Sesamoid Fracture in a Dancer: Email Advice

Hello Dr. Blake,

I am a 40 year-old dancer, though not professionally.  When I'm feeling my best, I dance approximately 1 - 1.5 hours per day 3 days per week, take 5 classes one day per week (tap and jazz), and one class on the fifth day of the week (hip hop), giving me two rest days.  

Dr. Blake’s comment: Probably too much at 40, but everyone is so different. Just think about your recovery time. With 5 days of weight bearing activities, definitely the 2 days should not be in a row (like Saturday and Sunday). 

I have injured my left foot three times now.  The first time, when I fell coming out of a turn, there was no reason diagnosis, but after the second injury I recognized it as a turf toe injury.  The second time (aggravated by lots of barefoot jumps and jump turns on hardwood) was diagnosed as metatarsalgia, rule out turf toe, and I did at least 9 months of physical therapy.  I had both a podiatrist and an orthopedist look at my imagining (x-ray and MRI, from what I remember) and neither saw any fractures or anything indicating any significant injury from either the first or second injury.

Dr. Blake’s comment: Accidents happen! Do you think you had fully recovered from these injuries before the latest one? Were you completely pain free and full activity after the second injury? 

Come to October 2020.  During the second half of a 10+ mile hike, on the last day of what became 25+ miles of hiking in Yosemite, I suddenly felt like I was stepping on a bruise.  I recognized the pain as being in the same area.  My doctor recommended conservative management, which I did.  Pain had not improved after one month and so I was seen in urgent care, they did x-rays that the radiologist said showed no abnormalities, and they gave me a post-op shoe to wear and said I was okay to be wearing my work boots.

Dr. Blake’s comment: Sudden pain like this, without a fall, in an overuse situation is a stress fracture until proven otherwise. 

I just saw a podiatrist at the beginning of January 2021.  He told me my lateral sesamoid is fractured and that he thinks it's been there since the first injury.  He did not listen to what I tried to tell him about what happened during the previous treatment.  His only treatment recommendation was to tell me to stop dancing.  Not for a discrete period, but as a blanket statement.  

Dr. Blake’s comment: I hope you can find a real sports podiatrist!!! Terrible advice! Check out the AAPSM website for members near you. 

When I tried to explain the importance of dance, he told me to get dancer's pads and then I could dance again.  He said that I will need to have surgery at some point in the future and told me that he would do a CT to see the level of separation.  He declined to do any additional imaging at that time and told me to keep him updated and that the referral will be active for 3 years.  He didn't want to see anything I've been doing on the meantime, didn't listen to the time I have taken off from dance already, nothing.

Dr. Blake’s comment: The CT is a good idea since you will have more information, although I would like an MRI first. 

I'm trying to figure out the best way forward and have already asked my doctor for a referral for a second opinion, but seeing as most people seem to think this is just some silly hobby, instead of understanding that I'm a hobby athlete and artist in one, it would be very helpful to have some idea what to look for going forward.  I just want to give myself the best possible chance to heal.  These injuries have been very frustrating and it's hard to believe that the only option is to do nothing until I need surgery.  I'm sorry this is so long.  I'm just frustrated and trying to figure out some options so that I can advocate for myself.  I appreciate your time and any assistance you can provide.

Dr Blake’s comment: I know you wanted to tell me your complete story, but try to start with October in a new email. Get an MRI (which you will probably repeat in 6 months) and go into a removable boot for now. You have to get the pain to 0-2 for the next 6 months. You should be icing and contrast bathing each day, and read alittle in my blog on the conservative treatments for sesamoid fractures. Please also get a Vit D level and probably bone density to make sure your bones are healthy.  Rich 

Sincerely,

Sesamoid Fracture: Email Advice

Hello, Dr. Blake! 

I was diagnosed with a sesamoid fracture on Nov. 18th, 2020. Throughout the two months, I have been wearing a walking boot and supplementing calcium, vitamin D, and taking a multivitamin. After two x-rays over the last two months, my doctor told me that there has been minimal healing. 

Dr. Blake's comment: Xray show only solid bone, and most of the initial fracture healing is with new skeletally immature bone that shows poorly on x-ray. Therefore, most agree that x-rays lag 1-2 months behind actual healing. Said in English, if an x-ray shows good healing in March, the bone was probably healed enough in February and probably January. So, minimal healing noted on x-ray is not really the whole story. MRIs are better for fracture identification, when x-rays are inconclusive, but you have to wait 6 months to the validation of some healing. I do x-ray for that information, and I get an MRI for that information, and I treat the sesamoid fracture and the patient based on getting them to be at 0-2 pain level as quickly as possible and then maintaining them at that level for 3 months. 

