Sesamoid Fracture: Email Advice

Dr. Blake,

Happy Holidays! Thank you so much for all the time you’ve put into this blog! I’ve read through many posts regarding sesamoid injuries, and there's more info here than anywhere else.
My 15 year old daughter fractured her sesamoid and her podiatrist hasn't known what to do, so I was wondering if you could help her out.

This is what she said:
In october, I felt a pop in my foot during cross country practice, and ended up in a lot of pain. I ran one final 5k a few days after, and went to homecoming in heels that night. Horrible idea. My foot was bruised and my pain level was about an 8 (10 being the most painful).

I went to the podiatrist, who said I just had sesamoiditis and could run again in a week. I took an entire month off just to be safe, and when I went back to the podiatrist because I was still in pain, he said it turns out that I had a fracture. I wasn't given a boot to immobilize it.

A few weeks later I felt another painful pop in my foot, went back to the podiatrist, asked for a boot, and here I am. I’ve been wearing the boot to immobilize my foot for the past 2 weeks and my pain level is at a 0, but it is very visibly swollen. I've been icing 3x a day and am going to start contrast baths as you recommended. I bought calcium supplements and am taking vitamins as well.
Dr. Blake's comment: So you are now starting about 3 months of immobilization with 10 weeks to go. Now until Feb 15th, the boot should be your friend in creating a consistent 0-2 pain level. The icing twice a day, and the contrast baths each evening are important. Gentle massaging the area with your palms 2-3 minutes three times a day with arnica, mineral ice, hand lotion, just to desensitize the area. Make sure you bike a lot of leg strength. Unfortunately 30 minutes of running is equivalent to 2 hours of biking outdoors, but probably one hour on a stationary bike.
     This part is the easy part. Soon, the podiatrist must make a good pair of custom orthotics to protect the sesamoid. These should be ready for you at 8 weeks into the immobilization, the earliest time to start transitioning into orthotics and athletic shoes. It is imperative you keep the pain level to 0-2 during this whole process. Sometimes, as you wean from the boot, you need to wear Hoka One One shoes or Bike Shoes with embedded cleats.
     Remember also to have your Vitamin D level tested as this is a frequent cause of stress fractures. If the normal range is 30-80, I want my athletes around 55. Also, a good healthy diet is crucial to get the building blocks for fracture healing.

I am just wondering if there's anything i'm missing. Also, how would I get an exogen bone stimulator? I assume I would need a prescription. I can also send you my MRI if you would like to see it. The radiologist confirmed that I have a fracture.

Dr. Blake's comment: Yes, you can send it to Dr. Rich Blake 900 Hyde Street, San Francisco, California, 94109. The podiatrist or your pediatrician can start the Rx process for the bone stim from Bioventus called Exogen. Hope all this helps. Rich
Here's the MRI report:

Technique: Routine MRI images of the right foot
Findings:
A marker has been placed beneath the medial forefoot and great toe to indicate the site of clinical concern. There is confluent marrow edema within the medial sesamoid bone indicating a nondisplaced vertical fracture or stress fracture and edema in the underlying soft tissues. The lateral sesamoid bone of the the great toe appears normal. No metatarsal stress fracture or suspicious lesion is identified. Normal signal is present within the muscles. No Morton's neuroma or ganglion cyst is evident. The flexor and extensor tendons are intact. There is no plantar plate tear.
Conclusion:
1. Nondisplaced fracture or stress fracture of the medial sesamoid bone of the great toe and edema in the plantar soft tissues.


Again, thank you so much for the blog!

Happy Holidays!!

The patient's mom sent me the MRIs for review. Here is my response:

 I had a chance to look at the MRIs. So, clearly there is a nondisplaced stable fracture of the medial (also called tibial) sesamoid which needs some protection going forward. You can protect it in different ways as you blend the Immobilization phase into the Return to Activity. The protection can come from Dr. Jill's dancer's pads, cluffy wedges, spica taping, custom orthotics, and removable boots. The boot is to prevent her from stirring it up and some of the patients only use while walking great distances (probably 4 hours a day to rest the tissue and trying to decide which 4 hours are the most meaningful. With return to sports, you have to see if sometimes she can wear an orthotic, say in her conditioning, and sometimes Dr. Jill's padding with cluffy wedges with or without spica taping. If patients feel good, they first stop taping. I would experiment as you place her on a 6 week return to full activity program. Each week she adds more and more stressful ball of the foot activities until she is at full speed and full activity at 6 weeks. It is the push off of most concern, so speak to the coach and see how this can be arranged.

