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Friday, September 2, 2016

Sesamoid Injury in a 14 year old Soccer Player

Good morning Dr Blake.  My 14-year-old daughter has had a foot injury with symptoms (swelling, pain and discoloration) since February 2016. She is a high-level soccer player that trains every day.

We went to her primary doctor on March 2016 and he said it as a sprain of her big toe so she rested it for about a month - RICE (actually she just trained less and modified her training schedule).

She continues to have pain and in April 2016  we went back to her Primary Doctor and got refer her to the first podiatrist, The first Podiatrist said in April that it was sesamoiditis and to rest more than she has been and recommended to look into orthotics and a boot on her next visit if symptoms continue and ordered an MRI.

Meanwhile, an MRI was requested but denied because this first podiatrist was not in my medical network

Now comes the second podiatrist. The second podiatrist agreed early on with the first podiatrist on my daughter having sesamoiditis and ordered a new set of xrays and told my daughter to RICE and prescribed Voltaren Gel.  The second podiatrist on the second visit and second set of  xrays  on  June 2016 indicated that she had an old fracture of her medial sesamoid bone.  Although the Xray report said it was not fractured but that it was bipartite. Our Podiatrist disagreed with the XRAY Report and put her on a boot for a fractured sesamoid.
Dr Blake's comment: I would have to agree with this podiatrist. At her age, you have to treat the worse case scenario, and so fracture protocol was started.

We are now approaching our third month (on September 6, 2016, next week) where she will be in her cam boot.

Meanwhile since my podiatrist does not feel the need for an MRI,  but my Primary doctor requested one on my request.
Dr Blake's comment: The podiatrist must have felt that it was a fracture, so let's treat it. I do however prefer an MRI even when convinced it is a fracture. I think the first MRI serves as a 6 month comparison even if you do not need it.

The MRI (taken 8-19-2016) which is attached indicated osteochronditis in her medial sesamoid and not a fracture. 
Dr Blake's comment: This does not look much different than a stress fracture, so it would be difficult to say. You still have to treat it like a fracture in my view.
Her podiatrist still does not agree with the recent MRI Report and strongly feels she does not have a bipartite sesamoid,  but instead is suffering from a slow healing medial sesamoid bone, which the podiatrist claims it is about 30% better of her fractured sesamoid based on her review of the last xray on August 19,  2016     

She has been in a CAM boot for almost three months with  no pain and very slight swelling.
Dr Blake's comment: There should be no reason for slow healing in a 14 year old. How is her bone overall? Is she getting her periods regularly? 3 months in a boot with no pain means we begin the weaning out process. The trick is to hold the pain level to 0-2, and first wean from boot to shoes with orthotics and dancer's pads, then start walk run program, then do drills specifically related to soccer, then participate in workouts at 80%, then be allowed to play. 
     If the doc feels 3 months boot has only given 30% healing, then there has to be a reason---poor bone, not obtaining 0-2 pain in the boot, not wearing the boot enough, not being prescribed bone stim, etc.

My questions are:

How long should she be in a boot? See above

When should she consider Orthotics? Now

How long until she sees improvement and how can we test her foot since she right now she has no pain and very slight swelling and no discoloration unlike early on with the injury. Although her improvement may be as a result of her having  no activity with her foot being in a CAM boot the  last three months.
Dr Blake's comment: From what you are saying, since bone healing can be internal, and the x rays lag 2 months behind the actual healing, I would start the weaning process. I would have to know why I am looking at 3 months in a boot with 30% healing. Something does not add up. 

Does a bone stimulator help with the Osteochronditis? 
Dr Blake's comment: That means inflammation of the bone/cartilage and is treated with a short term boot, orthotics and dancer's padding in all shoes, no barefoot, icing twice daily, and contrasts once daily. It gets better and better as the itis calms down, and the mechanical forces are changed with the padding, arch support, and temporary immobilization. 
  She is receiving a bone stimulator today August 29, 2016 for the fracture that the podiatrist claims she has.

Do you know of any doctors in the Pasadena, California area and any who would you recommend for orthotics?Dr Blake's comment: I love Dr Dan Altschuler or anyone his office recommends. 

What you recommend for treatment at this stage and future ? Above
Should she continue with the Voltaren Gel ? I think ice long term is safer.

Can I mail you the MRI? Yes, Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109 Keep me in the loop.

I am now trying to get another opinion of her XRAY and MRI ..... But that will take forever through my insurance.

The patient's father gave us feedback 15 months later: 12-14-17

Hi, DR.

Just want to give you an update on Briana Hernandez.  An MRI showed that the sesamoid fracture was present but   It never healed, but I tape her foot every day and use toe bunion strap/cast on her nightly.  We also did cold and hot treatment.

Although it never healed, she returned after a few months to play full contact soccer.  The reasons, by me doing the above the pain subsided.

Her accomplishments since:

El Salvador Women's National Soccer Team U17 - played in Panama in the U17 World Cup Qualifiers vs Honduras, Panama and Costa Rica
Is Currently on the LA Galaxy Girls Academy Team (highest level for girls Soccer)

She is back in full participation but continues to manage this injury every day.   As a 15-year-old and a sophomore, there are numerous Division One college coaches reaching out to her. I anticipate that within the next 60 days she will commit to a college that is division one with hopefully with a full scholarship.

Thank you

Guillermo and 15 years old Briana Hernandez

Dr Blake's comment: Congratulations. It may be a painless non-union, acting like a congenital bipartite. Hooray, the good guys win!! 


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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.