BASICS
DESCRIPTION
Painful inflammation (without radiographic change) of the two sesamoid bones embedded in the flexor hallucis brevis tendon under the 1st metatarsophalangeal (MTP) joint (1,2). � �
ETIOLOGY AND PATHOPHYSIOLOGY
- Inflammation results from repetitive stress loading
- Weight bearing and repetitive impact
- Forceful extension of the great toe
- May also be idiopathic (1)
Genetics
No known genetic predisposition � �
RISK FACTORS
- Young athletes are at risk for developing sesamoiditis.
- Athletes who repetitively put significant load on the sesamoids are at particular risk, such as the following:
- Long-distance runners
- Ballet dancers
- Baseball catchers
- Congenital factors increase the risk of injury.
- Asymmetry in the size of the sesamoid bones
- Malalignment of the sesamoid bones
- Condylar malformations
- Symmetrical enlargement
- Cavus feet (high arch) (1)
GENERAL PREVENTION
Sesamoiditis is most commonly an overuse injury; activity modification is key to prevention. � �
DIAGNOSIS
HISTORY
- Acute or gradual onset of pain under hallux ( "on ball of foot " �), which is exacerbated by direct pressure, weight bearing, and flexion/extension of the great toe.
- If there is a history of trauma, with immediate onset of pain, suspect a fracture.
PHYSICAL EXAM
- Redness and swelling may or may not be present.
- Focal tenderness over the affected sesamoid
- Painful passive dorsiflexion of 1st MTP joint
- Crepitus along the flexor hallucis longus
DIFFERENTIAL DIAGNOSIS
- Sesamoid fracture; turf toe
- Bursitis; osteochondritis; arthritis
- Avascular necrosis
- Osteomyelitis
DIAGNOSTIC TESTS & INTERPRETATION
- Order a forefoot radiograph to rule out fracture.
- Recommended views
- Weight-bearing anteroposterior and lateral
- Axial sesamoid (3)
Initial Tests (lab, imaging)
Follow-Up Tests & Special Considerations
- Bilateral comparison radiographs help distinguish a normal partite sesamoid from a sesamoid fracture.
- Bipartite sesamoid is bilateral in 34% of cases (3).
- Bone scan or MRI may be indicated if radiographs are inconclusive and/or symptoms persist (2).
TREATMENT
GENERAL MEASURES
- Soft-soled, low-heeled shoes
- Tape great toe in gentle plantar flexion.
- Decreased weight bearing/activity modification
- Orthotic device
- Gel inserts
- C- or J-shaped padding
- Metatarsal bars (1)
MEDICATION
First Line
- Activity modification is the key first-line treatment.
- Pain control
ISSUES FOR REFERRAL
- If symptoms persist after initial conservative therapy, consider short leg fracture brace/boot for 4 to 6 weeks.
- Athletes are often anxious to return to full activity, which can delay healing.
ADDITIONAL THERAPIES
If significant swelling is present, consider cortisone injection. � �
SURGERY/OTHER PROCEDURES
- Surgery is rarely indicated for sesamoiditis because sesamoidectomy may be complicated by the following:
- Weakness
- Digital nerve paresthesia
- Hallux deformity ( "cock-up toe " �) (1)
- Sesamoidectomy may be indicated for treatment of chronic sesamoiditis.
- Steroid injections may be an acceptable alternative for chronic sesamoiditis treatment (4).
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
- Continue conservative management for 8 weeks.
- Follow-up at 1, 4, and 8 weeks.
Patient Monitoring
If pain does not improve within 2 to 4 weeks, repeat radiograph to rule out occult sesamoid fracture; may also consider MRI or CAT scan for further evaluation (2). � �
PATIENT EDUCATION
- Patients can return to activity after symptoms resolve.
- Return to activity should be gradual. Use padding in shoes to relieve stress on sesamoids.
- Return of symptoms should prompt cessation of offending activity and reevaluation.
PROGNOSIS
- Complete symptom resolution is expected after 8 weeks of treatment and activity modification.
- Patients should return to activity gradually.
- Sudden increases in sesamoid stress can lead to recurrence and/or sesamoid stress fracture.
COMPLICATIONS
- Missed fracture
- Recurrence
REFERENCES
11 Dedmond � �BT, Cory � �JW, McBryde � �AJr. The hallucal sesamoid complex. J Am Acad Orthop Surg. 2006;14(13):745 " �753.22 Vanore � �JV, Christensen � �JC, Kravitz � �SR, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 4: sesamoid disorders. J Foot Ankle Surg. 2003;42(3):143 " �147.33 Kadakia � �AR, Molloy � �A. Current concepts review: traumatic disorders of the first metatarsophalangeal joint and sesamoid complex. Foot Ankle Int. 2011;32(8):834 " �839.44 Chin � �AY, Sebastin � �SJ, Wong � �M, et al. Long-term results using a treatment algorithm for chronic sesamoiditis of the thumb metacarpophalangeal joint. J Hand Surg Am. 2013;38(2):316 " �321.
ADDITIONAL READING
- American Academy of Orthopaedic Surgeons, American Orthopaedic Foot & Ankle Society. OrthoInfo " �Your connection to expert orthopaedic information. Sesamoiditis. http://orthoinfo.aaos.org/topic.cfm?topic=A00164. Accessed 2014.
- Garrido � �IM, Bosch � �MN, Gonz � �lez � �MS, et al. Osteochondritis of the hallux sesamoid bones. Foot Ankle Surg. 2008;14(4):175 " �179.
- Nix � �SE, Vicenzino � �BT, Collins � �NJ, et al. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage. 2012;20(10):1059 " �1074.
- Richter � �RR, Austin � �TM, Reinking � �MF. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis " �critical appraisal and commentary. J Athl Train. 2011;46(1):103 " �106.
CODES
ICD10
- M25.879 Other specified joint disorders, unspecified ankle and foot
- M25.872 Other specified joint disorders, left ankle and foot
- M25.871 Other specified joint disorders, right ankle and foot
ICD9
733.99 Other disorders of bone and cartilage � �
SNOMED
Sesamoiditis � �
CLINICAL PEARLS
- Sesamoiditis most commonly affects young athletes, presenting as pain in the ball of the foot.
- Sesamoiditis rates have increased with increased use of artificial playing surfaces.
- Sesamoid fractures may not be apparent on immediate postinjury radiographs. Repeat radiographs are indicated in patients with persistent symptoms despite conservative management.
- Sesamoiditis has an excellent prognosis. Activity modification is central to recovery. Sesamoiditis rarely requires surgery.