Sesamoid Fracture Advice

Dr. Blake's comment: The patient's mother kindly sent the MRI CD for me to review which I did not until 6/29/2020.

Hello again Dr. Blake,

Thank you for reviewing L's MRI.  Here is a recap of my initial email with updated/new questions.  We look forward to hearing from you and are very thankful for your time and expertise. 

History:

L is a competitive varsity cross country and track athlete with her high school.   In February of this year she sustained a left metatarsal stress reaction (diagnosed via MRI) during track and field training.  She was immobilized for 8 weeks in a CAM boot, sat out the track season, received PT and did aqua jogging and swimming to maintain cardio fitness.  She had a  full blood panel and everything was WNL. Vitamin D was WNL, but in the lower range (we  live in South Florida and she gets plenty of sun on a daily basis). She supplements now with Vit D.   She is a very healthy eater, healthy weight and has regular menses. After a slow progression to return to running over the course of months she has been pain free in the left foot and doing summer training with her cross country team.  She has always run in HOKA Cliftons, but does rotate with Mizuno Wave Rider and Brooks Adrenaline during cross training.  She currently uses the customizable NB2400 (by Aetrex) shoe inserts in her left shoe.  
Dr. Blake's comment: I love the routine change in shoes to vary the stresses.

On June 11th after a practice she complained of R foot pain in the big toe region.  Due to her previous injury, we did not waste time diagnosing and the next day visited her foot and ankle specialist and had an MRI of the right foot the same day . They placed L in a CAM boot to be worn at all times until her follow up July 22nd (approx 6-7weeks post injury).  She has started Exogen bone stimulator 1x day x 20 mins, has had 2 out of 6 scheduled ESWT treatments , and has begun 2x week acupuncture.    She does not complain of any pain. 
Dr. Blake's comment: I would have to see what the literature says about ESWT for acute fractures. Please ask the doctor if there is anything for us to read.

1. How long would you recommend she remain in the boot? 
Dr. Blake's comment: My general rule is 3 months, however at 2 months you can begin to gradually wean out of the boot into bike shoes with embedded cleats or Hoka's with the rocker sole. You have to maintain the 0-2 pain level. 

2. Do you allow patients to remove the boot for gentle ROM of the ankle (the boot is driving her crazy with c/o foot cramping) ?
Dr. Blake's comment: Yes, it is a removable boot for walking. She does not need to wear it when she is not walking. Many patients find that around the house they can walk flat footed in soft sandals and avoid the boot since they can avoid toe bend and still protect. 

3. When should foot strengthening be initiated?   and massage to desensitize?
Dr. Blake's comment: Foot Strengthening is now!! Massage is now!! The massage is best done by the patient since she can make sure that she is avoiding pain. Each massage should b 2 minutes with some massage oil or topical gel like mineral ice. The foot strengthening she should don is metatarsal doming, single leg balancing with a float for the big toe, double and single heel raises also with a float for the big toe joint. 

4. Do you recommend she incorporate a dancer pad (or similar sesamoid cut out)  in her CAM boot? should we add a cluffy wedge with this? 
Dr. Blake's comment: Depends on her pain level. You place pads in like dancer's or cluffy wedges if you need to get the pain to 0-2 within the boot.

5. She is wearing a Darco Toe alignment splint while in the boot.  Do you prefer spica taping over this?    Do you use spica tape and dancer pad at the same time?
Dr. Blake's comment: If the boot gives 0-2 pain, no need for anything else. If not, you have to see what works to drive the pain down. Typically, dancer's and spica taping are used in the next phase as she re-introduces her activities. She should be cross training with cycling, or swimming without pushing off, etc. Some patients can use the eliptical if they stay flat footed. 

6. When could she attempt pain free short bouts of WB for mineralization?  
Dr. Blake's comment: Typically, this is a weight bearing boot, even if you need to off weight with dancer's padding. Around the house, you typically need the boot off to do the contrast bathing and, as long as you do not bend the toe, and you have dancer's padding and overall cushioning in a slipper, you can meander around. Keep the pain low!! At 8 weeks, if the patient is doing great, symptoms are where they should be, you begin to spend more and more time in a Hoka shoe or other stable but cushioned shoe. You need your orthotics with dancer's padding made by then. 

7. At what week post injury do you recommend beginning Physical therapy?   Aqua jogging?   or Swimming?   (we would like her to get some kind of cardio exercise when safe to do so)
Dr. Blake's comment: Agua jogging in the deep end of the pool is now just not emphasizing the toe motion. Swimming also great without fins and without pushing off the wall. Cycling without cleats with the pedal on the arch, not ball of the foot. Eliptical with Hokas flatfooted is fine without using the arms. 

8. Do you have a preference regarding  HOKA Clifton's vs Bondi?
Dr. Blake's comment: No, but it seems that the Bondi is more stable. With Hokas, each shoe has a different rocker point. So, I would make the decision based on how she feels the bend protects the sesamoid. If they both feel the same, go with the one that feels like it has the most toe box area. You will need it for all the sesamoid protection. 

9. At what part of the recovery do you initiate getting fitted for custom orthotics?
Dr. Blake's comment: This should be done as soon as possible. You need to have a good supportive and protective orthotic device, which could take adjustments or re-dos, when she is trying to wean out of the boot at 8-12 weeks. 

10.Do you have any recommendations for a physician in the Sarasota/Bradenton Florida area?
Dr. Blake's comment: I trust Dr Brian Fullem (Clearwater) and Dr. Matthew Werd (Lakeland) and Gerald Cosentino (Tampa). You can call their offices for a closer referral. 

11. We have been advised to avoid any icing and/or contrast baths at this time while she receives the shock wave therapy. Would she still benefit from it 6 weeks from now? 
Dr. Blake's comment: Shockwave is meant to inflame, but help in the healing. I have no experience with it for sesamoids. Sorry. I assume that icing and contrasts are fine after that stops. 

12.  As this is her second fracture in less than one year, do you think we should request a bone density test for her?
Dr. Blake's comment: Our doctors have gotten bone densities at her age and use the same values as the 20 year olds for understanding of the bone density. It is a test if she has low Vitamin D levels repeatedly, if her eating habits are suspect, if her menses is irregular, or if she is slow at healing bone. Did everyone feel she healed the metatarsal fracture fine and in the normal time length? 

13. Are we missing anything?    The MRI report  references sesamoiditis, so does she have a double whammy or will the fracture treatment help with the sesamoiditis?
Dr. Blake's comment: Heal the fracture, heel the itis part with the icing and contrasts and protection. 

Running is a big part of L's life and we want the absolute best care for her. We would like to be aggressive with her treatment to prevent a more chronic problem, however I want it to be within safe guidelines.  Her team is her family and it is hard on her to be away from them for weeks as she heals. 

Thank you!  

Sincerely,

ps. on a side note, I should also mention that L was an idiopathic toe walker and as a toddler wore AFO's and spent years in PT.  She was a very difficult case to treat (we avoided surgery), and still has very tight calf muscles and poor dorsi flexion, which is more than likely pre-disposing her to her injuries.  Are you familiar with Aaaron Mattes and his stretching therapy?  He is in Sarasota and L was treated by him years ago for her toe walking.  His sessions are very costly, but if you are familiar with his techniques and feel it would benefit her, please let me know.  
Dr. Blake's comment: Tight achilles is a huge reason for athletic injuries to the front of the foot. You should do what you can to help stretch out the achilles and I will look at Aaron's work. On a ironical note, the tight achilles gives her power to do sports where you are up on your toes.