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Tuesday, November 10, 2015

Sesamoid Injury in Ballet Dancer: Email Advice

Good afternoon, Dr. Blake,

I noticed you helpfully answered a question regarding a young dancer a couple of weeks ago, and I'm hoping you can shed some light on my daughter's situation, as well.

My daughter is a 16-year-old classical ballet dancer at the pre-professional level. She dances 5 days a week, between 3 and 6.5 hours a day (depending upon the day). About half of this dance time is done en pointe. She is hypermobile with flexible pes planus (diagnosed around age 11 by a pediatric orthopedist), and has developed very strong feet and high arches through dance.

About four weeks ago she developed mild pain beneath her big toe on one foot, but kept dancing because it wasn't bothersome to her. One evening it suddenly reached a level where she could not dance on it. Through visits with a PT and to a orthopedist/foot & ankle specialist who treats dancers, and after a normal Xray, she was diagnosed with sesamoiditis. We placed a dancer's pad on an orthotic within a solid running shoe. After two weeks off and ultrasound therapy, she was beginning to make great progress--no pointe work and no jumping, but a gradual easing back in to barre and center exercises.

Last week she had a couple of great nights and was pain-free (still no pointe or jumping), taking things carefully during her classes. She was instructed that she could dance if the pain was below a 3, and she followed those instructions. That night she iced and elevated her foot preventively but did not have pain.

Apparently that was too much. The next morning, she woke up and had visible swelling and pain upon walking. It was like she was back to square one, or even square zero. We went back to the orthopedist, who confirmed her diagnosis but ordered an MRI just to be safe. She is now on crutches until she can walk without pain and will have the MRI at the end of the week.

Though I know it's impossible to predict the healing process, I wonder if you can recommend any practices or products beyond PT and ultrasound that might promote healing. She has numerous performances coming up, which we realize she will probably miss, and very important auditions for summer and year-round programs in January. Needless to say this is causing her a great deal of anxiety.

She has never been injured before, and there was no one event or accident (such as a hard landing) that triggered this pain. The only contributing factor may be walking about 2 miles from school after a switch in shoes--she had been wearing Birkenstocks in the warm weather, then switched to a less-supportive boot (with no orthotic, yipes!) about a week before the pain began.

Thank you for any light you can shed on this frustrating condition, and for your blog. I'm glad I found you!

Dr Blake's response:
     I am happy to help. It sounds like you did everything right. Definitely from this point on when dancing she should have dancer's pads and some medial Hapad arch support, and when not dancing orthotics with dancer's pads. Keeping her dance shoes as stiff in the arch also helps. She should be icing for 10 minutes twice daily, and do the full 20 minute contrast bath as a deep flush every evening. Glad the xrays were negative, so we will see what the MRI shows. I would rather she in a walking boot with orthotic/dancer's pad, than non weightbearing, since no weight bearing always increases the swelling. She should be massaging the tissue 3 times daily to de sensitize the nerves that can get real protective, also adding to the pain. And, there is always more of that with the first injury a dancer's has, especially one that may interfere with career goals. Use arnica, biofreeze, etc to help with the massage. Of course, any bone injury needs bone strength, so make sure dietary or supplement she gets 1500 mg calcium and 1000 units of Vit D. Have her continue to do floor and barre exercises, figuring out what she can or can not do this week, testing weekly if she can add to the routines. Center work can do be done when she can walk comfortably and initially avoid jumps. Releves can be so much more stressful, than actual pointe work, thus barre workouts can help us know what she can or can not do. Since there can be a stress fracture, avoid ultrasound treatments with a passion right now. Hope this helps some. Rich


  1. I can't thank you enough for your quick reply and exact instructions, Dr. Blake! What a tremendous service you are providing here. We live in a rural area and are limited in the providers we can choose--I believe we have found a good one somewhat locally, but it is always nice to get another trusted opinion.

    As for those crutches...right now my daughter says her foot feels like a balloon! As a first step we will work hard to get her weight-bearing without pain.

    We did read your post on contrast baths, and we will start them along with massage tonight. She tried arnica this morning and we just got our hands on Penetrex, which her PT used and seemed to provide some relief.

