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Thursday, October 12, 2017

Sesamoid Injury in a Young Athlete: Email Advice

Hi Dr Blake –
I wanted to thank you so much for all the information on your amazing blog – it has been such an incredible resource as I have been trying to help my 13-year-old daughter (gymnast and ballet dancer) with a sesamoid injury (stress response versus stress fracture). 

I was wondering if you would have time to provide some input on her case.  We live in Denver, but would be happy to arrange payment to you for your usual office fee for you to read through my email and provide a general response to some of my questions.   Or I would be happy to make a generous donation to support your blog J.  I would even consider flying out with my daughter for a visit if this is something you would suggest after reading my email.   I myself have had foot pain for 18 months  - probably hallux limitus after reading your blog – and could benefit from a visit as well!.   We have an HMO type plan so it would not be covered but would be happy to pay out of pocket.  I can also send x-ray and MRI images on disc if you think this would be helpful. 
Dr Blake's comment: Thank you for your kind words. Please email the disc to me at Dr Rich Blake 900 Hyde Street, San Francisco, CA, 94109. It is a free service so no money is expected. 

I have tried to inform myself as much as possible by reading your blog prior to emailing.  Also – if feel this may help others I am also happy to have you post this on your blog (perhaps minus my full name)

     13-year-old very active female PMH significant for Severs Disease on and off since age 8.    Competitive gymnast (3 hours, 5 days/wk, year round) ballet dancer (on pointe since age 11, usually 1.5 hrs/wk year round and up to 3 -4 hrs/wk  week when rehearsing for a show) and swimmer (2 month summer season only, stops dance during this time).  

     She first noticed some “big toe pain” during gymnastics competition season in the winter of 2017.  Very mild, mostly with vault. Was able to dance en pointe in a spring ballet show in June 2017 without significant pain.  

     In late June 2017 developed progressive pain in balls of both feet while vaulting and doing vaulting drills (sprinting down the minimally padded vault runway in bare feet with ankle weights).   The pain was up to a 6-7 when vaulting, but had minimal pain on other events and only intermittent mild pain when not at the gym (though noticed pain with flip turns at swimming).  Did not dance at all during this time as she said she was sure pointe would hurt.  After a few weeks, she stopped vaulting/running but now had pain on other events at the gym, especially when going into releve on beam (high toe).  In mid-July took a week off gymnastics to see if the pain would resolve but continued to swim and started PT (massage, ROM, ultrasound).  The pain was mild and intermittent mainly just with flip turns at swimming but PT found a very tender spot on the ball of the right foot so I took her to see pediatric sports medicine specialist in late July 2017. 

Here a separate on the tibial sesamoid is noted. Bipartite? Fractured?

You can tell by the smoothness of the separation of pieces probably bipartite. However, you can fracture the loose junction of material between sesamoid pieces in a bipartite sesamoid. 

The right side also has this smoothness between the parts of the tibial or medial sesamoid. 

     On exam, she was tender over her medial sesamoids in both feet.    Bilateral foot Xrays read as “no foot fracture or dislocation visualized” (x-ray of the left attached below my signature, I cannot access images of the one of the right or the MRI but I have them on disc) but the sports medicine doctor noted she had bipartite medial sesamoids in both feet. He diagnosed her with sesamoiditis versus stress response and suggested bilateral walking boots or casts for 2-4 weeks.  We chose to start with the walking boot as we leaving for vacation that day.   I requested an MRI to try to differentiate between sesamoiditis and stress fracture which showed the following:
Dr Blake's comment: With the symptoms she had, and the bipartite nature, you have to put her on fracture protocol (treat the worse case scenario). Typically this is 3 months of restriction of toe bend and off-weighting plantarly. More later. 

     7/28/17 MRI right foot:  The medial bipartite sesamoid at the first metatarsophalangeal joint has abnormal signal and abnormal adjacent medial collateral ligament and superficial plantar soft tissue. In comparison with the medial bipartite sesamoid of the left foot in the same location, the appearance is asymmetric. The distraction of the fragments with edema and abnormal adjacent medial collateral ligament appearance is more concerning for the potential of fracture/chronic distraction stress injury upon the fragments rather than simply sesamoiditis.
Dr Blake's comment: What side is worse? I am confused since they are talking about the right foot, but then the left sesamoid? 