     The difference between the 2 MRIs are minimal, which is to be expected. After the first MRI, I wait 6 months to repeat and go solely on the patients feel, and if they have to limp at all (a big no no!) It is usually a mistake to remove the sesamoid protection for the next several years. Part of me saying that is because I do not know her foot mechanics (some patients have 3-4 reasons that their sesamoids can be stressed) and part of that because I know sesamoid padding will not inhibit her ability to perform at the highest level.

     Contrast bathing remains the best home treatment to flush out the sesamoid of swelling that can cut off the circulation. Try to average 3-4 nights per week, and simple ice pack after workouts. Hope all this helps. Continue to listen to the pain, even if she is competing again. Rich

Sesamoid Fracture Email Advice

Dr. Blake, I am so happy to discover your blog!

     My daughter is 14-years-old, and being recruited for a college athletic scholarship. Comparing x-rays, MRI, and CT scan, the orthopedic has diagnosed a non-union medial sesamoid fracture. The break is horizontally across the middle, so the appearance is similar to a bipartite sesamoid. This was an acute injury, which occurred 11 months ago. Initially, she wore an orthotic shoe for 3 weeks, started to feel better, and was cleared to return to strenuous activity after 3 weeks. Well, here we are 10 months later and she plays in constant pain. Orthotics and taping have not worked at all. The doctor now suggests a non-weight bearing plaster cast for 6 weeks. I am happy to try any non-surgical option!   I have several questions for you. 

#1 Is there a chance cast will work to heal a non-union fracture. 
Dr Blake's comment: Totally, she should be in the Immobilization Phase of Rehabilitation for a 3 month period with a Exogen bone stimulator to use daily. During that time, you want to do contrast bathing once daily, and icing twice per day. She needs to substitute biking and swimming, with strengthening and flexibility workouts, for her main sport. The next 3 months are even harder, as you wean out of the cast, continue anti-inflammatory, keep the pain level 0-2, gradually increase the activities, continue cross training, and feeling loss a lot of the time (important to have a great PT or sports doc to help her through this time). Need to have a good protected weight bearing orthotic at that time. 

#2 If the cast does not work what is her best option to heal this trying to screw the bone or remove it? 
Dr Blake's comment: Most remove all, some partial. When removed, you have to wear protected orthotics forever for sports, and toe separators between the first and second toes in all enclosed shoes to help slow bunion development. 

#3 Are we risking all her years of hard work to get to this point athletically being ruined? 
Dr Blake's comment: If you go conservative, you have to be committed to 6 months of keeping that pain level between 0-2, and another 6 months to have surgery and healing, if the conservative treatment does not work. If you have surgery tomorrow, you will have to give 6 months to healing before she is back to her pre-surgical level of activity. As a physician, if I feel that there is a reasonable chance to heal conservatively, I will always recommend the conservative route, even in the face of loss of college scholarships, etc, because surgical complications can occur. Part is your comfort level with the potential surgeon. This does not mean we do not do surgery in the situation your daughter finds herself in, but at her age, much more caution and opinions are used. 

#4 Should she just play through the pain? 
Dr Blake's comment: No!! Playing through pain does so much damage to the joint potentially, and the rest of the body due to compensations. You also are risking nerve hypersensitivity which can disappear slowly even with surgery. 

Sesamoid Fracture in Growing Child: Email Advice

Hello Dr. Blake,

I am writing today regarding my daughter, Tonya (name changed). She is 13 1/2 and has a right tibial sesamoid fracture. First let me say, I know our feet are important to all of us....Tonya is extra special because she is a dancer. Five days a week and hours a day. She does almost every kind of dance you can think of from ballet to hip hop.

 She has already been told she can not perform in her upcoming ballet, which is heartbreaking, but we will do whatever it takes to get her at her best. She has another dance recital coming up in May, as well as tryouts for the High School program directly following. She is hoping to be able to participate in both of these things.  She is not getting a great deal of hope from her doctor of healing. She was in a hard cast for 3 weeks and has now been in a soft removable cast (non-weightbearing) for 2 weeks.

