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Saturday, December 30, 2017

Sesamoid inuries: Followup Email

Subject: RE: 13-year-old daughter (gymnast and ballet dancer) with a sesamoid injury (stress response versus stress fracture)

Hi Dr Blake –
Hope you are well and had an enjoyable Thanksgiving holiday. 

Just wanted to give you some follow up on my daughter and get your thoughts on her progress if you have time as you were so helpful several months ago.  A disc with her most recent images was sent on Dec 6 J

If you recall – she is a 13 yo gymnast and ballet dancer who developed bilateral medial sesamoid stress reactions versus stress fracture (R>L) in bipartite sesamoids in mid-July 2017.

Just to review: She stopped gymnastics due to around July 20, was in bilateral walking boots for 1 week starting 7/31 then bilateral casts (2 weeks on the left, 4 weeks on the right) for the month of August 2017.   She wore HOKA shoes and did PT for a month (Sept 2017) then tried to increase activity in Oct 2017 and developed recurrent sesamoid pain within 3-4 days which is when I contacted you initially. 

Since I contacted you in early October, she has been in HOKA sneakers full time initially with an insole with semi-rigid support under her metatarsal (this gave her the most relief) and now has a custom orthotic with a similar design.  She has been using an Exogen bone stimulator on both feet for 20 min daily and doing contrast baths several times a week and taking calcium and Vit d.   She has been doing PT (foot and ankle ROM and strengthening including theraband work, balancing exercises, hip strengthening) once a week with a PT and 3-4 times a week on her own.  At gymnastics, she rides the stationary bike, does her PT and other strength/conditioning exercises, bars over a foam pit and avoids any activities with any releve, impact or jumping (or even any kind of push off from her feet).  At dance, she wears her Hokas and does a barre work and center work without going up on releve or doing any jumps/turns.  During this time she has been able to remain fairly active (albeit with significant limitations – she is not able to perform or compete) and has mostly been in a 0-3 pain range. 

She saw her orthopedist in follow up in early December and had no pain to palpation over her medial sesamoids but had some tenderness between the first and second metatarsal on the right

Her orthopedist suggested repeating an MRI – he said that he expected that the sesamoid bones may not be fully healed but at least we would know if she was heading in the right direction, and he wanted to make sure there was nothing else going on given the location of her tenderness on exam.  I have included a photo of the report from  12/3/17 below and you should have received a disc with images.  Per her orthopedist  - the edema in the sesamoids was decreased but not completely resolved, and edema in the right 1st metatarsal head was resolved.  

Her orthopedist was pleased with the improvement on MRI and thought that she could begin a slow progression back to full activity over the next 6-8 weeks but did not outline a clear plan.  She tried doing some light gymnastics with her HOKAS on  (just cartwheels/walkovers and jumping into the pit (i.e. pushing off her feet but not landing on them)  and had some pain up to 4-5/10 in the evening after these activities, but it resolved by the next day.  Over the past 1-2 weeks, she has started to do some one-foot balancing exercises with her PT without her shoes on wobble board or airex mat and this has gone ok as well. 

However, she seems to have some apathy about increasing her activity further.  She does not seem to want to do anything that involves going on releve or pushing off the ball of her foot.  I think she is very concerned about the pain coming back or causing long-term damage to her foot (something her orthopedist cautioned her about if she tied to train through pain) and is having a hard time telling the difference between true sesamoid pain and other types of pain from disuse.  Her PT says he can reproduce some of the pain she described in her sesamoid by pressing on other areas of her foot which makes him think she has some neuropathic component to the pain or some tightness of the ligaments.  This s a little surprising to me given how much PT she has been doing and how active she has been, so my concern is that it is still some degree of true bone pain given that there is still some edema on MRI.