     7/28/17 MRI left foot:  Bipartite medial sesamoid at the left great toe with mild marrow edema representing sesamoiditis versus stress reaction.  No definite fracture line visible.
Dr Blake's comment: If I am reading this correct, the right is the worse by far. Is that the way it is clinically? 

     She wore bilateral boots for 1 week while we're on vacation with a reduction in pain.  Based on the MRI report he said he did not see fracture line to suggest stress fracture but that the bone was very inflamed and he suggested bilateral walking casts as the quickest way to get this to resolve.  The expectation was that this would give her the fastest healing and allow her to return to her activities ASAP. 
Dr Blake's comment: This is a doctor who wants her better, has compassion, but most sesamoid patients should be told 6 months from the get-go, and if it goes faster, great. This time frame is hard for docs to do. Even yours truly!!

    Bilateral permanent casts were placed when we got home from vacation on 8/2/17.  She had difficulty walking in the casts as they were up to her knees and had to use crutches and swing her feet so I would say she was also partially non-weight bearing during this time.  She remained in the casts for 2 weeks on the left and about 3.5 weeks on the right.  She had a lot of heel pain in the casts which were attributed to her Severs but her sesamoid pain seemed to decrease and perhaps even resolve completely during this time.  She wore a Hoka One One shoe (Bondi 5) on the left until the cast on the right came off and then wore the Hokas on both feet.   She continued to do upper body conditioning at the gym but no impact other than walking while in casts.
Dr Blake's comment: One of the reasons I hate permanent casts is that you can not really work on the inflammatory pain or the neuropathic pain which develops. You need to be icing, contrast baths, pain-free massaging, even pain-free PT at times. The casts ruin that option. Not to say it was not the right thing to do that this time. 

     After she came out of the casts she had severe heel pain on both sides attributed to a Severs flare.  It was so bad there was a concern about CRPS as she had some color changes and a bit of swelling around the Achilles insertion on the right but that seemed to resolve with ice, stretching and PT.  (After reading your blog I now realize the importance of making sure she was in a “pain-free environment” in regards to her sesamoids while transitioning out of the cats into her Hokas, but I did not realize this at the time -  I thought the casting had treated the sesamoid issue). 
Dr Blake's comment: So happy it did not develop into CRPS. Casts are notorious for that. 

    For the next 2 weeks, she did a lot of PT –balancing, hip strengthening, foot strengthening.  She would complain of pain in the ball of her foot between her first and second toe, but her PT said her sesamoids were not tender to the exam so he was not worried about this pain and thought it was tendon pain related to casting/disuse.  
Dr Blake's comment: Why am I not hearing about dancer's pads, with and without, arch supports, to protect the sesamoids? This is crucial. Even as the sesamoid heals, it can be very sensitive, so protection, massage, anti-inflammatory is crucial. 

    After 2 weeks of PT (around mid-September), she progressed back to some light activities  (cartwheels, walkovers, light jumping, yoga) initially in Nike frees and then in bare feet but always on padded surfaces or trampoline.  I also let her wear shoes other than the hokas a few times for a few hours…   Initially, she did ok but gradually her pain in the ball of her foot increased and the  “sesamoid pain” on the lateral side of her big toe returned in both feet.   She stopped all activity, went back to wearing the Hokas full time but the pain persisted. 
Dr Blake's comment: You have to get back to square 1 with the Immobilization Phase. Back into the removable boots to calm things down quickly. Up the anti-inflammation measures, and add the massage for the nerves.  

     We went back to the sports medicine doctor on 10/1/17.  We were told that this is a very difficult injury to heal and many kids have to give up their sport because of this injury.  He advised backing off on activity for several weeks to give it more time to heal but no other specific therapy.  He did not want to put her back in the boot because of how difficult a time she had coming out of the casts.  We left the visit under the impression that she would never dance or do gymnastics at a competitive level again.  It was a rough day and she was very sad and frustrated.
Dr Blake's comment: But, does not make hearing the news better, but you know better. The length of immobilization to create the healing environment needs to be longer. Hopefully, some healing has occurred, but this rush to get her well attitude is actually slowing her down. If she would be in my office now, back in the boot, design inserts to off weight, start more anti-inflammatory, plan on re-MRI in 3 months (but I have not seen the first one). 

