Sesamoid Fracture in a Young Athlete: Email Advice

Dear Dr. Blake,

     I want to thank you for all of the time and love you have put into your blog. It is by far the most comprehensive and detailed source of sesamoid injuries that I have been able to find. I was wondering if I could ask a few questions about my daughter because I would like to know if we are on the right healing path.

Dr. Blake's comment: Thank you for your kind remarks. I will be happy to answer them in hopes of giving you some guidance. 

     First, to give you some background, my daughter is a 9-year-old soccer player. She was diagnosed over a year ago with Sever’s disease, and despite our efforts to cushion her heels, the pain was quite severe. However, she continued activity and playing soccer through the pain, and tended to compensate for the pain by running on her toes.

Dr. Blake's comment: I hope now you understand how bad limping is. A child may not be able to describe the pain and use good judgment on what not to do, so I have to tell parents and coaches that as soon as they see limping, the child has to be pulled from the game or practice. 

    Flash forward to 8 weeks ago, she woke up in the morning with a very sore big toe after a week of heavier than normal activity. After x-rays and a referral to an orthopedic surgeon, she was diagnosed with a stress fracture of the fibular (lateral) sesamoid. The doctor’s recommendation was to get her in more supportive shoes, Superfeet insoles, and rest (no running, jumping, barefoot walking). After a week or two of this, and scouring the internet for advice, we added dancer’s pads and toe taping to the regimen. Additionally, we have been having her supplement extra calcium, vitamin D, and magnesium. With all of these modifications, her pain level was down to a 1 by her judgment.
Dr. Blake's comment: I would have put her in a removable boot, but I am glad you got the pain to 0-2 range for healing. The issue now is to keep an active child in this for the next 3 months to guarantee good bone strength. With a stress fracture, there is no visible gap of the fragments, which is an MRI diagnosis. This is very hard, but possible, to diagnosis on x-ray. I hope we are talking about the same thing. 

     At her 4-week check-up, slight healing could be seen on the x-ray, however, her pain had not changed.

Dr. Blake's comment: You can not follow the progress on xray, which the healing shown lags up to 2 months from where it is. You can also not follow the progress on palpation, because the bone will remain sore to touch months after it has healed. I had a 16-year-old, who was back running 10 miles a day 5 days a week tell me the bone we still just as painful for another 18 months on palpation. You immobilize the pull of the toe bend, you off weight the area, for 3 months on average, and then you gradually increase activity again. During the 3 months, you work on both nerve hypersensitivity with nonpainful massage 2-3 times a day and inflammation part of the healing process with contrast bathing and icing. 

     The doctor’s advice was to continue as we were and come back in 4 more weeks. During the 7^th week, she noted a small improvement in pain. At the 8-week check-up, the fracture looked only very slightly better than at 4 weeks. The doctor’s advice was to continue for yet another 4 weeks or go non-weight-bearing in a hard cast. He recommended to just continue as we were as he is not a fan of casting a child in this case.

Dr. Blake's comment: So if you are following it by x-ray, you are going to be misled. Sounds like it is a fracture, although without an MRI it could be a bipartite sesamoid that is bruised. Your doctor sounds like he/she has good wisdom. What are you doing gauge the pain? Remember, palpation is not a useful tool. The improvement in swelling would be a good indicator. I think going the 3 months in the boot keeping the pain level to 0-2 is just fine. If she is walking in the boot for 2 weeks with a 0-2 pain level, she can start the 2-6 week course of weaning out of the boot into a shoe, orthotic, dancer's pad, spica taping, and cluffy wedge. The initial goal is to keep the pain between 0-2 and wean out of the boot. The goal is not to have it look better on x-ray or feel better when you push on it. 

So, given all of this information, I would like to ask a few questions:

1. How often is this injury seen in a child so young? I have read that the sesamoid bones ossify around this age, could that have something to do with her becoming symptomatic? Do children usually go on to complete healing, or are we looking at a lifetime of issues? Dr. Blake's comment: It is rare for kids this early, but I have found if they are wearing cleats with long spikes right under the sesamoid it can get beat up. Some people have really prominent first metatarsals plantarly (on the bottom of the foot) and are prone. Kids are just are vulnerable as adults to bone health issues, so evaluation of any dietary issues could lead to bone density issues. Therefore, it is possible for many reasons. As I am treating a patient, I like to look for 3 possible causes of any injury besides bad luck (called the Rule of 3). For sesamoids, this can be bone abnormalities, bone health issues, cleat placement or shoe bend issues, biomechanics of how she runs, etc. 
2. Since she is able to currently keep her pain level below a 1 as long as she is in her shoes, would you say that it is ok to keep her like that? Or would you recommend switching to a boot or cast? Dr. Blake's comment: I am sorry but I thought she was in a boot. Definitely stay away from the hard cast, so hard to rehab from. I would definitely spend 4-6 hours in a boot and orthotics for the next 6 weeks if she has not been wearing a boot. I would forget about more x-rays if you take a photo of any of the images seen them my way. I prefer an MRI if possible to make sure we are dealing with the correct diagnosis. I have had some patients where we thought fracture, only to have the MRI show soft tissue bruise or bursitis. 
3. I’ve read your advice for contrast bathing. Is this primarily recommended to help with pain and swelling (which she does not have), or will it also promote healing? Dr. Blake's comment: Yes, probably the best thing you can do if she is getting the right calcium and Vitamin D are daily contrast baths. It is a wonderful flush of the deep swelling that sits in the bone and makes it hurt longer than necessary. The deep swelling can actually cut off the circulation to the sesamoids and stop healing. So, contrast away!!
4. Our doctor said that he didn’t think a bone stimulator is recommended for a child her age, and also suggested that insurance would not pay for it. Do you think it is ok? How would I go about getting one, or access to one, without insurance? Dr. Blake's comment: Yes, exogen is for skeletally mature individuals 18 or over. Sorry, this not an option.
5. After having taken 8 weeks off already, what would be a reasonable time-frame to expect that she could be back on the soccer field? Dr. Blake's comment: The normal would be 3 months of some form of immobilization maintaining 0-2 pain, then 2-6 weeks weaning out of the boot maintaining 0-2, then a walk-run program of which she can do in her cleats building up to 30 minutes of straight running, then sport specific drills from the coach like cutting, pivoting, etc which usually is progressive in terms of the demands on the tissue. So, 3 months is the fastest from now. During this time, based on symptoms, she may need different cleats, different orthotics, better evaluation of her biomechanics,  getting an MRI, so you see what it takes to keep her in the 0-2 range. When you do it smart and progressive in terms of loads, you avoid re-flares which are so frustrating for everyone. Hope this helps some. Rich

Thank you very much for taking the time to read this and for answering my questions.

Sincerely,