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Thursday, February 28, 2013

Sesamoid Fracture in Growing Child: Email Advice

Hello Dr. Blake,
I am writing today regarding my daughter, Tonya (name changed). She is 13 1/2 and has a right tibial sesamoid fracture. First let me say, I know our feet are important to all of us....Tonya is extra special because she is a dancer. Five days a week and hours a day. She does almost every kind of dance you can think of from ballet to hip hop.

 She has already been told she can not perform in her upcoming ballet, which is heartbreaking, but we will do whatever it takes to get her at her best. She has another dance recital coming up in May, as well as tryouts for the High School program directly following. She is hoping to be able to participate in both of these things.  She is not getting a great deal of hope from her doctor of healing. She was in a hard cast for 3 weeks and has now been in a soft removable cast (non-weightbearing) for 2 weeks.
Dr Blake's comment: Typically, sesamoid fractures take 3 months of immobilization (casts or removable boots as long as you are creating a pain free environment, following by 2 to 6 weeks of gradually weaning out of the boot, into orthotics and dancer's pads, and icing, with some physical therapy. Then 3 plus months of gradual return to activity. There can not be pressure due to upcoming performances, or the gradual process of healing has a chance to be rushed jeopardizing healing. Typically, 6 to 8 months after the immobilization is started, the dancer/athlete feels comfortable to return to competitive activities. And, this is just average, with some going alittle less time (5 months) and many going longer 12-13 months. I know this sounds like a long time, but complete healing of the fracture with her future ahead of her, has to be carefully guarded.
Her doctor has mentioned that this could be an activity changing injury.
Dr Blake's comment: This is rarely the case. So, why go to that discussion in these early stages? Remember, as tissue heals, there is a lot of swelling that collects in the area. The swelling is painful to walk on. Casts trap the swelling, and non weight bearing also does not allow the fluid to be pumped naturally out of the injured area. So, casts and non weight bearing are necessary evils in our fight, producing both good healing of injured tissue, and bad problems of swelling retention, muscle/tendon weakness, joint stiffness, nerve hyper-sensitivity. This is why the weaning process from the cast to no cast can be long (always too long). 

 We are doing all he suggests for her best chance of healing, but are looking for some more information.
Dr Blake's comment: So, I gauge you have 6-7 more weeks of immobilization. Hopefully, you can process to an removable boot eventually, so you can start the important anti-inflammatory part of icing twice daily and contrast bathing once day. Hopefully her diet is very well balanced with enough calcium. She should be getting 1500 mg Calcium daily in her diet/supplement, and 1000 units of Vit D unless she is out in the sun for a short time every day. I hope she has no history of eating problems, or on any diets. One of our MDs requires one serving of red meat daily with these bone injuries. Once in the removable, ask for advice on what she can strengthen, what to stretch, how to start balancing. I have a lot on my blog on this. But, it has to be pain free, what ever you do in this area. 

 Have you seen a teenager with this injury?
Dr Blake's comment: Yes, and they tend to heal just fine. Children have great bone metabolism and will heal things much quicker in general than an old geeser like me. Yet, children do not have a greatly developed nervous system. Pain can be much higher than it really is for some, and much lower than it really is for some. This makes the process of rehabilitation either slower than it needs (which I think is always okay) or much faster than it should (possibly dangerous). Parents affect the equation for the rehab specialist a lot. They must allow the process to go on without focus of upcoming events, possible scholarships, the emoitional heartbreak the child may have. The parents must be the voice of reason, of common sense. Talking to doctors, therapists, or reading this blog post, it must make sense to you. Your child must be protected and not harmed. There is a lot of weird advice out there. 

 What are her chances of healing?
Dr Blake's comment: 99.5% unless there is something else in the MRI that I do not know. A simple sesamoid fracture in a child, with all the time in the world to heal, good diet, good parental advice, heal these things very well. If they do not heal, something else is going on. 