     We sought a second opinion from an adult foot and ankle orthopaedic surgeon on 10/2/17.  He reviewed her MRIs and history.  On exam, he felt her medial sesamoids were tender but not exquisitely so (3-4/10 pain with pretty deep palpation).  He obtained additional foot x-rays (single view) which are attached below my signature and were read as follows:  

10/2/17 XRAY Left foot: Single sesamoid view demonstrates normal medial and lateral sesamoids with normal articulation between the sesamoids and the metatarsal head.  Soft tissues are unremarkable.
10?2/17 Xray Right foot: Single sesamoid view demonstrates subtle irregularity at the deep margin of the medial sesamoid without joint abnormality.  The lateral sesamoid is normal.

      He felt we had not given the sesamoids adequate time to heal and suggested 6 more weeks of no gymnastics/dance.  He also thought that some of her ball of foot pain in the middle of her forefoot  may be from atrophy/disuse after being in the casts and not doing enough PT (though I thought she had done a fair amount of PT…) He wanted her to continue wearing the Hokas and obtain a custom orthotic to “float the sesamoid”.  He also ordered an Exogen bone stimulator and suggested calcium and vitamin D supplements  (vitamin D level was normal).  He also wanted her to continue PT for hip, core, foot and ankle strengthening.   Currently, she says she is probably at a 3 in regards to her pain which is in both feet and mostly in the middle of her forefoot between her 1st and second toe  - rather than more medially over where I think it would be from the medial sesamoid.  She also says she notices it when she is at rest as well as when standing/walking.  After reading your blog, we are also going to start contrast baths and try spica taping her big toe and dancers pads to get her pain down until we receive the custom orthotics.   
Dr Blake's comment: This doctor could be my brother. Same thought process!! Create the 0-2 pain level with whatever it takes, and gradually add one activity at 70% force at a time (typically every two weeks you make a change). 

I have several questions I was hoping you could provide guidance on:

