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Friday, July 15, 2016

Sesamoid Injury: Email Advice

Dear Dr. Blake,

     Last July I was dancing in a regional production of Hello Dolly.  I began experiencing pain in the ball of my foot and up my big toe but didn't really think much of it because I was dancing long days in heels and was used to some discomfort. 

     The pain got worse and worse until I could barely walk after the shows.  I took a week off from dance after the run of the show was over and felt completely fine.  I went back to dance and felt good after my first class back but after my second I was experiencing the same pain.  I went to a doctor who gave me an X-ray that showed I have partial sesamoids. 
Dr Blake's comment: Partial sesamoids is a name given to the sesamoids when the condition is considered congenital, not traumatic. 

      She thought I maybe had fractured one of the bones and put me in a boot for a month.  I tried to start dancing again after that month and experienced more pain.
Dr Blake's comment: I tend to see that if a boot is needed, 3 months is the key unfortunately. We all think we will be the exception. 

      I went to a podiatrist who made me orthotics and told me to get an MRI.  He told me dancing wouldn't further damage it, so I began dancing at a lower level of intensity.  I went to see a doctor to give me an MRI, and he said that his advice would be the same regardless and just told me to take five months off from dance.  I went to a different podiatrist who told me to "light up the area" before the MRI to be sure that the sesamoid was causing the problem.  He suggested that the day before the MRI I aggravate the area, so I ran around my block a few times and subsequently felt a lot of pain.  I brought my MRI to a dance doctor in NYC who suggested I get a PRP injection at NYU.  I went to NYU and they gave me an ultrasound which showed I did not need a PRP injection, but they said that my fracture was very bad and very active. 
Dr Blake's comment: So, you have a fracture, and your career depends on it. I love Hello Dolly BTW and my son played Patrick in a local production. I know it does not help you. Fractures need prolonged immobilization with the boot with dancer's padding, bone stimulator for 9 months,  contrasts and icing combinations, spica taping, dancer's padding, orthotics with dancer's padding, dietary counseling with calcium and Vit D intake considerations, etc.

     I was then put on crutches for three weeks.  I saw a podiatrist in NYC who specializes in dancers and he said that I should stay on crutches for another four weeks and gave me a bone stim machine.  I went from the crutches to a boot to new orthotics.  I then started experiencing a very mild amount of pain after walking long distances.  I got another MRI  (after stopping the bone stim for three weeks) which showed no difference.  I have been told to try dancing and seeing if I have pain, and if I do to consider surgery.  
Dr Blake's comment: Professional athletes do have surgery more often than us mere mortals, due to the loss of income. But, sesamoid removal is a potentially career changing surgery. For the patients who can afford to wait, a careful 3 month immobilization period with bone stimulation, followed by a 3-6 month restrengthening and return to moderate dance phase, and finally full activity. I would be happy to look at your MRIs for an opinion. My address to mail is Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

     I have also been told that I shouldn't ever consider taking out the bone.  I really feel like I am at a complete loss with very little direction as to what to do next.
Dr Blake's comment: Now that is baloney, or salami, or swiss cheese. Patients do well post sesamoid removal. And, unfortunately, when your care is not great, you have a higher chance of needing surgery. You only have a 10% chance that the surgery, when all is said and done will effect your career. Even, though 10% is high, it is considered wonderful in surgical odds. When I have a patient who needs sesamoid surgery, I wish I could have avoided it, but I never feel like it will ruin their life. It is a highly successful surgery. 

     I am not sure if some pain is normal when getting back to dance or how to gauge whether it has healed.  I have one doctor telling me it has to be healed because I experience very little walking pain and have really exhausted my options.  My other doctor seems to think it hasn't and wants to follow the MRI.  I am 20 and feel like I am watching my dance career slip away.  I need to get back to dancing as soon as possible but am so scared to further delay the healing process.
Dr Blake's comment: I like the first doc. Yes, continue the bone stim for 9 full months, continue to keep your walking and dancing levels at a 0-2 pain level, learn to spica tape, learn to maximize your own dancer's padding in all shoes. Avoid barefoot, as you increase activity keep the pain at 2 or lower. Look at your Vit D levels, your calcium intake, your bone health and diet. Get bone density test if there are questions. Send me MRIs if you need some advice. I hope this helps. I hope you dance in San Francisco and I can watch you. My wife and I would love it. Good luck . Rich

Thank you,

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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.