Ballet Dancer with Sesamoid Injury

Hi Dr Blake,

     So happy to stumble upon this today.  My 10 year old daughter is a dancer and suffered a sesamoid fracture in april 2014.  Her foot was immobilized non weight bearing for about 3 months and used the exogen bone stimulator since.  She's using a carbon fiber foot bed in her athletic shoe...is transitioning back into dance... but, has started having pain again.  We saw the MD this week and he is suggesting another week of immobilization before attempting to "transition" back into dance.  I'm looking for suggestions on how to make this transition. 

 Thanks for your time!
  Libby (name changed)

Dr Blake's response:

     Thank you so very much for the email. I love working with ballet dancers, and hope some of my thoughts are helpful. The key points to your rehabilitation at this point assuming the fracture has healed (and it should of), but can remain sensitive with bone remodeling for the next 6-9 months. 

1. Daily 10 minute ice pack twice and full contrast bath for 20 minutes each evening for deep joint and bone swelling flush. Non weight bearing rehab especially makes the swelling sit into the tissues longer, than even partial weight bearing.
2. Deal with the severe weakness which sets in with this amount of immobilization with a pilates based physical therapy program of the core and lower extremity. Pilates is the best for this, but when not available, physical therapy is crucial. 
3. Ballet instructor's evaluation of technique (no rolling in of the arch) and corrections to keep the weight centered to slightly to the outside. It is crucial to avoid over turning out at the hips at this point which always pronates the arch more placing too much pressure on the sesamoid.
4. Leg strength with every other day pilates or stationary bike. 
5. Wearing shoes day to day that are supportive and pain free. This is when you have orthotic devices designed or at least some insert that off weights the area of the sesamoid. She needs to be walking up to 2 miles pain free daily to build strength in her bones that soften with this amount of rest/immobilization. Focus must be then on what is in the shoe to make this painless. The carbon graphite is used, like the boot, to walk more, but we need to get her off that for bend when possible.
6. She needs a dancer's pad in both ballet slippers, and perhaps arch support. Typically, the shoe stores that sell those shoes can help, but you can also get extra small Hapad longitudinal metatarsal arch pads of adhesive felt to self attach into the ballet slipper. Go to www.hapad.com.  The dancer's pads can be made of 1/8th adhesive felt ordered from www.mooremedical.com. Sorry you have to buy a lot, but you can donate to the ballet school when you do not need any more. You can find images of this in my blog. 
7. It is okay to go back and forth with the boot, even when you are starting ballet again. The boot may be what is worn at school, while you try to get the shoes and inserts correct.
8. Definitely, she should have been doing floor exercises all along, and perfect for now. She should start barre exercises for the next two weeks, but no single leg releve on the injured side until it seems like she is surviving the double sided releves. It is so much easier to releve with proper centered weight doing it with 2 sides initially. So, perhaps start with 5 minutes of tendu and plie and 2 minutes of double sided releve every other day. When she finds that level comfortable, increase each by 3 minutes every time she increases. Definitely twice per level is recommended. 
9. In summary, start floor and barre exercises now, work on day to day walking pain free, get to strengthening the foot, ankle, leg, knees, hips, and core. Use pilates based physical therapy if possible. Doing daily anti-inflammatory work. Work on technique issues so keep the foot centered, especially with turnout. Use the boot only if needed to allow more walking to build strength. Set benchmarks of what she can do today, and every other week check if function is improving. I hope all this helps in some way. Rich

En Pointe!! The Art of the Ballet Dancer's Shoes Revealed

I make my own orthotics for my patients, distance runners struggle to keep their blisters away, the cyclist perfects every part of the bike, the baseball player chooses the right bat, all expressions of the artist at work when success is so fragile. This video is inspiring, and gives us a little glimpse into the pointe shoes of a ballerina. The art, and yet the science revealed, is passed on. One generation to another for the art of ballet must be passed to the next generation successfully. 

The Ballet Blog: Looks Like a Great Site

http://www.theballetblog.com/index/487-pain-at-the-front-of-the-ankle-on-pointe.html

Here is a Ballet Question I get asked all the time. When is a safe for my daughter to go en pointe? 

My typical answer is 12 years old when there is enough skeletal maturity and when the child has enough strength to maintain proper technique (normally after 3-5 years of training) throughout the entire class. Poor technique leads to bunions, hammertoes, pain in many areas. Dr Rich Blake

Big Toe Length Differences and What It Means

http://www.dreamstime.com/free-stock-image-fine-yogas-rimagefree2133158-resi2565486

Here the left big toe is clearly longer. This is called the Egyptian Foot in Ballet and leads to too much pressure in the big toe joint over time. If you imagine a dancer on pointe with this long first toe trying to balance and finding it very difficult. This foot type occurs in about 10% of the population.

See the long second toe in this patient.

Here is an xray of the most common foot, the Grecian Foot, with the long 2nd toe and 2nd metatarsal. The measurement taken means nothing, but the line straight across from the 2nd joint shows the typical 3 or 4 mm shorter length of the big toe. This is actually crucial in gait during propulsion, or AKA push off, to have the big toe shorter than the second so it can plantarflex or drive into the ground to lift up to 10 times body weight. This Grecian Foot occurs in 70% of the population.

Another example of the Grecian Foot with the long second toe and metatarsal. This also is not perfect for ballet since the ground reactive forces pushing back on the second toe causes it to eventually buckle and cause a hammertoe.

Here is my case study of Paige. Paige has the Egyptian Foot. She presented to my office with severe pain around the big toe joint and I feared she broke something, especially the sesamoids. She how long the first metatarsal is. In propulsion, the first metatarsal has a harder time plantarflexing (pushing down into the ground for pushoff) because it is already jammed into the ground before pushoff begins.

Again, Paige's numbers mean nothing, but you can see that in relationship with the 2nd metatarsal, the first metatarsal is not 3 mm shorter, but actually 4 mm longer. This is a 1/4 inch too long. Paige will have to use some form of Dancer's Pads for activity forever to balance these forces.





Here is the happy news I gave Paige yesterday. She had not broken her sesamoid, the sesamoid is seen under the first metatarsal. The MRI showed how inflammed the joint was, but the bones were doing well. She is taping the joint, icing, contrast bathing, dancer padding, and eventually I will design some orthotics to off weight the area  more custom made.

This is close to the final type foot, The Peasant Foot. It is where the first and 2nd toes are the same length. It is the ideal foot for ballet in this regards (there are other foot properties that make a foot good or bad for ballet). Even pressure is exerted at pushoff through both these key metatarsals and toes. I have not done enough research to know if it also gives an advantage to walkers and runners like th Grecian Foot does. Sorry Paige, but with alittle padding you can have the same function and comfort as the Greeks do.