1)      At this point, can she continue in the Hokas or would she get better healing in bilateral walking boots?  (I am worried about the boot causing heel pain and muscle atrophy…)
Dr Blake's comment: She should be in whatever enables 0-2 pain for her present school and home activities. The Severs should have an insert like the red Sole which can go into the boot or Hokas. It may even need a gel heel cup on top of. 
2)      I am trying to understand her injury/imaging.   It sounds like sesamoiditis/stress response in the left medial sesamoid but more like a stress fracture (or at the least severe stress response) in the right medial sesamoid?  (Though the sports medicine doctor and orthopedist say they do not see a stress fracture on the right on the MRI…)
Dr Blake's comment: I would interpret a bone bruise left sesamoid and stress fracture right, but I know you are sending me the MRIs. Definitely, the right sounds worse, and will probably need more overall protection and take longer to heal. 
3)      How can you tell the difference between a bipartite medial sesamoid with a stress reaction/stress fracture versus an overtly fractured sesamoid (i.e. that was not bipartite before the injury)? This seems to be an important distinction for treatment duration and prognosis (let me know if you would like me to send her MRI).  If it helps, I have a bipartite medial sesamoid in both my feet on x-ray/MRI
Dr Blake's comment: First of all, bipartite sesamoids can get injuries like stress fractures. The x-rays look like normal bipartite sesamoids, so it is the MRI that is crucial. Again, you have to treat the worse case scenario until you get an MRI, assuming the symptoms warrant that (and she was totally disabled for what she wanted to do), and treat it as a stress fracture within the bipartite. I think bipartite sesamoids are more prone to injury than solid sesamoids, and their injuries cause much more disagreement about what to do. The junction between the pieces of a bipartite sesamoid should be smoother edges than a fractured sesamoid that started out whole. 
4)      I recall seeing on your blog that a bipartite sesamoid can fracture within the connective tissue bridge and that this type of fracture does not heal.  Is this something we need to consider in her and if so what is the prognosis/long-term consequences of this?
Dr Blake's comment: The connection between the parts of a bipartite sesamoid can be fibrous, cartilaginous, or osseus. I was probably talking about a fibrous bridge that torn, like an ankle ligament. These may not heal, but do not generate bone reactions on the MRI. I do not think she has this. Typically this sprain of the tissue between the sesamoid pieces, if immobilized, have nowhere to go, and should scar in. 
5)      Are there benefits/potential risks of “Shock Wave” therapy  i.e. Extracorporeal Pulse Activation Treatment (EPAT) for this condition?  Our orthopedist thought it could help but after reading the one post on your blog about this I have some concerns…
Dr Blake's comment: The idea behind this is to break apart the scar tissue and fragile bone cells, that seems to be not healing, and sort of re-breaking the bone. So, you are starting again, and the 3 months of immobilization should begin again. It will break down unneeded scar tissue, that may be getting in the may, but is worth starting afresh? 
6)      How much PT should she be doing right now– she says that theraband foot strengthening exercise cause “soreness” in her big toes so should she avoid these for a while? 
Dr Blake's comment: She could easily be in therapy 2 days a week, even 3, to work on all the body parts that are deconditioning. Definitely, I am not a believer in pushing through pain so I would not do what hurts today for one month, and then retry. A good therapist can set benchmarks for you of what to do and not do, and make changes as things change and symptoms improve. I know children are less discerning about pain levels, but they definitely know 0, 5, 7, and 10 in general. You want no limping, and as close to 0 as you can. Sharp pain that last for 3 seconds then goes away is fine. 
7)      Do you think she could (with time) get back to a high level of gymnastics or dance? She has been out since July and is devastated and feels like she is getting behind and wants to get back to both ASAP.  I know from reading your blog we need to be patient and not put a timeline on this but for her planning, it may be helpful to have a sense of what a timeline for a 13-year-old might look like, especially as many of the recommendations on your blog pertain to adults.   She has Nutcracker performance in Mid December though her teacher is willing to significantly modify her choreography and allow her to do it on flat rather than pointe and  without jumps or leaps.  Her gymnastics season begins in January and goes through April. 
Dr Blake's comment: There is nothing in this injury that normally does not make full recovery with full activity. So, that is my expectations. You seem so very knowledgeable, which is so wonderful, and you are asking the right questions so I will pose one to you: Why do you think she hurt herself in the first place? The answer may shed some light into how to rehab this injury better, and also how to prevent future injuries. I have some ideas but want to hear your thoughts. If any of my readers are going through this, what comments can you leave that may help in the future. 
8)      Finally –Do you have thoughts as to which activity (dance versus gymnastics) would be less likely to cause re-injury?   Her sports medicine doctor suggested that she would have to pick one activity, that she could not continue to do both. Gymnastics seems to be associated with higher impact (especially vault) and this was likely the trigger for her injury.  However, at least there is some padding at gym… and she could wear a light gymnastics slipper with a dancers pad for vault.  With dance, everything is done on a wood floor and pointe work puts a lot of stress on the foot. She had a bone age done recently and her growth plates are still open so after reading your blog I have some concerns about her going back to en pointe form that perspective.  She is a good swimmer and I guess that would be an option but her heart is in gymnastics and dance…
Dr Blake's comment: This is a question in my mind for the short term. We modify to allow activity, in order not stress the sesamoids too much initially. Monthly you add another task as she survives the first. This is the best way to succeed, but it is also the best way to avoid giving up on something she loves. Unless we find out that her bone density is poor (a good idea now is to ask her doc how you should assess her bone strength), she should completely heal. It is October in San Francisco, so this has only been going on 3 months. Nothing really. I remember a patient of mine broke her ankle and did it heal slowly. Initially, the docs thought it was tendinitis, so one year went by before I saw her and got an MRI diagnosing the fracture. The delay forced her to miss her Junior and Senior years in college of gymnastics. Except, the only thing she could practice since she remained on the team was the parallel bars with no dismounts. For about one and one-half years she practised and practised, but never dismounted. She healed the break finally, could work 3 months on the dismounts and won the league finals in parallel bars. She helped her team to the Championship. And, she would admit, that was her worse event in her Freshman year. Circumstances forced her to adapt. You want the physical therapist, doctor, and coaches of these sports, to know what is going on, and gradually add more and more and more. That is the fun part. If she plateaus at some point, more decisions are to be made. 
9)      After reading her case, do you think it would be helpful to arrange an in-person consultation with you?  Or is there someone you would recommend in Denver that could help guide her rehab?
Dr Blake's comment: I know Dr William OHalloran in Denver. Let me look at the MRIs you are sending. Sounds like the doc is spot on, need an orthotic maker there, need a good physical therapist (the gymnastics center or dance people may know someone). Yes, you can come here, but I need a week to make orthotics, etc. I am happy whatever seems right. Good luck!

