Ballet Dancer with Sesamoid Injury

Hi Dr Blake,

     So happy to stumble upon this today.  My 10 year old daughter is a dancer and suffered a sesamoid fracture in april 2014.  Her foot was immobilized non weight bearing for about 3 months and used the exogen bone stimulator since.  She's using a carbon fiber foot bed in her athletic shoe...is transitioning back into dance... but, has started having pain again.  We saw the MD this week and he is suggesting another week of immobilization before attempting to "transition" back into dance.  I'm looking for suggestions on how to make this transition. 

 Thanks for your time!
  Libby (name changed)

Dr Blake's response:

     Thank you so very much for the email. I love working with ballet dancers, and hope some of my thoughts are helpful. The key points to your rehabilitation at this point assuming the fracture has healed (and it should of), but can remain sensitive with bone remodeling for the next 6-9 months. 

1. Daily 10 minute ice pack twice and full contrast bath for 20 minutes each evening for deep joint and bone swelling flush. Non weight bearing rehab especially makes the swelling sit into the tissues longer, than even partial weight bearing.
2. Deal with the severe weakness which sets in with this amount of immobilization with a pilates based physical therapy program of the core and lower extremity. Pilates is the best for this, but when not available, physical therapy is crucial. 
3. Ballet instructor's evaluation of technique (no rolling in of the arch) and corrections to keep the weight centered to slightly to the outside. It is crucial to avoid over turning out at the hips at this point which always pronates the arch more placing too much pressure on the sesamoid.
4. Leg strength with every other day pilates or stationary bike. 
5. Wearing shoes day to day that are supportive and pain free. This is when you have orthotic devices designed or at least some insert that off weights the area of the sesamoid. She needs to be walking up to 2 miles pain free daily to build strength in her bones that soften with this amount of rest/immobilization. Focus must be then on what is in the shoe to make this painless. The carbon graphite is used, like the boot, to walk more, but we need to get her off that for bend when possible.
6. She needs a dancer's pad in both ballet slippers, and perhaps arch support. Typically, the shoe stores that sell those shoes can help, but you can also get extra small Hapad longitudinal metatarsal arch pads of adhesive felt to self attach into the ballet slipper. Go to www.hapad.com.  The dancer's pads can be made of 1/8th adhesive felt ordered from www.mooremedical.com. Sorry you have to buy a lot, but you can donate to the ballet school when you do not need any more. You can find images of this in my blog. 
7. It is okay to go back and forth with the boot, even when you are starting ballet again. The boot may be what is worn at school, while you try to get the shoes and inserts correct.
8. Definitely, she should have been doing floor exercises all along, and perfect for now. She should start barre exercises for the next two weeks, but no single leg releve on the injured side until it seems like she is surviving the double sided releves. It is so much easier to releve with proper centered weight doing it with 2 sides initially. So, perhaps start with 5 minutes of tendu and plie and 2 minutes of double sided releve every other day. When she finds that level comfortable, increase each by 3 minutes every time she increases. Definitely twice per level is recommended. 
9. In summary, start floor and barre exercises now, work on day to day walking pain free, get to strengthening the foot, ankle, leg, knees, hips, and core. Use pilates based physical therapy if possible. Doing daily anti-inflammatory work. Work on technique issues so keep the foot centered, especially with turnout. Use the boot only if needed to allow more walking to build strength. Set benchmarks of what she can do today, and every other week check if function is improving. I hope all this helps in some way. Rich