At my last visit, Jan. 14th, 2021, he felt around my foot and I didn't feel any pain (although he was very gentle). He instructed me to wear regular shoes, and ditch the walking boot so long as there is no pain. He told me to try exercising, but avoid inclines and do not run. If I continue with no pain, then he said it is okay if I go about my life with the bone still fractured. If I experience pain, he plans to take an MRI of my foot on Feb. 10th to see if he needs to remove the sesamoid bone. 

Dr. Blake's comment: I hope you just mis-understood. Continue to wear the boot until 2/18, and if you have taken it off before you read this, add a few more weeks so you can say you wore the boot for 3 months. It takes a year or more to know whether you need surgery. I am assuming that the pain in the 0-2 range while you are in the boot. Between now, and the time you are getting out of the boot, you need to have protective orthotics with dancer's pads to off weight the sesamoids, typically Hoka One One shoes are used due to their rocker. The transition from full time boot to full time out of the boot may take 2-6 weeks on average since pain level has to be your guide. 

It was May 2019 when I originally injured the bone. I noticed the pain when I had finished my third day in a row of working in the same pair of shoes (Chacos, not yet fully broken in). After a few days, the pain subsided for the most part. After several months of sporadic pain, I got an x-ray at a walk-in clinic, and they told me that nothing was wrong. After training for and running a marathon, I finally went to a foot doctor who then found the fracture using x-rays. Throughout the year or so of pain, it was never as painful as the first 24 hours of when it was originally injured. 

Dr. Blake's comment: This is great. Hopefully, the injury, while frustrating will not prove very serious when you get the MRI. You could have a normal bone that lies in multiple pieces that was fractured slightly last May, but now needs a little help to finish the healing. If there is swelling in the tissues, or seen on MRI, then contrast bathing to flush the bone and create better circulation should be done close to every night. 

To be honest, I am afraid of taking my doctor's advice of potentially living the rest of my life with the fracture in my foot. I read on your blog that it takes 2 years in some cases to heal the sesamoid bone, and it is rare that the bone does not heal. I do not want the bone to be removed; I fear the side effects of surgery may be worse than simply living with the fractured foot. Dr. Blake's comment: Yes, you will not live with a broken down. You are too smart for that. You may need an Exogen bone stimulator to help, along with spica taping, cluffy wedges, great off loading orthotics, Dr. Jills Gel Dancer's Padding, etc. 

My purpose in writing to you is to get a second opinion on my doctor's plan for my sesamoid fracture. In the meantime, I plan to wear stiff shoes and use dancer pads to keep the weight off my sesamoids in both feet. I use heat and ice on my foot as well when the swelling feels worse. 

Thank you so much for being the doctor we all need in our lives. I appreciate that you take the time to listen to people and give thorough advice. 

I hope this email finds you well. Dr. Blake's Comment: You are welcome, and good luck Rich 

Sesamoid Fracture Advice

Dr. Blake's comment: The patient's mother kindly sent the MRI CD for me to review which I did not until 6/29/2020.

Hello again Dr. Blake,

Thank you for reviewing L's MRI.  Here is a recap of my initial email with updated/new questions.  We look forward to hearing from you and are very thankful for your time and expertise. 

History:

L is a competitive varsity cross country and track athlete with her high school.   In February of this year she sustained a left metatarsal stress reaction (diagnosed via MRI) during track and field training.  She was immobilized for 8 weeks in a CAM boot, sat out the track season, received PT and did aqua jogging and swimming to maintain cardio fitness.  She had a  full blood panel and everything was WNL. Vitamin D was WNL, but in the lower range (we  live in South Florida and she gets plenty of sun on a daily basis). She supplements now with Vit D.   She is a very healthy eater, healthy weight and has regular menses. After a slow progression to return to running over the course of months she has been pain free in the left foot and doing summer training with her cross country team.  She has always run in HOKA Cliftons, but does rotate with Mizuno Wave Rider and Brooks Adrenaline during cross training.  She currently uses the customizable NB2400 (by Aetrex) shoe inserts in her left shoe.  
Dr. Blake's comment: I love the routine change in shoes to vary the stresses.

On June 11th after a practice she complained of R foot pain in the big toe region.  Due to her previous injury, we did not waste time diagnosing and the next day visited her foot and ankle specialist and had an MRI of the right foot the same day . They placed L in a CAM boot to be worn at all times until her follow up July 22nd (approx 6-7weeks post injury).  She has started Exogen bone stimulator 1x day x 20 mins, has had 2 out of 6 scheduled ESWT treatments , and has begun 2x week acupuncture.    She does not complain of any pain. 
Dr. Blake's comment: I would have to see what the literature says about ESWT for acute fractures. Please ask the doctor if there is anything for us to read.