Thank you in advance from the bottom of my heart for any assistance or advice you can provide.  Scroll down for images below my signature. 

Warm regards,

The patient's mom responses:

Dear Dr Blake –

Thank you so very much for your detailed and thoughtful response in regards to my daughter on your blog.  You are so kind and compassionate and I wish I had come across your blog sooner.  The disc with her MRI's should arrive today. 

I have tried to answer the questions you posted below.  Please feel free to post this on the blog along with images from her MRI if you feel they are informative to the community or let me know if you would like me to post this in the comments on the original post.  (When I tried to post directly the bold font did not show up and I think it is helpful…).    

1)      You are correct that it was the right sesamoid that was worse initially - both clinically and on the MRI.  Although currently her pain is intermittent and seems to be more on the left then the right.  She had only a total of about 3 weeks immobilization on the left and 5 weeks on the right with the initial boot/casting in August – far short of the 3 months you feel is ideal for a sesamoid stress fracture.   As far as her current pain level with everyday activities I would say she is definitely not a 5, but not a zero either – probably a 2-3 when she has pain which is not all the time.  Overall, she is doing better in regards to pain over the past week since she has stopped activity and started wearing the Hokas full time.  Her Severs heel pain is gone.  Perhaps after you look at her MRI you can provide thoughts about whether the Hokas will provide enough immobilization for healing at this point or whether a boot would provide a better healing environment.  And whether we are back to square one in terms of 3 months of immobilization from now, or whether she can get any “credit” for the initial immobilization period. 
Dr Blake's comment: I reviewed the MRIs showing injury to both tibial sesamoids, right greater than left. The right also has some first metatarsal involvement, which will make unprotected weight-bearing uncomfortable for quite a while. I know you will create the 0-2 pain level, and Hokas are fine if we can keep her protected with orthotics and dancer's padding. See if the rest of October, with the Hokas, she can stay in the 0-2 pain level. We have to wait until Jan 25th, 2018 to repeat the MRI and see how things are going, before we really feel comfortable about the healing. That will be 6 months post first MRI. That does not mean she is not going to be progressing, with each month doing more than she did the month before. Is she riding a bike or swimming now?

2)      We started the Exogen bone stimulator 2 days ago.  Can the bone stimulator impact pain levels in people with sesamoid injuries?  After using it on her right foot only the first night she had no pain in the right foot the next day.  The next night she used it on both feet and it seemed to cause some discomfort on the left (but not on the right – which was the more injured bone, but also the one that was immobilized longer). 
Dr Blake's comment: Bone stim increases circulation, and swelling can hurt. So, like contrast baths daily, the bone stim may be giving a good flush to the tissue. 

3)      You also mention anti-inflammatory several times in your response – are you talking about NSAIDS or ice/contrast baths?  I would be interested in your thoughts on the role of NSAIDS in sesamoid injuries?  I have avoided giving them to her as I do not want to mask pain, or potentially impair bone healing. 
Dr Blake's comment: Ice/contrast baths. No NSAIDS in bone injuries. 

4)      We also saw an orthotist yesterday.  I have a pair of custom orthotics with an arch support and cutout under the first metatarsal to offload the sesamoid that I do not wear as they never helped me (my problem is not in my sesamoids).  However, I brought them to the visit and the orthotist said they fit my daughters arch/feet perfectly!  My daughter tried them in her Hokas but did not like the way they felt.  The orthotist took them out, and next tried a firm approx 1/8 inch thick pad about 3 inches long and 1 inch wide glued to the bottom of her Hoka insole to limit the movement of her big toe.  That seemed to be more comfortable so she said to try it for a few days and if it worked she could build a custom orthotic with arch support using this strategy.  Is this right time to obtain a custom orthotic? 
Dr Blake's comment: Yes, a lot of experimentation may be needed. It is important to note that dancer's pads off weight but allows motion. The type of insert you mentioned immobilizes the joint and works like a little cast for the toe. It is not to be used when the gait gets better and push-off improves. 

