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Sunday, January 17, 2021

Sesamoid Fracture to Return to Activity: Email Advice for 12 Year Old

Hi Dr. Blake,
I found your information awhile ago when I was researching online about my daughter’s  sesamoid fractures and sesamoiditis. I feel like you know so much about this condition and I was wondering if I could run our situation by you and see if there is anything we are missing or should be doing. We also had an online appt with Caroline Jordan to get some ideas about dealing with a sesamoid injury.

Here is my daughter’s situation - again any advice or thoughts you have are greatly appreciated.

My daughter is 12 years old and plays soccer. I will give you what happened month by month starting in November 2019 until now January 2021. It helps me to keep organized with how everything has gone.

November 2019
-She starting to complain of foot pain toward the end of Fall Soccer season. She had some pain in both feet but more on the right foot. She also had some knee pain. The pain would come and go and did not impact her playing. I knew that she would be getting a good 6 week break from end of November to beginning of January and made an appt with a sports podiatrist that my friend knows and this physician is involved with the podiatry care of a professional football team and seems to have a lot of experience.
Dr. Blake's comment: This was the perfect thinking. 

December 2019
-Had her appointment with the sports
podiatrist and based on the way her foot hits the ground and her mechanics it was recommended to get custom orthotics. She was fitted for the orthotics. She was on break from playing soccer.
-She was given a sort of temporary insert to put in her sneaker and cleat to try to help until her real orthotics came in
Dr. Blake's comment: Also the right idea to try to distribute the weight differently while in the soccer cleat and any training with other shoes. 

January 2020
-She went back to off season training. Her feet and knees were feeling better from the rest. Also, the off season training was 30-50% of the usual fall soccer training, so she was getting more rest days and it was less intense. 
-At the end of the month, her orthotics came in and we also started to find a cleat that would fit the orthotic. 
Dr. Blake's comment: The only thing I would of added is daily icing to cool down any inflammation that had collected during soccer. Inflammation can tend to be stubborn and outlive the periods of rest so it is still there when you return to sports. 

February 2020
-During an outdoor soccer practice, she felt a pop in her right foot when she was making a cutting type of move. She then felt pain. She was still able to finish up practice. At this point we had a follow up appt in one week at the sports podiatrist. Things were very hectic that week and we iced her feet and took that week off from practicing and her feet were feeling better.That weekend though she had 2 futsal games and felt well enough to play. 
Dr. Blake's comment: Some patients pop, snap and crackle alot when there is some inflammation. The fact that she felt well enough to play, and I assume not limp, was still okay. 
-After the 2 futsal games she could not really walk in her feet. Our follow up appt at the sports podiatrist was a few days later and the x-rays revealed 3 fractures in the one of the sesamoids in the right foot. She was put in a boot. No soccer and no exercise.
Dr. Blake's comment: So, this does not sound good, but because sesamoids can be normally in multiple pieces, and MRI has to be ordered to confirm. You also have to treat the worse case scenario which is a fracture of the sesamoid appropriately. I found 3 months in the boot is great for healing. 

March 2020
-Still in a boot
-Follow up appointment was moved back so to lockdown with Covid
Dr. Blake's comment: When a patient goes into the boot, it is to rest the tissue. The pain level in the boot has to be 0-2 for those 3 months. Caroline Jordan's video has alot of exercises you can do to keep strong. Do not do anything that makes the pain increase. 

April 2020
-Was able to get 2 telehealth appts 
-Continuing to wear boot and then toward end of April could start to stop wearing boot.
-Left foot started to hurt but not as bad.
Dr. Blake's comment: While in the boot, if you have been successful at achieving the 0-2 pain level, most podiatrists will start the gradual wean out into shoes and orthotic devices at the 2 to 2 and 1/2 month level. This is fine for some patients and at least rushed for some patients. The doctor always wants to look like a hero in the patient's eyes, but sometimes the patient/parents can be unconsciously making the doctor feel pushed to get out of the cast. This is why I keep my recommendation at 0-2 pain level, and tell the patient that we do not want to start over. 

May 2020
-Some pain still
-got an in-person appt toward the end of month
-x-rays revealed 3 fractures of sesamoid on both the right and left foot. 
-fitted for thick rehab orthotics
-plan is to be out of soccer until Spring 2021 season
-offload feet
Dr. Blake's comment: I am so sure that this was terrible news. However, it is close to impossible to get this scenario. Three fractures on both feet. #1 cause is bilateral tri-partite congenital sesamoids (that got injured). I want an MRI on both feet to know more. 