My questions are as follows:

1)      It has been approximately 4.5 months total (though her initial immobilization phase was relatively short).  Do you think it is too soon to try to re-introduce dance and gymnastics activities? 
Dr Blake's comment: The 12-3-17 MRIs still showed edema in the sesamoids which were better than July, but still present. If she has level 4-5 pain after workouts, she is still doing too much. You can probably keep her where she is at, but you can not increase the ball of the foot bend or impact. I was happy to see the first met edema on the right side was normal again. She is healing!!!
2)      If she does start to re-introduce activity, what is the best general progression?
Dr Blake's comment: So, we have 2 factors that influence the sesamoids now. The bend of the big toe which as she releves, the sesamoid is pushed into the first metatarsal head. And, the direct impact onto the ball of the foot which also will drive the sesamoid into the metatarsal head. The far more dangerous, and thus the last one added is impact. You gradually add speed to the walk on a weekly basis taking her from here until March first (9-week buildup). You gradually add time on the ball of your foot, and time up on releves. Look at each skill she does and break apart these 2 components. Email me some of your thoughts. She probably has nine skills to manipulate. If she is doing the vault, we won't allow impact just now. So, over the next nine weeks, one week at a time, she increases her walk to sprint down the runway. You walk, then fast walk, then slow jog, then medium jog, then fast jog, then if she gets through each one, she sprints. And, that is only one skill in a gymnast. Whew!!
3)      Should she try to introduce activity in her HOKAS first and then progress to bare feet? Or do the HOKAS with the orthotic force her to use her feet too much with pushing off and should she actually try barefoot activities on a  well-padded surface (like the soft, carpeted spring floor at gymnastics)?
Dr Blake's comment: This, of course, is a whole other variable. I hate barefoot for sesamoids for the next 6 months if I can get away with that emotionally. I also do not think training in Hokas is that realistic. You would have to start all over again when you start going to gym slippers. I would use Hokas only if walking in whatever shoe you can like a ballet or gym slipper with dancer's pads and spica taping and cluffy wedges was still painful. So, you would first try to get out of your Hokas before you started a faster walk, then slow jog, etc. 
4)      What kind of Pain is OK as she re-introduced activity?  
Dr Blake's comment: 0-2 when doing the activity, and 3-4 after, that settles down before the next workout back to 0. If you want to progress to more and more activity levels, you have to maintain 0-2 during, after, while sleeping, while doing your homework, brushing your teeth, texting friend, do you get my point? If the athlete feels 0-2 during, but more than 4 after, or the next day, on 2 different days, you must lower your activity by where you were 2 weeks ago. Each level should be maintained for a week. 
5)      Do the ganglion cysts on the MRI mean anything and/or could they be causing pain?
Dr Blake's comment: I do not believe they are causing any pain.
6)      Do you see any role for extracorporeal pulse activation therapy (EXPAT) also called “shock wave” therapy?  I know this type of ultrasound treatment can sometimes make things worse before they get better, but my concern is that the bone stimulator is only treating one very small area (about 1.5 x 1.5 cm) and that some of her pain seems not to be exactly in the area of the injured sesamoid bone (i.e. in the surrounding tendons and soft tissue). There is a local podiatrist who has been using EPAT for years with reportedly good success rates  - several of the gymnasts at her gym have done it for severs or plantar fasciitis with very good results.  Her orthopedist has also purchased a machine for the new University of Colorado Foot and Ankle Center that just opened, so it seems to be gaining some credibility.   I read a case report of EXPAT being successfully used to treat sesamoiditis in a football player   I also saw some case reports and small studies of it being used to promote fracture healing including promoting healing of non-union fractures.  I feel like we are stuck with her not being willing to increase activity due to ?nerve/soft tissue pain and I am not sure how to get past this and it seemed like it might help.  In addition, doing it over the upcoming holiday break would be ideal as she would not have to miss school for appointments and she has time off school/activities so could let her foot rest more during the treatments.   
Dr Blake's comment: I think these things have their place, but the word "chronic" is important. Your daughter does not have chronic sesamoiditis which would warrant this treatment, she has 2 very well healing sesamoids. They are sensitive due to the edema and some nerve hypersensitivity, but if we were not talking about a high level athlete doing things barefoot, explosively, ballistically, we would not be talking about re-injurying the bone to hope it can heal better. The ECSW therapy is to produce fresh acute injuries to reheal tissue. Basically to wake up the healing when sometimes gets chronic. The body tends to stop healing for some reason. I see no reason based on the last MRIs. 

Thanks so much for any thoughts, feel free to post to the blog if you think it will help!

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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.