5)      As far as WHY she had this injury – my first instinct is that she has a bipartite sesamoid which you mention is more susceptible to injury coupled with doing sprints on the vault runway in bare feet with ankle weights which placed an incredibly high load on the sesamoid bones.  This may alone have been enough to cause the injury, but I do think her long history of Severs heel pain may have played a role as well in that 1) she learned to train through foot pain and 2) she may have learned to run, tumble, and land in a manner which placed less impact on her heel (to avoid pain) and thus more impact on her forefoot?  I am very interested in your thoughts on this, as well as any possible contribution from pointe work. 
Dr Blake's comment: That is fascinating and may be the reason she got both sides. Typically in landing with the vault in gymnastics, are you taught to stick it with both feet at the same time? 

If you only have time to answer a few questions you can focus on the first paragraph.  I have also tried to pose the questions in a way that would be helpful to the community as a whole rather focus solely on her specific case. J 

And once again, thank you for your knowledge and insight!!!

Another correspondence:

Thank you SO much, you are an angel for all the help and insight you have provided, it has given me hope that she will heal but also realistic expectations both about the time course and the importance of being patients as well as thinking about how to prevent re-injury. 

It seems that sesamoid injuries are so poorly understood my many. 

I will respond to your questions  in the comments on your blog – but yes, vault in women’s gymnastics  a two footed landing.  It also invokes about a 20 yard all out sprint in bare feet down  the vault runway (basically a carpeted wood platform with minimal padding) and a 2 footed punch off a springboard onto the vaulting table.   

Here is a video from you tube of what it looks like – the landing is usually pretty padded but the run and punch off the springboard is where I think a lot of the impact occurs.   

Thanks so much!


  1. Thank you again for your thoughts on her case, you are so kind and compassionate. It has given me hope that she will heal but also realistic expectations both about the time course and the importance of being patient with this injury as well as thinking about how to prevent re-injury. Some follow up on your questions/comments.

    1) Thank you for reviewing her MRI. Could you comment more on what you observed in the first metatarsal on the right? Is this a common feature of sesamoid injuries?

    2-3) Over the past few days she seems to be almost completely pain free in the Hokas. She has not had any more pain with the bone stimulator. We will stay in the Hoka's through the end of October. She is swimming 1-2x a week, and doing PT 2-3 x a week. She is doing strength only at gymnastics.

    4) As far as orthotics, she is walking normally now without pain in the Hokas with the insert under her big toe. However, you mention that this should not be used when gait gets better and push off improves. Should we try to remove this insert and switch to a custom orthotic and/or dancer's pads? Or keep it for now since it seems to be helping?

    5) Yes vault is a 2 foot landing but the 60 ft barefoot sprint down the minimally padded vault runway and the 2 foot punch off the springboard probably causes more impact than the landing. She was also doing this with 2 lbs ankle weights on as a training exercise over the time frame when the pain worsened significantly. We will avoid the addition of ankle weights in the future. What do you find are the most important factors in avoiding re-injury to the sesamoid in dancers/gymnasts?

    Thanks SO much! Also - what is the best way to donate to your blog? I do not see a link to Paypal...

  2. You are welcome. The metatarsal head above the sesamoid had some edema indicating bone bruising there. So, when the sesamoid pushs upward into the metatarsal it is very sore. The dancer's padding helps, avoiding high impact or barefoot, and the bone stim should do its thing.
    Yes, it is okay to keep the padding and Hokas since they are doing well. There may be a time, do to pain, that experimenting with orthotics and dancer's padding will give the most relief. Just an educated guess.
    In dancers and gymnasts, they need to place the adhesive padding on their feet or in the shoes. They can not change technique for fear of a worse problem.
    Not sure why the donate button is not there on the first page of the blog. Thanks. Rich

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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.