June 2020
-rehab orthotics came in
-wear rehab orthotics
-off load feet
Dr Blake's comment: I am assuming off load means dancer's padding. 

July 2020
-continue rehab orthotics
-mentally feeling very sad about not being able to play
Dr. Blake's comment: Between the Pandemic and this injury, she must have been very sad

August 2020
-continue rehab orthotics
-appointment with Caroline Jordan to see about how to deal with this injury
-started Physical Therapy - working on strengthening overall body while still offloading foot
Dr. Blake's comment: I am so thankful for Caroline. This is the appropriate approach, limit weight bearing, maintain 0-2 pain levels, get cardio and core and lower extremity strength work. I have not mentioned, but get a Vitamin D level to see if she isn't low which could make it hard for bones to heal. Also, remember the 3 sources of pain. Especially after 3 months of an injury, it seems like all 3 can be important to deal with. You are using mechanically treatments, so make sure that you are icing for the inflammation daily, and add one of the nerve treatments like non-painful massage to the area for 2 minutes twice daily. 

September 2020
-continuing Physical Therapy offloading foot and rehab orthotics

October 2020
-X-Rays reveal Right Sesamoid fractures almost healed and Left Sesamoid fractures improving
-Continuing Rehab Orthotics and Physical Therapy offloading feet
Dr. Blake's comment: So, bi- and tri-partite (2 or 3 pieces) congenitally separated sesamoids never start healing. There is no reason to. So, we can assume from this that she had the misfortune of having a rare bone injury. I still want the MRI and now I definitely want to know about her bone health. Also, she sesamoid fractures can be due to hard ground and soccer spikes overloading her bones, was she in a spiked cleat with one of the spikes under the sesamoids. 

November 2020
-Continue Rehab Orthotics and Physical Therapy offloading feet

December 2020
-X-Rays reveal both Right and Left Sesamoid fractures clinically healed
-Physical therapy begins to gradually increase loading feet in small increments
Dr. Blake's comments: Great news, but they can be healed, but very weak due to the off loading. The progression has to be gradual from here, and I wish that there were never any time limit (like unfortunately an upcoming soccer season). So important to not have the pain over 0-2, except for an occasional transitory jab of pain. The coaches and parents have to watch her like a hawk for any limping. Of course, you have to assume it is only 80% healed as you move forward, with ice after sports drills, and no NSAIDs at all which slow down bone healing. 

January 2020
-Physical Therapy continues to increase loading feet and moving towards integrating soccer 
-Physical Therapist and Soccer Coach talk and agree on plan to gradually work on in corporations her back into off season practice drills
-fitted for sports orthotics to fit in cleats
-finding appropriate cleats to wear with sports orthotics
Dr. Blake's comment: This is all perfect. Remember, if there is any increase in pain with practice, she can not participate again until it is back down to baseline (0-2). Some patients are restricted to light drills for awhile every other or every third day. 

So far, she has been to 3 off season practices / her pain level has ranged between a 0-7. Is this normal? Should we get an MRI? What do you suggest we do?
Dr. Blake's comment: This is where the timing of the pain is necessary to advise you. What is the baseline pain during the day? What pain level during weight bearing activities? What is her pain after practice? Is there any swelling or redness? When her pain is over 2, what is she doing? These and any others will be added to this post.  I hope some of my thought process helped. Yes, an MRI of both feet would be great, but you may not need at all now. Since we have both feet supposed with three fractures each, you should answer individually for each foot. Rich 
I really appreciate any thoughts you have on her case.


The Mom’s response to my questions:

Hi Dr. Blake,

Thank you! Here are the answers to the questions and I have a thought of what might be going on and wanted to see what you think. Everything you mentioned makes sense. I am sorry for the long email. My wheels are turning about a few thoughts I have about what is going on.

Here are our answers, comments, and questions:

1. We are not nearly icing enough. Alicia does not regularly ice. How much should she ice at this point? Should it be done automatically on a schedule or just when she feels pain?
Dr. Blake’s comment: The problem for most patients is that they only do it for pain, instead of trying to avoid the pain of inflammation. Icing a small superficial bone like the sesamoid is maximum 10 minutes, after every time she does anything that could make it hurt (like weight bearing drills), and 3 times a day for now. You never ice before a workout  up to one hour. An ice pack reusable is preferable. 

