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Tuesday, June 12, 2018

Sesamoid Injury in Soccer Player

Dear Dr. Blake,

I came across your website while researching my son’s injury.  I wanted to reach out to you to ask for your opinion on his injury.  I have mailed you a copy of his MRI and CT for your review.  I am so grateful for the information on your blog and would really appreciate it if you could take a look at his MRI and CT when they arrive at your office.
Dr. Blake's comment: Will do. 

My son, Ben (13 years old), is a very competitive soccer player.  He plays soccer on average 5-6 days a week.  During a game this past Spring (March 11th), he felt pain in his left foot.  He did not suffer any direct trauma to his foot but thinks the pain started when he planted with his left foot and went to cut right.  After the game, it was hard bearing any weight in his left foot.  We thought that perhaps he had turf toe (he was playing on turf, but wearing hard spiked soccer cleats) and had him rest for a few days.  When it appeared that he wasn’t improving, I took him to see a podiatrist on March 15th (4 days after the injury).
Dr. Blake's comment: One of the culprits is the cleat right under the sesamoid pushing up hard. Please consider removing it as part of the treatment. 


Find the Cleat right under the Sesamoid to remove or file down

The podiatrist’s X-ray showed that the medial Sesamoid was in 2 pieces.  He was not sure if it was a bipartite sesamoid that was inflamed or a fracture.  He recommended an AmnioFix injection, saying that if it was sesamoiditis is would help speed healing and it could do the same for a fracture.  I was not familiar with AmnioFix, but at the time I felt that if it could give Ben a better chance at healing, we should do it.  Looking back on it, I am upset at myself for going through the injection because it caused Ben an intense amount of pain and swelling for about 3-4 days and with the information that we found out later, I wonder if it made things worse (edema causing poor blood flow which impacted the development of AVN?) The podiatrist put him in a walking boot after the injection. I purchased a dancer’s pad for him to wear with the boot.
Dr. Blake's comment: I am not doing any of the regenerative medical treatments, like PRP or Stem Cell, or AmnioFix. I have always thought AmnioFix as a skin substitute, or collagen former that would be helpful in achilles tears or plantar fascial tears or diabetic ulcers. I, therefore, have no idea why it was put into your son. Sorry. It is hard to get info on it but it should be degraded by now. The acute inflammation should not cause any long-term AVN problems. 

I decided to take him to see a Foot and Ankle Orthopedist the following week.  He thought that the distal fragment of the medial sesamoid “looked funny” so he ordered an MRI.  I have enclosed the MRI.  The MRI showed edema, sclerosis, and avascular necrosis of the distal fractured portion of the medial sesamoid.  I’m wondering if the swelling/inflammation from the AmnioFix injection caused the AVN or made it worse.  Can AVN happen so quickly-9 days passed from the date of injury to the day the MRI was taken? Could he have had this injury “brewing” for a while (he never complained of foot pain)? The doctor told Ben to wear the boot and dancer’s pad for the next month and return for a follow-up.  I asked the doctor if an Exogen Bone Stimulator was a good idea and he said that it was okay to use and gave us an order for the machine.  He has been using it daily for 20 minutes since March 29th.
Dr. Blake's comment: Please talk to the Exogen rep for me about the age restriction. I know the bone has to be skeletally mature, but not aware of recent studies on age. Did see some studies that 13 was the earliest including in the Exogen study. It is hard to imagine in a child that some short-term swelling will lead to AVN. I have not seen it. I have seen AVN occur when a year has passed and the inflammation was never under control due to inadequate treatments.

We returned to the orthopedist on April 23 for a follow-up.  He did a CT scan in his office and said that “the bone did not fragment, but still showed AVN” and Ben could transition into an orthotic as soon as possible and if he felt good, he didn’t need to return to his office for any follow-up.  He didn’t indicate that Ben should be restricted in any way or need physical therapy.  Because of what I read on your website, I thought that 6 weeks was a little premature to be out of the boot, especially with AVN.  
Dr. Blake's comment: Yes, first of all, you need the boot to achieve the 0-2 pain level? Sometimes you need an orthotic or dancer's padding to accomplish that. If I can good pain wise, and I have good 0-2 pain control, I will begin weaning from the boot and orthotic to shoe and orthotic at 10 weeks. As long as the pain does not go higher. Keep him in the foot for at least 4 more weeks. 
     If we are worried about AVN, then contrast bathing twice daily, Exogen bone stim if good for his age, and weight bearing as long as we keep the pain between 0-2. Also, bone health should be important with proper Vit D, Calcium, protein, perhaps asking a nutritionist if there are diet changes to make to ensure stronger bone. 

I was disappointed to have Ben discharged from his care without any type of follow-up or plan for returning to play.  Instead, I decided to follow your recommendations of 12 weeks in the boot with dancer’s pad, daily bone stim,  and daily contrast baths.  I’ve had him on Vitamin D3, calcium, and magnesium since the beginning of the injury.  Ben has also been doing body weight exercises and using the rowing machine while wearing the boot.  
Dr. Blake's comment: Great, what pain level are we having?  

