Saturday, June 23, 2018

Sesamoid Problems? You Have Lots of Company



2017 Kona racer heading to the changing tent and 26.2 more miles before day's end

"Give me three steps, gimme three steps mister..." Lynyrd Skynyrd

This is a reprint of a 2009 blog which has stimulated 1000s of athletes.
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I was asked recently about an athlete with a foot problem and a possible sesamoid fracture. It occurred to me that most folks didn't know they had sesamoid bones, or if they did, where they were. 

The simplest definition of a sesamoid bone is one that's surrounded by tendon or intratendinous. The most obvious example would be the knee cap. This blog will be devoted to the pair of sesamoid bones underneath the ball joint of the big toe. They are about the size of a lima bean, normally glide front and back with each stride and rarely give us much cause for concern. But as with any bone in the foot, they can be broken or subject to a stress fracture. A true fracture takes a pretty significant injury such as a fall from a height where we in the endurance sport world are more likely to see a stress fracture from the usual causes. (See my two 2009 blogs on this injury pattern.) The athlete with a true fracture is going to be immobilized between 4 and 8 weeks, will be made non-weight bearing on crutches, and like likely be doing all of his/her training in the pool for a while. Treating the stress fracture is much less aggressive, but here, too, your running shoes will see no action for longer than you'd like.

Often times, sesamoid problems present as sesamoiditis, an inflammation of the area caused by the usual culprits of too much too fast, especially speed work or hills. One starts with the gradual onset of pain under the big toe, initially present during only the hardest portion of the workout and increasing to any running, even walking. There doesn't seem to be much redness or bruising. They can be slightly swollen but frequently it's not easy to see.

So what do you do? Back off for a while. Maybe do a percentage of your weekly run volume in the pool. (It can be fun.) Then, if you can unload the area of distress by using a metatarsal pad or other device to very slightly overload the non-injured portion of the foot being certain to ice down the area once the run is over. Don't be so aggressive that you risk frostbite but 15-20 minutes ought to do it.

It's not uncommon for an exact diagnosis to be difficult to make. Stress fracture, old fracture, acute fracture, etc. Even then, the treatment can be both prolonged and frustrating. If your doc suggests the possiblity of surgery, this would be one of those instances where, in my opinion, a second opinion is mandatory.  This is your foot you're talking about and you only have one chance to get the right answer the first time.

Lastly, trying to go through your log book examining each week, each run, for clues as to the cause and how to never have it again is always beneficial.  And if you're successful, your "three steps" will be crossing the finsh line without pain!

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