2. Would our doctor know at this point if the sesamoids were definitely bilateral tri-partite or actually fractures? So if the pieces of the sesamoids merge together it would show healed fractures? I remember our doctor saying he was not sure at first if her sesamoids were naturally in 2 pieces and that some people are born that way. Dr. Blake’s comment: Unfortunately there is no definite here. It is a good sign that the sesamoids showed healing since congenital bi- and tri-partite sesamoids always look broken. It is academic now if she goes back to full activity. However, an MRI should be ordered if you hit a plateau on the healing. 

3. When I keep mentioning offloading I mean to not put more on her feet - she could just do a regular day to day getting around, but no additional weight bearing exercises on her feet. I am not sure if I am using that word correctly. We have never used a dancer’s pad and I am not sure I know what it is. Is it like a cushion you can stick on your foot or in a shoe to kind of act like an orthotic? Dr. Blake’s comment:
See how the dancer’s padding floats the big toe joint

Get Dr. Jill’s Dancer’s padding both right and left and both sizes: 1/8th inch and 1/4 inch. These usually take alittle effort finding the right position for their hole, and discovering which side you need. These however only supplement the dancer’s pad built into the orthotic device, or can be attached later. I will try to show one below that is simply added to the shoe insert. 

4. She did get her Vitamin D Levels checked in August 2020 for her bloodwork for her well visit and her Vitamin D levels were normal.
Dr. Blake’s comment: With Vitamin D, I always want to know the value and the normal range for the lab she got it!! Very important that athletes function at the middle of that range, not at the low end of normal. 

5. How do you do the nerve treatment of non-painful massage? Do patients do it thenselves? I know that the physical therapist did more of that in the beginning of physical therapy. He also did cupping on the sesamoid area, which he could not give definite feedback that it was really doing something, but he has had positive feedback from his patients. My daughter says that cupping makes her feet feet feel better, but they are doing it less and less now. Dr. Blake’s comment: Sorry, I have no experience with cupping for a sesamoid injury. Does not make sense to me, but having no experience really does not qualify me to comment. Neuropathic treatment for right now is just her taking the palm of her hands and some hand or face lotion and massaging the area for 2 minutes. As long as the area does not hurt, the biofeedback to the brain is that she is fine and the sometimes hyper sensitive nerves in the area relax. 

6. I remember that our doctor did not want to bring her mood down because she was already so upset. He told me when she was not in the room and after the x-rays showed healing that he was so happy her x-rays showed healing because this was a bad injury. 
Dr. Blake’s comment: Sounds like a very deceit human being!!

7, Our doctor also told me that the reason these fractures happened was due to the way her foot hits the ground when she runs and that this sesamoid area was receiving so much more grinding every time she runs that it was just a matter of time that fractures were going to happen. My understanding was that the only way we could have avoided this was get her into orthodics as soon as she started to play sports when she was little. He also mentioned that basically we have to protect her from herself - meaning her mechanics and structure was causing this so we need to use orthodics, correct footwear, adding more rest days, going by what her feet feel like. That she is going to be the player that will be icing more, stretching more, may need to take days where she watches practices because her feet need to rest, that she may need to do other forms of cardio like biking instead of more running to balance her feet and she may have to plan her activities to make sure she is giving herself the best options to play.
Dr. Blake’s comment: Sounds incredible!! A very good plan moving forward. 

8. She was wearing cleats with the spike under the sesamoid. I am finding most cleats have a spike in that area - is there any cleats that do not have that spike there? Our doctor wanted her to start with turf shoes. We got her both cleats and turf shoes. She said that the turf shoes are not comfortable at all and her feet feel worse and feels like she cannot move the way she wants to. Both of the cleats and turf shoes are able to fit her rehab orthotics. Dr Blake’s comment: I usually remove one half of the cleat at the start. This is a cleat related problem for sure. The turf shoes is a good idea, but dancer’s padding is needed. If you remove half of the cleat under the sesamoid, and spend some time in practice in the turf shoes, she will be having a lot less stress on the sesamoids. 

