. with a podiatrist and saw him on Wednesdy. After telling him my story he thought it could be my slight bunion bothering me, but I insisted the pain was intense when I touched the area though I could walk better by then. He did a physical examination of my sesamoid bones (very painful!!) and looked at the xray and said I could have broken it.

    For treatment he said I should use insoles with a hole cut out to reduce pressure and try to rest my foot as much as possible, but he also said if I would have come in the day of or after he would have put me in crutches for 8 weeks. He said I was too far out from the injury for that to help now.

    After reading you blog I feel like you advise an aircast or some kind of non-wieght bearing treatment for the first 6-8 weeks. I'm just concerned that I should be doing something more than just using an insole with a cutout circle so this doesn't become a long term issue as I continue to walk on it. And of course I want to run again someday!

    What would you suggest? Thanks for listening.

    Tracy in Colorado

    ReplyDelete
    Replies
    1. Tracy, I will copy and paste and answer completely on my blog tomorrow as a new post. Rich

      Delete
  3. Good vibes. Everyday, all day.
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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.