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Young professional dancer assumes demi-point and 'breaks down'. Hobbles into the clinic, complaining of pain along the MLA. Jacks test/windlass reproduces symptoms, as does resisted hallux plantar flexion. The plantar fascia is very tender to palpation along the mid and distal aspects. The plantar aspect of the 1st MPJ is extremely tender and less so on the opposite foot.

I 'diagnosed' an acute PF tear, then taped low-dye. Clinical tests subsequently improved including jacks test. Gait discomfort reduced.



But...an MRI (while finding no abnormality of the distal half of the plantar aponeurosis on either side), depicted mild oedema consistent with stress changes without fracture...within the left sided sesamoid bones of the great toe...with no fractures.



In view of the MRI findings, in association with the palpatory tenderness of the plantar aspect of the 1st MPJ, I strapped on some thick poron donuts which made gait and demi-point less symptomatic. I envisage that this will assist in the acute stage, as well as having some role in his dancing slippers when return-to-activity is contemplated. I also added a thick poron plantar single wing to his old orthoses to offload the 1st met head.

I have also removed the heel raises put in by another practitioner for an old achilles issue, as this, in my mind, loads the sesamoids more??



Any treatment advice? Any referral advice?

 

The most common reason I think that some of my treatment of "sesamoiditis" has failed with donut type padding was that it was really a flexor hallucis tendonitis in the area of the seasmoids.

Also the latest JAPMA has a paper on osetonecrosis of the sesamoids as a ddx.

 

The fastest way to get a dancer back with a sesamoid stress fracture is to put him in a camboot for two to three months (depending on how long it has been present before commencing this immobilization). If you really want to kick in the turbo, use an EBI machine or Exogen device concurrently. This technic works quite well if the injury is caught early. Don't let absence of symptoms after the first couple of weeks' camboot seduce you into following the dancer's entreating to resume dance too soon. Two months camboot at least. A follow-up MRI at two months would be great to affirm healing.

Then of course you have to find out why it happened...a misstep; weak peroneals causing medial overshift to avoid sprained ankle; harder floor than used to; basically bad technic; tap shoes' soling rubber worn out; more classes than used to; etc.

If nothing undoable like the above is present, the cause may be structural (global pes cavus or inadequate plie would first come to mind), for which deft padding shaped like a negative image of his forefoot frontal plane contour might help, the pad extending to the sulcus. During the time of immobilization he should be keeping other parts of his body strong and flexible (Pilates, floor barre), and attending rehearsal and perhaps performance. After immobilization, the dancer should gradually return to dance. Dancers must get used to pads with easy class before attempting them for rehearsal; sometimes they avoid using the pads for performance because it throws off their "feel for the floor".

Also, check FHB strength and calf strength once healing has occurred. If FHB is weak it could easily cause sesamoid fracture. If calf is weak, the dancer is not a good leaper and had better strengthen or he'll be looking at forefoot (as well as rearfoot/leg) injuries throughout his career.

Please help me...what's Jack's test?

 

PS The picture in my replies is of a fourteen year-old, pain free, normal-looking ballerina's foot. By this time, they don't have feet anymore...they have adapted instruments for dance.

 

Sesamoiditis

Dear Atlas

Have you tried the Jones Stress strain technique. I learnt it a short while ago and have used it on 3 patients so far all of which had resolution of pain almost immediately. There seems to be two techniques, the one I used is to apply pressure to the painful sesamoid and d/flex and pl/flx the hallux until the pain goes then hold the pressure for 90 seconds. The other slightly different is described at this site www.musmed.com.au.

Have a good day Dave Smith :)