1. How long would you recommend she remain in the boot? 
Dr. Blake's comment: My general rule is 3 months, however at 2 months you can begin to gradually wean out of the boot into bike shoes with embedded cleats or Hoka's with the rocker sole. You have to maintain the 0-2 pain level. 

2. Do you allow patients to remove the boot for gentle ROM of the ankle (the boot is driving her crazy with c/o foot cramping) ?
Dr. Blake's comment: Yes, it is a removable boot for walking. She does not need to wear it when she is not walking. Many patients find that around the house they can walk flat footed in soft sandals and avoid the boot since they can avoid toe bend and still protect. 

3. When should foot strengthening be initiated?   and massage to desensitize?
Dr. Blake's comment: Foot Strengthening is now!! Massage is now!! The massage is best done by the patient since she can make sure that she is avoiding pain. Each massage should b 2 minutes with some massage oil or topical gel like mineral ice. The foot strengthening she should don is metatarsal doming, single leg balancing with a float for the big toe, double and single heel raises also with a float for the big toe joint. 

4. Do you recommend she incorporate a dancer pad (or similar sesamoid cut out)  in her CAM boot? should we add a cluffy wedge with this? 
Dr. Blake's comment: Depends on her pain level. You place pads in like dancer's or cluffy wedges if you need to get the pain to 0-2 within the boot.

5. She is wearing a Darco Toe alignment splint while in the boot.  Do you prefer spica taping over this?    Do you use spica tape and dancer pad at the same time?
Dr. Blake's comment: If the boot gives 0-2 pain, no need for anything else. If not, you have to see what works to drive the pain down. Typically, dancer's and spica taping are used in the next phase as she re-introduces her activities. She should be cross training with cycling, or swimming without pushing off, etc. Some patients can use the eliptical if they stay flat footed. 

6. When could she attempt pain free short bouts of WB for mineralization?  
Dr. Blake's comment: Typically, this is a weight bearing boot, even if you need to off weight with dancer's padding. Around the house, you typically need the boot off to do the contrast bathing and, as long as you do not bend the toe, and you have dancer's padding and overall cushioning in a slipper, you can meander around. Keep the pain low!! At 8 weeks, if the patient is doing great, symptoms are where they should be, you begin to spend more and more time in a Hoka shoe or other stable but cushioned shoe. You need your orthotics with dancer's padding made by then. 

7. At what week post injury do you recommend beginning Physical therapy?   Aqua jogging?   or Swimming?   (we would like her to get some kind of cardio exercise when safe to do so)
Dr. Blake's comment: Agua jogging in the deep end of the pool is now just not emphasizing the toe motion. Swimming also great without fins and without pushing off the wall. Cycling without cleats with the pedal on the arch, not ball of the foot. Eliptical with Hokas flatfooted is fine without using the arms. 

8. Do you have a preference regarding  HOKA Clifton's vs Bondi?
Dr. Blake's comment: No, but it seems that the Bondi is more stable. With Hokas, each shoe has a different rocker point. So, I would make the decision based on how she feels the bend protects the sesamoid. If they both feel the same, go with the one that feels like it has the most toe box area. You will need it for all the sesamoid protection. 

9. At what part of the recovery do you initiate getting fitted for custom orthotics?
Dr. Blake's comment: This should be done as soon as possible. You need to have a good supportive and protective orthotic device, which could take adjustments or re-dos, when she is trying to wean out of the boot at 8-12 weeks. 

10.Do you have any recommendations for a physician in the Sarasota/Bradenton Florida area?
Dr. Blake's comment: I trust Dr Brian Fullem (Clearwater) and Dr. Matthew Werd (Lakeland) and Gerald Cosentino (Tampa). You can call their offices for a closer referral. 

11. We have been advised to avoid any icing and/or contrast baths at this time while she receives the shock wave therapy. Would she still benefit from it 6 weeks from now? 
Dr. Blake's comment: Shockwave is meant to inflame, but help in the healing. I have no experience with it for sesamoids. Sorry. I assume that icing and contrasts are fine after that stops. 

12.  As this is her second fracture in less than one year, do you think we should request a bone density test for her?
Dr. Blake's comment: Our doctors have gotten bone densities at her age and use the same values as the 20 year olds for understanding of the bone density. It is a test if she has low Vitamin D levels repeatedly, if her eating habits are suspect, if her menses is irregular, or if she is slow at healing bone. Did everyone feel she healed the metatarsal fracture fine and in the normal time length? 

