Sesamoid Pain in a Rock Climber: Email Advice

First of all, thank you for you wonderfully helpful blog and for your tremendous generosity in spreading your knowledge to help others. 

I have read through a lot of your blog and videos regarding sesamoid injuries, and have a couple questions about my particular situation. I am an avid rock climber -- and it is a pursuit I would like to continue at a relatively high level (weekend warrior) as much as possible. 

Last November (2017) I noticed a pain in the ball of my left foot. The appearance of the pain was fairly sudden, although I do not remember it occuring with a specific move; however, I do believe it occurred while climbing. The pain would really only be present when putting significant body weight on that portion of my foot (big toe or sesamoid area), or when I would try to bend the toe forward or backward to a large degree. It bothered me primarily while climbing but was generally not bad while walking. I never noticed any swelling or discoloration. I figured it was a minor tweak and didn't pay much attention. For unrelated reasons, I ended up having to take three months off from climbing (Jan - Apr 2018, though I still played some recreational tennis occasionally), and when I returned to climbing, the pain was not any better when that part of the foot was weighted, so I finally went to see a podiatrist. To be clear, the pain was generally only present when standing with most of my bodyweight on a very small chip of rock using just that portion of my foot/toe -- not while walking normally

Xray did not show anything, so was given diagnosis of sesamoiditis, and since the toe really only bothered me while climbing, it was suggested that I try some over-the-counter 3/4-length orthotics inside my climbing shoes (not very realistic) and sent on my way.

The toe did not bother me much for a couple months (although the pain during specific climbing moves was always there), but after a week-long climbing trip, it flared up significantly to the point where there was some pain/soreness even just while walking/standing. Upon returning to the podiatrist, an xray showed "small lucency to the medial sesamoid with concerns for fracture" so the podiatrist said there might be a small fracture there but basically suggested there was nothing really to be done, and that given that my symptoms were mild and intermittent, I should just modify my levels of activity to avoid overly stressing that area ("let pain be your guide").

It is true my symptoms are mild and manageable for every day activity. I can walk with no pain. However, for climbing, I would like to heal the bone to the point where there is no pain when I weight that area. Reading up a bit more about sesamoiditis and sesamoid fractures, I am wondering:

1/ Is it still advisable to go through the immobilization phase (given that the initial injury was 10 months ago, and that current pain levels are in 0-2 range)? I'm hoping the answer is no, but is an immobilization phase important for healing (even if the potential fracture occurred months ago)? If so, what level of immobilization? Tall boot? All the time / even when sitting at a desk or in bed?

Dr. Blake's comment: So many injuries do not heal unless placed back , even 10 years later, in the Immobilization Phase. However, we would need an MRI to know how inflamed the bone is, and really if you have something to gain by resting. Many of my patients go into the small anklizer boot for 4 months, for all activities other then their main sport, to give themselves a chance of healing. You already have the 0-2 pain level down, so hard to know if you will gain anything. How is your overall bone health? Has your Vitamin D been tested lately? Have you had a bone density? Good diet? 

2/ If it's OK to skip the immobilization phase, what would you recommend now? Contrast baths and runners pads/orthotics, no climbing on that foot, no tennis for some (what number?) weeks, then reintroducing those activities? (Given my low levels of pain, it doesn't seem like my podiatrist will be up for doing an MRI or bone stimulation.... or even custom orthotics...)

Dr. Blake's comment: Yes, I can tell you have been reading the blog!! Thank you!! All of these should be used. Contrast bathing once to twice daily as a deep bone flush is the most important. Common sense says you should pick on the bone less, so Dr. Jill's Dancer's Pads stuffed into the rock climbing shoes is also key. Orthotics have too much bulk and the main part in the front to protect, so just go with the dancer's padding protection. Really, the MRI is important to tell us what we are dealing with. It can be the structures next the sesamoid that are injured changing the treatment plan. You hurt with rock climbing, so I do not care if you do not hurt walking, unless you want to just be a walker. Some patients only hurt running, and they would fire me as their podiatrist if I told them to stop running forever and just walk. Get my point? The MRI is also baseline in case we need them again. Get them and send them to me if you want my read. 

3/ Any suggestions on how to best go back into climbing/tennis and over what length of time? I feel like both of these sports are situations where there might be sudden severe weighting on the pain spot (not repeated weighting like in running), and I don't want to risk re-injury, but I also wonder how to know when I've healed. Currently I'm not playing tennis and am avoiding any left-forefoot-weighting (and generally minimizing use of left foot) in climbing and basically having no pain, so I'm not sure how to tell when things have improved to the point where I can start weighting the left forefoot and/or playing tennis.

Dr. Blake's comment: This is exactly why we get the MRI. A very positive MRI today may mean that the sensitivity you feel loading the sesamoid may be there for up to 2 more years. Let's find out now, and it saves so much anxiety for the next 2 years. I find with negative x-rays, a positive MRI for bone swelling, you do contrast bathing daily, 9 months of bone stimulator, protect the bone with dancer's padding, and we see where you are at next June. That is the next time you really think about it. You wear the boot four hours a day to rest the overall tissue. You modify activities and cross train to stay as healthy as possible. Hope  this thought process is helpful. 

Thanks in advance!