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Saturday, July 9, 2016

Sesamoid Injury: Email Advice

Dr. Blake,
Thank you for taking the time to read through this email. I just started reading through your blog and have read all the sesamoid related posts over the last couple days trying to soak up as much information as possible. I have learned that I need to ice twice daily now and start contrast baths at night, but there are some things I'm worried about.

To preface I dance classical ballet as a hobby so my typical cross training is pilates and cardio. Last summer (June '15) while on vacation I wanted to lose some stubborn weight so I upped the cardio (plank jacks, burpees, jumping jacks, etc). I wasn't paying attention to the fact that most people wear shoes while doing these exercises and I prefer to be barefoot anyways so I didn't bother with shoes.

Jumping Jacks without shoes on a hard surface is a recipe for disaster

 I started to notice a stubborn pain in my left foot under the ball and a severe decrease in ROM. I paused all exercise that involved being on my feet and stuck to mat pilates only to heal. It seemed to get better though it was still very stiff. So I began a very typical dancer's routine for stretching and strengthening my feet with therabands and returned to more static plank exercises to see what I could handle.

Everything seemed fine until early September when I was doing plank jacks (still barefoot) and felt a very sharp pain in the ball of my foot.

This time it never healed. I had to pause dancing and the cardio exercises I liked and resume mat pilates. But the pain kept getting worse. In mid October I was so frustrated with how stiff it was that I pulled on my toe until something popped and resettled. The pain greatly reduced very quickly after that, but I really didn't give it much time to heal. At the end of October I went to a career fair and walked all day in heels until I was in tears. I had to stop exercising again for a few weeks and I started icing around the base of my toe after massaging it. Nothing was improving the range of motion but the pain was now down to a three most of the time (which was amazing to me).

In January I decided whatever was still wrong was chronic and started to dance again. It wasn't too hard to dance on my foot, but as a ballet dancer I have a high pain tolerance and really my pain was chronically around a 3 or 4. I started wearing sesamoid pads in my shoes and stayed in some ancient running shoes all the time except at dance as any other kind of shoe caused more pain.
Dr Blake's comment: Most dancers need to learn the difference between good and bad pain.

At the end of last semester I went to the doctor (finally) and got x-rays. The doctor referred me to the podiatrist to see if he could determine the source of the stiffness and pain. He determined sesamoiditis was most likely with a possible fracture. (When he went prodding around the area was "too" tender and he was concerned about the stiffness in the joint and he was also concerned about the general compressibility and flexibility of the foot) He wants me to start conservative with orthodics alone in my shoes (he actually placed dancer's pads in my shoes for me, but instructed me to experiment until I was pain free. It turns out I had them in wrong so they weren't helping). He wanted me to come back after walking around on the pads after two weeks, but my schedule has not allowed that and won't until mid August unfortunately.
Dr Blake's comment: You really need to spend some time in a removable boot with dancer's padding to float the sesamoid. This is Phase I of rehabilitation which you may need to be in a short or long time to the indefinite amount of healing of your injury. That would be guess work for everyone. 
Example of accommodative padding of 1/4 inch being used to off weight an area of pain. For this patient, the hole of course would be under the sesamoid.

 This next appointment was to be the one where we would plan an MRI and if the pain were still too much I would need a cast. I want to avoid a cast if possible but I've had no luck getting pain free walking. At a minimum my foot is very sore at the end of the day. I also have all sorts of strange feeling referred pain. For instance, when I try to test my range of motion I feel a sharp pain on top of my foot where my big toe joint meets the toe. For some reason this type of pain leaves me with the impulse to "break through" the block but instead I back off. Still my ROM is not improving and I'm worried I waited too long to get treatment and now the foot is ruined. I keep up with mat pilates but it hurts too much to do anything on my feet. I walk plenty for work anyways (~10,000 steps most days, I honestly wish I could rest it more).
Dr Blake's comment: There is 3 types of pain: mechanical from the injury, inflammatory from the body's attempt at healing, and neuropathic as the nerves become hypersensitive in trying to protect a chronically painful area. This neuropathic pain can end up being what takes so long to heal. Make sure all 3 of these pain sources are addressed in your upcoming treatment. I just learned about a new device called Quell that may help you. I am only beginning to study it. The website is 

I really like this doctor, he fractured his own sesamoid and healed it without surgery and he assured me that everything looks like I could heal too and dance again. He told me to be patient but it's hard. I hate feeling like I'm "sitting around doing nothing". I don't want to see him in mid August and end up stuck in a cast but I fear I'm not healing and maybe getting worse. What more can I do?
Thank you again.
Dr Blake's comment: Please review my latest video on sesamoid fractures and then add your comments to this post. Hope all this helps.

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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.