    No one else has indicated the importance of calcium and Vitamin D for healing, and it is obviously so important. We will be adding that right away.

    I have two additional questions at the moment:

    In other posts you recommended spica taping of the big toe in some cases of sesamoid pain. Your video on this made it look very easy. Do you think that and/or other taping would be something worth trying? If yes, when/how often should we do it?

    Also, would a completely flat-bottomed shoe, like a Converse sneaker with orthotic and dancer's pad, be preferable to the running shoe with orthotic and dancer's pad that she is currently using?

    You are correct that releves cause her the most discomfort. The roll-through sensation was her biggest complaint, followed by landing after a jump. Pointe was actually not an issue for her once she was up, interestingly enough, probably because the shoe itself is a bit like a cast.

    I will keep you posted on the results of the MRI when they are available. The orthopedist is optimistic that she is only dealing with sesamoiditis and not a stress fracture, so we will keep our fingers crossed. In the meantime, no dancing until the walking is under control.

    Many, many thanks to you!

    1. Spica taping would be non ballet activities if you can not get the pain level between 0-2 otherwise. Definitely the idea of zero heel drop shoes should help, but sometimes you lose cushion. A little trial and error is needed. You can try the New Balance 928 or Hoka One One line of shoes for their rocker effect that limits joint motion. Rich

  2. Hello again, Dr. Blake. We have the MRI results (non-contrast, sagittal axial images and coronal images were obtained with both T1 and T2 weighting)--no fracture seen:

    "There is significant induration along the plantar aspect of the 1st digit's flexor digitorum tendons. The tendons appear intact. The marrow signal at the level of the 1st metatarsal tarsal sesamoid is abnormal. It appears very dark and sclerotic. There is no edema on the sagittal inversion recovery sequences. This dark signal can be seen in sclerosis or avascular necrosis. This appears to be a chronic process as the inversion recovery sequences do not demonstrate edematous marrow. The induration superficial to the flexor tendons is very discrete. It measures approximately 1 cm in dimension.

    1. Occult fracture not seen.
    2. Normal alignment of the metatarsal phalangeal joint.
    3. Induration superficial to the flexor digitorum tendons along the plantar aspect of the foot at the level of the 1st metatarsal phalangeal sesamoid.
    4. The sesamoid does not appear to be malaligned or abnormal in shape. However, it has very dark signal on T1 suggesting sclerosis. I do not see evidence for edema on the T2 image or evidence to suggest a sesamoid fracture.

    The orthopedist explained this to us as consistent with the symptoms described (sesamoiditis and some tendonitis). The joint looks good. There is fluid around the medial sesamoid and it extends a bit into the flexor halisis brevis tendon. There is sclerosis without facture.

    My daughter has been instructed to rest, conservatively work back into barre work as tolerated that does not bear weight on the affected foot (no releves or pointe), and to return for evaluation in three weeks. She was also prescribed a topical inflammatory creme that also has a mild muscle relaxer in it, to be used two times a day (compounded, p-cycloben 2% ketop 10%). We discussed not using it prior to dance class in the event it might mask pain.

    After 2 full weeks of not dancing, she is still experiencing some discomfort while walking but not more than a 2 pain level. She has been swimming and feels like this works her foot muscles well. Sometimes she describes the feeling in her foot as more fatigue than pain. Her PT has slowed down due to the holiday, but we hope that after she can continue 2x/week because ultrasound, in particular, seems very helpful. She is icing, massaging and contrast bathing.

    In light of these results, is there anything else she should be watching out for? She is committed to a slow and safe recovery. Your thoughts have been tremendously helpful and we are so thankful for your interest and expertise. Have a good weekend!

    1. I am so happy for the great MRI. These are common findings when an area is chronically stressed due to an activity, but rules out fracture. The swelling seen continues to need the icing and contrast baths. Make sure she is using dancer's pad and Hapad arch pads.

  3. Thank you so much, Dr. Blake. She will keep up with the icing and contrast bathing. The hardest part now is being patient and not pushing too hard, too fast. Have a great day!

