Fractured sesamoid in the foot

I have an female athlete (who won the steeplechase at the NAIA Nationals last spring) who has a fractured sesamoid bone in her right foot. She has not run (unable to run because of the pain) since Nationals. I have had athletes with plantar fasciitis, stone bruises, fractured cuboid, stress fracture of the metatarsals, etc. but have not experienced a fractured sesamoid. She had a bone scan recently which showed activity within the sesamoid. It is a very frustrating injury for this athlete. Any words of wisdom out there?

As a starting point, I’d switch her workouts to the pool (not touching bottom) while you sort out the best treatment options. you can keep a substantial level of fitness up during the recovery period. Based on history (are you training on the track a lot?) you might consider recovery pool workouts as part of the regular program- maybe once or twice a week.

Paul, not that uncommon of an injury in running athletes.
Answer some questions.
Is she non-weight or partial weight bearing? Have you tried a rigid orthotic with or without a sesmoid pad? First stress fracture? Any evidence of female triad that may need to be addressed?

Stick to the pool workouts as suggested by CF. Perhaps stationary bike as long as there is minimal pressure put under the first metatarsalphalangeal joint.

This is the same injury I have. The bone, from what I have read, almost never heals back into one piece. Many people are naturally have it as a “bipartate” (I believe that is the spelling), where the sesamoid is split into two pieces.

Some questions:
Are you using a bone stimulator?

Is the athlete supplementing is glucosamine, chondroitin, bromelain, and/or any other joint products?

What is the pain like? Is it when she is running/jogging/skipping/etc. or at random times?

Let me say what I have experienced so far. I was lucky enough to have a bone stimulator, which helped a lot as I had avascular necrosis. I have no received any MRIs, X-Rays, or anything since, as the doctor said as long as pain is gone or very low, then that is the most you can do. Surgery has a low rate of success with this injury (most doctors simply are not doing it to help an athlete) and can cause pain for a long time. A friend of mine had surgery and it took 2 years for him to feel normal from it again. Moving on, after about 8 weeks from injury, my walking boot was removed and I began light activity on it. I noticed soon (and much more apparent now), that “natural” movements like light jogging, skips, marches, and even build-ups (no sprints yet) cause little to no pain, but things like walking down stairs where the toe may make contact first (toe, not sesamoid) and then come down does in fact hurt. I am still unsure 100% for the reason, but I believe it may have something to do with the tendon there. Moving on, after I have had either a massage on my foot or myofascial release via a ball, the pain is virtually 0 under any circumstances. When I squeeze the bone, there is no pain.

I still do get some pain when the toe is put in a large ROM (like the stair situation) as the ROM at this point has been limited and I am looking for solutions for it.

My suggestions (not a doctor or pro coach so don’t take these as a matter-of-fact) for something to start with:

-If you don’t have a bone stimulator, get one immediately. Quality insurance pays off in this situation.

-Marching: It helps break up some of the scar tissue in the area and help the connective tissue form the way it needs to for successful performance. Easy skips can be a good thing to try after this has been exhausted and pain is lowering.

-Medicine Ball work. The motion brings some extention (on throws for example where you go onto your toe) that can begin rehab.

Keeping up general fitness is not exceptionally hard. Work on the areas that you normally don’t (thanks Clemson) have time or energy for. Maybe this is increasing flexibilty, or core and spine stability/strength, or whatever the athlete is lacking that the foot is not holding back.

I have a journal in the Member’s Journals section that you can look at to see my experience with it (although I do not have a TON of info on my foot, it can give you an idea of what I have been doing to work around the situation and rehab the foot).

I understand that in your Fundamentals 2 DVD you show a guy with a problem with flexibility in the big toe. How would you suggest one goes about this if a skilled therapist (as seen in the DVD who uses electro-stim w/ accupuncture needles) is not available? Could massage or chiro work suffice, or would the method you show be the best and most appropriate solution?

I am not her sport coach but her strength coach. But I know that she did quite a bit of on the track work before her injury. She was in a boot for six weeks and is currently weight bearing with a bit of compensation (she walks with most of her weight on the lateral side of her foot, semi-supinated gait pattern). She can do some pool work now but early on even that caused pain and some swelling. Within the past couple of weeks she is able to do some biking. She does have orthotics in her shoes now, which seems to help. I have seen progress with her but she is extremely frustrated with the slowness of the rate of healing. There has been many tears shed over this frustration. My role has been “chief pep talk giver” and listener. More words of wisdom would be greatly appreciated.

as her strength coach, maybe you could start her on an EMS program at this time. you can get some great gains with it. I trained a girl who had a severe ankle sprain on the ice who couldn’t run at all for several weeks. we relied on EMS as the primary strength work through that period (with plenty of cals and some pool work).
With only a couple of runs on the track, she opened the season with the world lead in the 500m.
As for pain with pool work. she could use two boots to immobilize both feet equally and keep the workload the same.

Paul, is she still having pain while weight bearing? If she is pain free why the continued compensation with suppination and not re-education of normal gait?
Do her orthotics contain a sesmoid pad?


Comments on big toe flexibility?

The sesmaoid bones have extremely low vascularity and it is easier for avascular necrosis to occur to the area. They are many things you can do to compensate for the problem (orthotic or even just a pad to offload the area, walking boot, etc) and many things have been mentioned in terms of training, but ultimately, it requires a long period of healing (definitely more than 8 weeks). A bone stimulator is definitely a good idea, but surgery may lead to other mechanical problems of the big toe joint.