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Saturday, June 22, 2013

Sesamoid Stress Fracture: Email Advice

Hi Dr Blake,

I am a 22year old British female 100m sprint hurdler and have represented my country internationally at various competitions both home and abroad. In September 2012 I switched my training group. 

The training load increased massively
to what I was normally use to and within 3months my testing results had improved greatly my sprint times had dropped by half a second and lifting in the gym had gone from an 75KG PB for clean to a 90KG PB. However, January 3rd 2013 I woke up and was unable to put any pressure through my foot, a week later I was put in an air cast and 2 weeks after that I was diagnosed with a stress fracture in my sesamoid bone.
I was in an air cast boot and crutches for 9weeks in total adapting my training and doing aqua jogging, upper body and abb circuits only. After 9weeks the doctors felt it was time to come out of the boot and start walking but continue with Aqua jogging and introduce Watt Bike sessions and progressing to jogging/low intensity running on the grass.

4weeks ago I had specific insoles designed to off load my sesamoids which have helped a lot and I'm also working closely with my podiatrist using a monitoring sheet to write down my pain scores each day after sessions and throughout the day.
After doing grass sessions my foot always reacts 2days afterwards reaching pains of 5-6 and settling again after a further 2days. On average I always have a constant pain of 2-4 and randomly will get sharp pains every now and then. On Sunday 9th June 2013 we decided to progress my training from the grass to the track but still at an intensity of 70% and 2 days afterwards my foot reached a pain of 8 with throbbing/ swelling and as of yesterday it has only really settled properly again.

I feel that I haven't really ever completely rested and given my foot chance to heal as the doctors have said its fine to do bike and pool sessions, and I just feel so confused as what is the right thing to do. I know that I do not want surgery on removing the sesamoids but I feel that I'm stuck and my foot isn't completely heeled and I fear that I'm not letting it has its always at a pain level 2-4. I'm not sure if the right thing to do now is have a complete month off it and don't do any training wise at tall and the only loading will be daily activities on it with my insoles in my trainers or if infact what I'm doing now isn't making it worse and is still helping the heeling process.

I asked a close family friend who is the Head Radiologist and a Consultant for Professional football players and he replied saying;

Hi, sorry to hear it has not settled yet . Have spoken to a couple of professional physios and they also think you can't do much more to let it settle down than you are already doing . Another scan will not help, if you are in pain then it has not heeled up yet. Also follow up scans can be very difficult to interpret, because the sesamoids will look very odd. The only option if conservative management doesn't work is surgical removal , which is seldom done or necessary. Maybe complete rest till Sept may be the best option, given that most activities produce pain. I suspect you have done an Internet search, which offers similar advice.
Good luck

After coming across your website in the early hours of this morning and reading your blogs and advice I decided to email you to get your opinion on what you suggest I do. The winter season starts in September and I want more than anything to be able to train almost pain free. Should I have a month off and see how it reacts, carry on with what I'm doing now or is there anything different I can do?

Please could you help me.

Dr Blake's comment:

     Thank you so very much for your email. I am sorry to hear about the stress fracture, and unfortunately, they can remain sore for months and months after they are healed and strong enough to run with. That is because of the bone remodeling that occurs for up to 1 year from the time of the complete healing. That bone remodeling leads to bone swelling which hurts. The patient and doctor and physio are always perplexed at how much healing has occurred during this time. 

     These are the essential things you can do for the next 3 month segment of time. Train with all the great strategies except barefoot running (non-orthotic) as much as possible. Bike, Bike, and Bike some more for great leg strength. Run with shoes that fit your orthotics and have them make a pair with more arch and more dancer's padding to see if that is better protection. Ice, Ice, and Ice some more. 10 minutes of ice pack while you do something else could be done 10 times a day, 3 minimum. I like at least 1 session of contrasts per day. You must get rid of the bone inflammation as best as possible, so that the pain you are experiences is fracture pain. Just this tends to bring the pain down 2 to 3 levels, so your 2-4 hopefully will become 0-2.

     Make sure that your Vit D3 and calcium are all great, and your diet healthy. If you are not a red meat eater, our clinic recommends two 4 ounce serving of red meat weekly. 

     If you have had an MRI, you really should wait for 6 months to get another to check healing. I am happy if you send me a copy of some of the images T2 weighted that look close to the ones on my other posts. I get an MRI to confirm the diagnosis, check if there is anything else wrong, and have a baseline if I need it in 6 months. 

     You definitely need to Listen to Your Body and create that pain free (0-2) environment for the next 3 months. Follow the advice above, learn to spica tape, run if you can (sounds like you were smart except for the barefoot part), and give me a monthly progress report. As you begin to run in spikes, remove the one directly under the sesamoid please.

     Sure hope this helps. Rich

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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.