  4. Back with an update and some questions--thank you for your patience and support, and for reading this long comment!

    We are about 8 weeks since the start of symptoms and my daughter is still at around a pain level 2 when walking. She has been to two ballet classes, barre only/no releves, and icing and massaging afterward. This was tiring but did not increase the pain noticably. At home she is doing PT exercises, floor barre, icing, massage and contrast bathing in the evening. The PT says there is still swelling in the mid-foot, in the tendon, but my daughter says she does not have any symptoms there unless the therapist pokes around at it. (It also is not visibly swollen.)

    She has had some inconsistent treatment from her dance PT which is making us question whether we have the right therapist. In addition to ultrasound, the therapist has done something different with her at every visit--exercises, Pilates, turnout boards, etc. There doesn't seem to be any building on skills, and there hasn't been any real progress with pain management--in fact, at her last visit the PT had her remove the pads from her ballet shoes and releve repeatedly, despite both of those things being against doctor's orders and my daughter's complaints of pain. Then she recommended pool therapy, and getting a prescription for a different anti-inflammatory cream that would require her not to dance or walk for a week, but did not say specifically why.

    We are holding on PT until after the next orthopedist visit on 12/11 because of this, and she will continue her home exercises and reduced ballet schedule through then.

    I'm wondering what we should and shouldn't be looking out for as my daughter continues to heal from this injury. Are there treatments that would be considered too aggressive at this point, such as steroid anti-inflammatory creams or injections? Are there any red flags we should watch for in terms of treatment suggestions or approaches?

    I feel like your advice, and being patient with this slow-to-heal injury, has been the most helpful so far. My daughter knows her body and has been working within its limits well. With this recent PT experience, I am feeling a bit wary of taking her back to the same therapist, or to consider more aggressive treatment, and we don't yet know the orthopedist well enough to determine if she is conservative in her treatment of young dancers.

    I greatly appreciate your thoughts!

    1. Thanks for your followup. I am sorry for the inconsistencies with PT, which is so crucial for her. It is wonderful she is in the 0-2 pain range, which will remain for another 4 months, with each day her injury getting better and stronger. The plan should not do anything that increases pain over this (thus I do not believe in no pain no gain in this instance). She will have an occasional sharp pain, but it should resolve within in hour. Daily work on anti-inflammatory, strength, and mobility. All in all your program sounds fine, as long as you guys direct it!!!Nothing should be recommended now that she has to lower her function, as it should be gradually increased. The dance shoes should be loaded with dancer's pads and arch support, as well as her day to day shoes. Keep me in the loop. Rich

  5. Hi, Dr. Blake. Another update: We saw the orthopedist again last Friday, and the doctor didn't like that the inflammation was still not going down, though my daughter has seen some very slow and small improvement. She is now in an aircast boot, fitted with her orthotic/arch support and dancer's pad, for three weeks. We will go back again on December 30.

    The orthopedist did hesitantly bring up the idea of a cortisone shot, feeling like that may be the thing to break through the inflammation, but we declined and opted to wait things out a while more. I have heard conflicting reports about cortisone.

    PT is continuing with a new therapist, who did a gait analysis and saw that she is favoring the outside of her affected foot, as well as walking with her tibia turned slightly out. The PT thinks that work on evening out hip range of motion will also help with foot mechanics. They worked on hip strengthening and stretching exercises, did foot massage, and the PT also performed ultrasound as well as LLLT on the ball of the foot. She is continuing with icing, contrast baths, massage, etc. ...

    1. With a negative MRI, the use of a short acting, not long acting cortisone shot is okay. Typically, if the therapists can do EGS and Ice or Contrasts for 4 times in 2 weeks, you get the same results. Rich

  6. Thank you again, Dr. Blake. We have switched doctors and have a new PT, as well. It appears we are finally on the right track and that this is getting better, with orthotics added into the equation. I am very grateful for your expertise and hope that my daughter's experience will help some of your other blog readers. Happy new year!

    1. Hi Dustbunny, My name is Natanya, I have symptoms similar to your daughters. I'm also a dancer. I wanted to check in and see how your daughter's recovery is going, and as about what worked and what didn't work. Thanks!

  7. Why are ultrasounds bad for stress fractures?

  8. Dear dr blakes, is ultrasound therapy good for fracture sesamoid bone ?


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.