Dr Blake's comment: Typically, sesamoid fractures take 3 months of immobilization (casts or removable boots as long as you are creating a pain free environment, following by 2 to 6 weeks of gradually weaning out of the boot, into orthotics and dancer's pads, and icing, with some physical therapy. Then 3 plus months of gradual return to activity. There can not be pressure due to upcoming performances, or the gradual process of healing has a chance to be rushed jeopardizing healing. Typically, 6 to 8 months after the immobilization is started, the dancer/athlete feels comfortable to return to competitive activities. And, this is just average, with some going alittle less time (5 months) and many going longer 12-13 months. I know this sounds like a long time, but complete healing of the fracture with her future ahead of her, has to be carefully guarded.

Her doctor has mentioned that this could be an activity changing injury.

Dr Blake's comment: This is rarely the case. So, why go to that discussion in these early stages? Remember, as tissue heals, there is a lot of swelling that collects in the area. The swelling is painful to walk on. Casts trap the swelling, and non weight bearing also does not allow the fluid to be pumped naturally out of the injured area. So, casts and non weight bearing are necessary evils in our fight, producing both good healing of injured tissue, and bad problems of swelling retention, muscle/tendon weakness, joint stiffness, nerve hyper-sensitivity. This is why the weaning process from the cast to no cast can be long (always too long). 

 We are doing all he suggests for her best chance of healing, but are looking for some more information.

Dr Blake's comment: So, I gauge you have 6-7 more weeks of immobilization. Hopefully, you can process to an removable boot eventually, so you can start the important anti-inflammatory part of icing twice daily and contrast bathing once day. Hopefully her diet is very well balanced with enough calcium. She should be getting 1500 mg Calcium daily in her diet/supplement, and 1000 units of Vit D unless she is out in the sun for a short time every day. I hope she has no history of eating problems, or on any diets. One of our MDs requires one serving of red meat daily with these bone injuries. Once in the removable, ask for advice on what she can strengthen, what to stretch, how to start balancing. I have a lot on my blog on this. But, it has to be pain free, what ever you do in this area. 

 Have you seen a teenager with this injury?

Dr Blake's comment: Yes, and they tend to heal just fine. Children have great bone metabolism and will heal things much quicker in general than an old geeser like me. Yet, children do not have a greatly developed nervous system. Pain can be much higher than it really is for some, and much lower than it really is for some. This makes the process of rehabilitation either slower than it needs (which I think is always okay) or much faster than it should (possibly dangerous). Parents affect the equation for the rehab specialist a lot. They must allow the process to go on without focus of upcoming events, possible scholarships, the emoitional heartbreak the child may have. The parents must be the voice of reason, of common sense. Talking to doctors, therapists, or reading this blog post, it must make sense to you. Your child must be protected and not harmed. There is a lot of weird advice out there. 

 What are her chances of healing?

Dr Blake's comment: 99.5% unless there is something else in the MRI that I do not know. A simple sesamoid fracture in a child, with all the time in the world to heal, good diet, good parental advice, heal these things very well. If they do not heal, something else is going on. 

 Do you have any added suggestions? She is taking calcium and a bone/joint health supplement daily. And of course the power of prayer is our biggest help. Is there anything more we can do? Her doctor has stated that surgery is not an option at her age.

Dr Blake's comment: No doctor wants to do surgery on a young child. Treating ballet dancers, I have done my share of surgeries on these fragile athletes, and it is scarey (if you have anything of a conscience). You are just in the Immobilization Phase of the Injury which will last for probabaly 12 weeks longer. The next phase is the Restrengthening Phase, which you can start somewhat when you are in the removable boot. All doctors use these at different times during these initial 3 months. This Phase goes on for 9-12 months, and is blended with the first phase and the last phase. The third phase, after you have successfully and painlessly weaned out of the removable boot, is the Return To Activity Phase. It should be slow, normally run by a physical therapist, and the pain can not get over 0-2 on a pain scale of 0-10. It will be important to read my post on "Good vs Bad Pain", and familiarize yourself with the pain scale.

Right now, we are scheduled to go back after 3 weeks in the soft cast. The doctor said he will take a look then and decide where to go from there. He did mention that when the day comes that she is "better", she will need 3-4 weeks of physical therapy.

We are looking for some more input and advice. Maybe you will just tell us to keep being patient. If so, we can and will.

Thank you for your time!

Dr Blake's comment: I sure hope you comments have been helpful. Read all my posts on Sesamoid Injuries, so you are aware of padding, taping, MRIs, etc, so you can help your daughter the best. Remember, Complete Healing is the most important, not when that occurs. Please leave that in God's Hands.