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Wednesday, January 17, 2018

Sesamoid Injury in a Rock Climber

First, thank you for the blog and book—both have been extremely helpful as I have been dealing with a frustrating sesamoid.  I am writing to get your opinion on returning to activity with this injury.

I’m a rock climber who sometimes loves to trail run.  I started having low-level foot pain in April. My pain gradually increased with time (had to quit running in June), but it never got to a point where I had to quit climbing.  One doctor told me I have AVN of my medial sesamoid.  The other two doctors I have seen said that the sesamoid is fractured but the bone hasn’t collapsed/isn’t sclerotic, so I should try to treat the fracture.   I found your blog around this time and started to follow some of your advice.  So for the past 4 months, I have been:
·      using the Exogen bone stimulator
·      taking Calcium and Vitamin D supplements
·      Wearing custom orthotics full time
·      Lots of icing and contrast baths
·      Activity modification (No climbing, lots of swimming and biking)

I have gotten to the point where I no longer have pain doing everyday activities, so I decided to start a walk/run program in December.  I can now jog for a total of 12 minutes with no pain.  (Yay!)  In January, I decided to see what climbing feels like.  After a little trial and error, I have found that with certain shoes, I will have no pain after 2 pitches.  But I definitely have pain if I do more climbing or if I wear shoes that are too soft.

Multi-pitch climbing. Multi-pitch climbing is the ascent of climbing routes with one or more stops at a belay station. Each section of a climb between stops at belay stations is called a pitch. The leader ascends the pitch, placing gear and stopping to anchor themselves to the belay station.

So based on my levels of pain, I was feeling like I was making progress.
Recently I got new X-rays and they showed no change/improvement.  My doctor doesn’t think I should be running or climbing at all for another 3 months if I want to give this thing a chance to heal.  And if it doesn’t heal after three months, then I need to think about whether I can manage/tolerate the pain or if I want to have surgery.
Dr. Blake's comment: I am so pleased what you are doing. You are doing everything right. Creating the 0-2 pain level is all you need for healing. And you need to stimulate the tissue for strength. A runner has to run and a rock climber has to climb. It is a basic part of sports rehab having the athlete do sports specific activities as long as they keep the pain level between 0-2 consistently. The xray will look bad for a while, even when internally it is healing. An MRI will show bone edema-indicating injury repair for long after the fracture has healed. How you feel is more important at this point because you are through the Immobilization Phase of Rehab, past the Restrengthening Phase, and into the Return to Activity Phase. Bone Stim for 9 months total. 

I have gotten so much value from your book and blog, so I am writing to get your opinion on a few things: 
Is it really necessary to give up the small amounts of climbing and running that I have recently added to my life?  No, unless there is more than just comparison x-rays, having another MRI 6 months after the first is great. Or, getting a CT scan to look for AVN signs now. If we have no other info, I say keep listening to your body and gradually build up what you are doing. 
Do you know anything about using shockwave therapy to treat sesamoid fractures (that was another suggestion recently made to me)? Sure, it is to cause microfractures in the bone to take a chronic healer and make it acute. You would then go back into a boot for 3 months and start the process all over. That does not make sense now. It also makes no sense to me that patients are getting this powerful treatment like a physical therapy session with no changes in activity, restrictions, etc. 
How and when do I go about making decisions about surgery vs. just dealing with it?  To me, surgery makes more sense than dealing with it. That can cause a breakdown in the joint, and compensatory pain. The surgery is typically very successful and then you have to protect the other sesamoid at high-risk activities with your orthotics. Not too big of a deal for most. But, in general, you want to save it if you can, common sense. If you were in my office tomorrow, and we had no cost restrictions, I would get a CT scan and repeat the MRI six months after the first. Then we would have a wonderful idea what the next year looks like. 
At this stage, climbing is really the only thing that gives me pain—but it is also my favorite thing to do.  I seem to keep meeting other climbers with sesamoid problems—do you have any experience working with climbers?  If so, any tips for returning to my favorite sport? 
Dr. Blake's comment: First of all, stay in rigid shoes that accommodate your orthotics and spend this year working on technique challenges that use mainly your upper body. Let your big toe have a break, so it is able to completely heal. Drills, like seen in this video with Daniel Woods, can be modified to avoid toe bending of the involved side. We are only talking about a short time in your long life. 

Thanks again for all the information--I really can't express how much it has at helped at a time when I have really struggled finding a medical team who understands my goals. Welcome

1 comment:

  1. I'm in the same boat. I am also a rock climber (Sport climbing & Bouldering), runner, and still occasionally play basketball. I have had this little discomfort for about 3 months now and I finally saw a podiatrist and got an xray, I have a right foot tibal sesamoid fracture. my podiatrist was short with me, and told me to stay in a boot for 3 weeks but nonetheless I am motivated to do whatever I can to return to 100%. In your opinion, is this an injury I can heal back to 100% or will I always have some discomfort down the line in your experience? What is a typical timeline for returning back to climbing? Is there anything I can do naturally to speed up the healing and promote more blood circulation? Thank you for what you do....


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.