9. Here are pain levels and when:
Just relaxing or doing things at home - 0-3
Soccer and Running - can go up to 7 Dr. Blake’s comment: (this is where the sesamoid is still being overloaded)
If it goes up to 5-7 it may last 1-2 hours after practice. It is back to 0-2 when she wakes up the next morning, Dr. Blake’s comment: This is a great sign!! More icing after practice, 2 hours later, and right before bed. She can try icing for 20 minutes 2 hours before practice to see how she does. 
The 7 pain level had been when using her regular sneakers with the rehab orthodic during the indoor practice on a kind of turf rug. They cannot wear cleats in the indoor places where they are training. Dr. Blake’s comment: Here she is most vulnerable. She may need in this environment the addition of Dr. Jills Gel Dancer’s Padding, spica’s taping and cluffy wedges (which are all in my blog—use the search area). She may also need to change the orthotics or shoes. 
She says she feels her rehab orthodics shift in her sneakers when she is doing soccer moves. Dr. Blake’s comment: Probably have to be redone full width of the sneaker (can send the lab the sneaker insert). If the lab is redoing for more width, have the doctor decide if more arch and more dancer’s padding (called Reverse Morton’s Extension) can be added. 
She says the cleats with the orthodics feel better than when she is exercising in her sneakers with the rehab orthotics. Dr. Blake’s comment: It is always good that one mechanical environment actually feels better than another. This means mechanical changes can help. Something has to be done to the other environment to make them equal. 
This is only for the right foot. She says her left foot has been fine. Dr. Blake’s comment: Hooray!! However, unless there is a reason, whatever you do to the right at least half should be done on the left for balance. 1/4 inch dancer’s padding right should be balanced by 1/8 inch dancers padding left. 
She has never noticed any swelling or redness in either feet. Dr. Blake’s comment: When dealing with sesamoid fractures, they should produce an inflammatory response. Did anyone ever comment on any swelling in this process? 
She also told me that her rehab orthodics in her sneakers used to feel better when she first got them. Dr. Blake’s comment: This needs to be investigated. 

10. She walks barefoot in the house - she says it is more comfortable. Is this ok to do? Dr Blake’s comment: Get some Oofos sandals for the house to protect these feet.

11. Could this be what could be causing the problems right now in practice or aggravating things:
- if her Rehab Orthodics are shifting when she is trying to do indoor training - could it be not off loading due to bumping into the sesamoid area? Correct
- is the reason she is doing a little better with the cleats outdoors is because the cleats are new and holding the rehab orthodics in place more so they are doing their job better off loading? Correct, and the ground gives more!!
- the x-rays show she is still growing - if her feet grew a little could the sesamoid area of the orthodic not be in the right place and not off loading like it should? Typically dancer’s padding that float the sesamoids are pretty big. However, do the lipstick test for me. Put a little lipstick (any shade will do!!LOL) on a que tip (sp??) and mark the exact spot she hurts. Then place her foot into the shoe and see where the mark ends up as far towards the toes. Ignore any smug mark getting the lipstick mark in the shoe. This will tell you exactly where to put the dancer’s padding to protect the sesamoid. You can of course due this better if you remove all the laces. 
- she just got fitted for sports orthodics but maybe if her feet grew she is going to need a mew pair of rehab orthodics as well. 
- is this just too much too soon - should she be taking the steps to get back more slowly?
Dr. Blake’s comment: This is a busy time in the rehabilitation and getting the pain down to 0-2 for all activities is ideal. I do not want these 3-7 pain levels at all. You may have to step back from those activities until orthotics are changed, you shave the spike, you learn to spica tape, you ice more, you learn cluffy wedges, etc. 
- should she hold off on soccer practice or monitored running at physical therapy until it is determine if she did grow and the orthodics are shifting or that the shoes are a little looser from wearing them for a number of months and making the orthodics shift? Do the lipstick test, get the orthotics wider, add the dancer’s pads, etc. 
- with the sesamoid area on the orthodics - do you need to be more vigilant about making sure that she has not grown and moved out of that sesamoid off loading area?
-should I push to get an MRI at this point? Dr. Blake’s comment: I am not sure what the MRI would tell us over the above discussion. However, in treating sesamoids, I always tell patients when they get an MRI it is there first of at least 2. The second one is 6 months down the line to check healing. We can assume good healing now and that the right biomechanics and inflammatory and neuropathic treatments are not yet in place. If you get them in place, and you still can not keep the pain between 0-2, MRI is completely indicated. I sure hope this has been helpful. Rich 

Again thank you so much! 

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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.