Addressing Sesamoid Pain In Dancers
Sesamoiditis and sesamoid fractures. Sesamoiditis and sesamoid fractures can be annoying problems because they heal so slowly. Sesamoiditis has many causes. Here are some causes to keep in mind.
• Contusion. Contusions will respond to conservative therapy but often heal slowly.
• Sprain of a bipartite sesamoid. The injury X-ray film compared to an old film will sometimes show widening of the distance between the two fragments.
• Stress fracture. The bone scan will be positive.
• Fracture. A fracture will usually heal either by bone or fibrous union.
• Avulsion fracture of the proximal pole.
• Osteonecrosis. This condition occurs often in the lateral sesamoid, occasionally in the medial and in both on rare occasions. The cause is unknown and the prognosis is often poor because the bone may fragment as it heals and pain may persist. In some patients, healing will occur but the process is slow and uncertain.
• Osteoarthritis with loss of the cartilage space and spur formation. You’ll usually see this on the X-ray sesamoid view and it usually affects adults.
• Entrapment neuropathies, especially adjacent to the medial sesamoid, can mimic sesamoiditis or be part of the problem. In this condition, a Tinel’s sign will usually be present.
Performing a sesamoidectomy is usually not necessary for dancers because the pain will almost always subside eventually with conservative therapy alone. It is often difficult to get the dancer to be patient but the pain will usually go away if one can just wait long enough. (The exception to this rule is osteonecrosis.)
Conservative therapy of sesamoid problems may take six to 12 months. During this period, you may use pads to offload the sesamoids and dancers should minimize demi-pointe work. If the dancers still have disabling symptoms after one year of conservative treatment, you may consider a sesamoidectomy. When you’re treating osteonecrosis, you may shorten the period of conservative treatment to six months, given the poorer prognosis associated with this condition. However, keep in mind that you should never remove both sesamoids.
Dr. Caselli (pictured) is an Adjunct Professor in the Department of Orthopedic Sciences at the New York College of Podiatric Medicine. He is a staff podiatrist within the VA Hudson Valley Health Care System in Montrose, N.Y.
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