 Do you have any added suggestions? She is taking calcium and a bone/joint health supplement daily. And of course the power of prayer is our biggest help. Is there anything more we can do? Her doctor has stated that surgery is not an option at her age.
Dr Blake's comment: No doctor wants to do surgery on a young child. Treating ballet dancers, I have done my share of surgeries on these fragile athletes, and it is scarey (if you have anything of a conscience). You are just in the Immobilization Phase of the Injury which will last for probabaly 12 weeks longer. The next phase is the Restrengthening Phase, which you can start somewhat when you are in the removable boot. All doctors use these at different times during these initial 3 months. This Phase goes on for 9-12 months, and is blended with the first phase and the last phase. The third phase, after you have successfully and painlessly weaned out of the removable boot, is the Return To Activity Phase. It should be slow, normally run by a physical therapist, and the pain can not get over 0-2 on a pain scale of 0-10. It will be important to read my post on "Good vs Bad Pain", and familiarize yourself with the pain scale.
Right now, we are scheduled to go back after 3 weeks in the soft cast. The doctor said he will take a look then and decide where to go from there. He did mention that when the day comes that she is "better", she will need 3-4 weeks of physical therapy.
We are looking for some more input and advice. Maybe you will just tell us to keep being patient. If so, we can and will.
Thank you for your time!
Dr Blake's comment: I sure hope you comments have been helpful. Read all my posts on Sesamoid Injuries, so you are aware of padding, taping, MRIs, etc, so you can help your daughter the best. Remember, Complete Healing is the most important, not when that occurs. Please leave that in God's Hands. 


  1. Hi Dr. Blake,

    After doing much research, I stumbled across your blog pertaining to sesamoid fractures. It has been the most informative information thus far to understand this injury and rehab it. My daughter, 11 years old, is a competitive gymnast and has been experiencing ball of the foot pain for a year now. We took her to a podiatrist about 3 months into this injury who found no fracture on x-ray and diagnosed it with sesamoiditis. Without taking time off, my daughter continued to train while experiencing pain and swelling. We just got an MRI this November which shows a nondisplaced transverse fracture to the medial sesamoid. The doctor also found a vertical fracture as well. We tried 6 weeks non-weighbearing in a cam walker and crutches but to no avail as it is still fractured with patchy bone marrow edema and diminutive in nature. We attempted contrast baths in this time frame to try to stimulate blood supply. She's taking Vit d supplements. The doctor pretty much said that since this has been going on for a year, he feels that more time in a boot will not heal this bone since the blood supply is compromised and the damage is already done. He pretty much sent us on our way with loss of hope and with no direction. He said if she experiences unbearable pain, the surgery is indicated. So she is presently in a sneaker, just looked into custom orthotics, and now going for a 3rd opinion. I necessarily dispute the diagnosis but I am not ready to "give up". No doctor speaks of rehabing this foot and that is what I like about your blog. Is there any hope of healing this bone and getting the blood supply to it? Bone stimulator is apparently contraindicated in children. Wanted to see if you feel accupuncture could help, laser therapy, physical therapy? Any advise or direction would be greatly appreciated. I have the MRI's and reports as well if that would be of any help. Thank you.

    Kim B.

  2. Kim, thanks for the comment here, and the email also. I just wrote about shockwave on the blog that you should look into at least. Please send me the MRIs on CD so I can review. Use my regular email to tell me if you sent it. The address is Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. Non weight bearing only makes the swelling collect. Try the Dr. Jills dancer's pads, get the 1/8th and 1/4 inch thicknesses to limit the pressure in all shoes. Please have her work on the parallel bars without dismounts so she can participate while this heels. Also biking with the pedal in the arch will keep some leg strength. Contrast baths are a must, twice daily, even if one time is only 10 minutes long. Have her massage it painlessly for 2-5 minutes for circulation and desensitization. Have her to do single leg balancing and other yoga poses standing on a pad that protects the sesamoids. Acupuncture is wonderful for circulation for sure. The bone stim can not be done until growth plates close 12-14 in girls. Get the good orthotics to off weight the sesamoid. Hope this helps some. Rich


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.