Getting An Athlete With A Sesamoid Fracture Back To Running Safely
I recently got an email from a runner who was on a walking break during an easy run in November when she felt a "crunch" in the ball of her right foot. It was followed by immediate pain. Her doctor said nothing looked off on the X-ray and she should return in four weeks if the pain was still present. The doctor did not mention anything about a boot at that time but told her to try to keep weight off the foot.
The weekend after the injury, the patient performed in a musical, dancing on the foot for three days and icing it when she could. Her doctor wasn't thrilled that she did this but said she should be fine just for a weekend. Four weeks later, the pain was still there. She went back and got another X-ray, revealing a fracture visible in the medial sesamoid. The doctor put her in a walking boot and scheduled a follow-up for six weeks later. He asked her to limit weightbearing activities.
When she went in for her six-week follow-up, the X-ray didn't show any improvement at all. She is feeling very discouraged. The doctor mentioned that she is a candidate for surgery now that it has almost been three months since the initial injury but she is wary of that option.
The patient bought some Hapad metatarsal pads and dancer pads for her shoes. Does she need further immobilization?
I would advise her to spend three months in a boot. If she attains the 0–2 pain level on the Visual Analogue Scale, she should begin another two to six weeks of weaning out of the boot with no increase in pain. This usually means experimentation with orthotic supports, dancer padding, spica taping and shoe change (possibly Hoka One One). She may want to use Exogen bone stimulation (Bioventus) for nine months. It is way too early to consider surgery.
The patient wonders if she will be healed enough to run her first marathon this November. Her training starts in June. While runners with sesamoid fractures can get back to running, she should not have any deadlines on her calendar because there is a potential for rushing through the rehab and taking too many risks. Patients like these should set goals to get better and avoid participating in events for the time being. The first goal is to get out of the removable boot in five to six weeks pain-free.
Caution patients not to read too much into X-rays that do not show healing after six weeks. X-rays can be two months behind showing the actual healing of the bone so they are poor indicators of bone healing at times.
Editor’s note: This blog originally appeared at https://www.drblakeshealingsole.com/2017/02/sesamoid-fracture-email-advice.html . It is reprinted with permission from the author.