13. Are we missing anything?    The MRI report  references sesamoiditis, so does she have a double whammy or will the fracture treatment help with the sesamoiditis?
Dr. Blake's comment: Heal the fracture, heel the itis part with the icing and contrasts and protection. 

Running is a big part of L's life and we want the absolute best care for her. We would like to be aggressive with her treatment to prevent a more chronic problem, however I want it to be within safe guidelines.  Her team is her family and it is hard on her to be away from them for weeks as she heals. 

Thank you!  

Sincerely,

ps. on a side note, I should also mention that L was an idiopathic toe walker and as a toddler wore AFO's and spent years in PT.  She was a very difficult case to treat (we avoided surgery), and still has very tight calf muscles and poor dorsi flexion, which is more than likely pre-disposing her to her injuries.  Are you familiar with Aaaron Mattes and his stretching therapy?  He is in Sarasota and L was treated by him years ago for her toe walking.  His sessions are very costly, but if you are familiar with his techniques and feel it would benefit her, please let me know.  
Dr. Blake's comment: Tight achilles is a huge reason for athletic injuries to the front of the foot. You should do what you can to help stretch out the achilles and I will look at Aaron's work. On a ironical note, the tight achilles gives her power to do sports where you are up on your toes. 

Sesamoid Fracture Email Advice

Hi Dr. Blake,

I wanted to thank you so much for recommending hiking shoes to me a while back in August of this year. I was able to do some light hikes and felt comfortable for the most part.

However, I’d like your opinion on my sesamoid and if you think I have a fighting chance of it ever healing. I’d be happy to pay you for this opinion, so please let me know how I can. I’m worried that I may need surgery and I’d love to send you my xrays and mri if possible. Let me know if you accept them via drop box or if you want me to send to you.

Dr. Blake's comment: Yes, please send. You can give a donation on the blog, but none is required. They are sent to Dr. Richard Blake, 900 Hyde Street, San Francisco, Ca, 94109. Email at rlb756@gmail.com when you put in the mail to be on the lookout for. 

Here’s my story: Late September 2018, I was experiencing severe foot pain and decided to wait a week until I would visit a doctor. On October 2nd, I went to a podiatrist and he diagnosed my right foot with a medial sesamoid stress fracture. I was in the air cast for about 8 weeks and then he recommended I use a u shaped pad for offloading in my tennis shoe for two months. After walking about a week in the tennis shoe I experienced a horrible relapse in pain and was unable to walk comfortable. Any weight placed on my foot was painful. I visited them again and they recommended a cortisone steroid injection. He injected it right into my fat pad on the ball of my foot and it did absolutely nothing except cause my foot to swell and increase in pain. After 2 weeks of feeling worse pain, post injection, I decided to get a second option and visited and orthopedic surgeon.
Dr. Blake's comment: Yes, no cortisone injections around bones you are trying to heal. Hopefully they gave you short acting cortisone which is safe for the bones, but really not that effective. 

The orthopedic surgeon said I had lots of edema and that my fracture was still not healed. He recommended me to be completely non-weight bearing for 2 months. I used either a knee roller and crutches for that time. Once the 2 months was up, my pain decreased from a 9 to about a 4 and it has remained a 3-4 since early February this year.

Dr. Blake's comment: Even though non weight bearing is almost never necessary, your case it is was justified since you have to get the pain down to within 0-2 for healing to occur. 

I’ve visited this orthopedic surgeon and another one and received the same recommendation. Use a carbon foot plate and get custom orthotics with a cut out for my sesamoid. I’ve work these since March and though I am able to walk it has not improved. Walking for a long period of time or bending back the ball of my foot (for example, when trying to do a push-up or calf raise) still causes a sharp pain or dull ache in the bottom of my foot to the point I cannot do these activities.

Dr. Blake's comment: When you get an MRI, and I like them early in sesamoid injuries, it is a baseline. 6 months later you typically get the next one to compare. I like going to the same place for both if the quality is great. I like 3.0 Tesla if you can get that, but Saint Francis has 1.5 which is very good. You can ask the doctor reading if it is good quality. Doctors know. So many times at the 6 month interval MRI the sesamoid is clearly only 25-50% healed. At least I can help the patient with their expectations then. 

I’ve told my doctors this and they say to wait it out or proceed forward without recommending any further treatment. I just would like to know if my sesamoid has a chance or if I need to proceed with surgery. Based on my mri please let me know if you think a bone stimulator, contrast bath or if you have any other recommendation would help me to avoid surgery! 

Dr. Blake's comment: Will do!! Rich

Thanks again for your help. Your help is greatly appreciated. 

Regards,