Ben reached the 12-week mark on June 3rd and his been weaning out of the boot and into a Hoka shoe with the orthotics.  The orthotic had to be a very low profile in order to eventually fit into a soccer shoe. The orthotic has a carbon fiber plate with the metatarsal cutout and dancer’s pad for the left foot.  The right orthotic does not have the carbon fiber plate or dancer’s pad (only has the metatarsal cutout). Ben has very high arches which probably contributed to his injury (along with wearing hard spiked cleats on turf and perhaps overtraining).  This past week, Ben says he feels good and has no pain with walking.  He says he gets a little bit of pain if he puts a lot of pressure on his left foot to “test the orthotic”.  He has some pain with palpation of the area to the side of the medial sesamoid (along the base of the big toe)-he describes it as “tingling pain”.  He has not done any running or jumping.
Dr. Blake's comment: Wow, this sounds wonderful. You are doing a super job. All of those symptoms fit in the 0-2 range. Palpable pain can be normal well after a person is back running with full activity due to some nerve hypersensitivity. Massage the area for 2 minutes twice daily with the palm of your hand. The massage is for desensitization and cannot be painful. 

Thank you for taking the time to read this and look at Ben’s scans.  I want to make sure that we haven’t missed anything and if there is anything else we should be doing.  Do the orthotics that he has sound appropriate for his injury/needs? Should I also be spica taping him? Continue with bone stim and contrast baths? Any recommendations that you have on how to progress his activity from here would be greatly appreciated.  He is tolerating the orthotics and can walk about 1 mile without pain.  
Dr. Blake's comment: Definitely needs another pair for normal athletic shoes that can have more bulk (more padding, more dancer's protection, more arch?) As he begins to increase activity (longer walks, then walk-run program) experiment how spica taping and cluffy wedges feel. Check about the bone stim for his age. Contrast bathing until a new MRI 6 months after the first one, or we have stopped worrying about AVN (bone death). 

How do we know if the bone has healed and no longer has AVN?  I’ve read that it can take up to a year for a bone with AVN to come back. Is it safe for him to play soccer before we have proof that the bone is okay?  It has been extremely difficult for him to sit out the last 3 months and the competitive nature of his team/league makes it difficult to come back after a prolonged injury.  However, I’d rather be safe than sorry.
Dr. Blake's comment: It can take one or two years to know that a devitalized bone has revitalized (I know big words for me). Typically, we first follow the symptoms, as long as we are doing the above bone stim, contrasts, bone health, weight bearing. If the symptoms and disability (inability to play soccer) are stalled at 6 months, a CT scan and another MRI are ordered. The signs of AVN are bone fragmentation and no marrow signal from the bone. This is getting the buggy before the horse right now. 

Thank you for taking the time to read this long message!  I so appreciate it.  The information from your blog has been so helpful!
Dr. Blake's comment: Thank you. Sounds like you are doing wonderfully. Look forward to seeing the images. Good Luck. Rich

The Patient's mother responded: 

Dr. Blake,

Thank you so much for your recommendations.  Looking forward to hearing your thoughts on Ben’s films.


I spoke to the Exogen rep about the age limitations on the bone stimulator and he said that studies have not been done on children, but it has been used in kids Ben’s age without any negative effects (that we know of).

Side View of the Tibial Sesamoid with 2 fragments looking nonfractured and smooth edges, but the distal fragment (closest to the toe on the left side) looking sclerotic (sign of AVN) brighter white than other fragment.



Take care!


Dr. Blake's review of the images sent: CT, and MRI. Selected images presented. 


                                                               Again the tibial sesamoid on the left side looking more sclerotic in its distal or bigger fragment, but the two pieces look typically bi-partite (round, smooth edges). The trauma appears only to the distal fragment.

These are side by side comparison of the tibial sesamoid in T2 MRI where the normal bone is dark and inflammation shows up as white, and T1 where normal bone is white. See this distal fragment does not change consistency. This is very unlike a new injury where trauma to a bone would make it white on T2. Possible AVN? Probable old AVN! MRI after 6 months of Exogen, contrasts, weight bearing will be conclusive. Long wait I know. 

 Here the arrow above points to a medial collateral ligament irregularity. Also, note the tremendous swelling on the whole joint. This points to a Turf Toe injury which is acute (3 months old). Taping of the joint crucial to allow healing. This could be a reason to do surgery to sew up the ligament or consider PRP or prolotherapy. However, no joint instability has been found, so again I would wait for the followup MRI. I would do even if the joint is doing well.


 These 3 CT scan reconstructions are conclusive to me. The 2 fragments have the classic appearance of a bipartite sesamoid, round, different sizes, smooth edges at the junction. The distal fragment with the possible AVN looks healthy, nonfragmented, just like the uninjured fibular sesamoid. Good sign!!



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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.