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Sesamoiditis

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Sesamoiditis

BASICS

DESCRIPTION

ETIOLOGY AND PATHOPHYSIOLOGY

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). пїЅ пїЅ

No known genetic predisposition пїЅ пїЅ

Initial Tests (lab, imaging)

Follow-Up Tests & Special Considerations

If significant swelling is present, consider cortisone injection. пїЅ пїЅ

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). пїЅ пїЅ

11 Dedmond пїЅ пїЅBT, Cory пїЅ пїЅJW, McBryde пїЅ пїЅAJr. The hallucal sesamoid complex. J Am Acad Orthop Surg. 2006;14(13):745 " пїЅ753.22 Vanore пїЅ пїЅJV, Christensen пїЅ пїЅJC, Kravitz пїЅ пїЅSR, et al. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 4: sesamoid disorders. J Foot Ankle Surg. 2003;42(3):143 " пїЅ147.33 Kadakia пїЅ пїЅAR, Molloy пїЅ пїЅA. Current concepts review: traumatic disorders of the first metatarsophalangeal joint and sesamoid complex. Foot Ankle Int. 2011;32(8):834 " пїЅ839.44 Chin пїЅ пїЅAY, Sebastin пїЅ пїЅSJ, Wong пїЅ пїЅM, 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 " пїЅ321.

  • Inflammation results from repetitive stress loadingWeight bearing and repetitive impactForceful extension of the great toe
  • May also be idiopathic (1)
  • Weight bearing and repetitive impact
  • Forceful extension of the great toe

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 runnersBallet dancersBaseball catchers
  • Congenital factors increase the risk of injury.Asymmetry in the size of the sesamoid bonesMalalignment of the sesamoid bonesCondylar malformationsSymmetrical enlargementCavus feet (high arch) (1)
  • Long-distance runners
  • Ballet dancers
  • Baseball catchers
  • Asymmetry in the size of the sesamoid bones
  • Malalignment of the sesamoid bones
  • Condylar malformations
  • Symmetrical enlargement
  • Cavus feet (high arch) (1)

GENERAL PREVENTION

DIAGNOSIS

HISTORY

  • Acute or gradual onset of pain under hallux ( "on ball of foot " пїЅ), 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 viewsWeight-bearing anteroposterior and lateralAxial sesamoid (3)
  • Weight-bearing anteroposterior and lateral
  • Axial sesamoid (3)
  • 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).
  • Bipartite sesamoid is bilateral in 34% of cases (3).

TREATMENT

GENERAL MEASURES

  • Soft-soled, low-heeled shoes
  • Tape great toe in gentle plantar flexion.
  • Decreased weight bearing/activity modification
  • Orthotic deviceGel insertsC- or J-shaped paddingMetatarsal bars (1)
  • Gel inserts
  • C- or J-shaped padding
  • Metatarsal bars (1)

MEDICATION

  • Activity modification is the key first-line treatment.
  • Pain controlNSAIDIce (3)
  • NSAID
  • Ice (3)

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

SURGERY/OTHER PROCEDURES

  • Surgery is rarely indicated for sesamoiditis because sesamoidectomy may be complicated by the following:WeaknessDigital nerve paresthesiaHallux deformity ( "cock-up toe " пїЅ) (1)
  • Sesamoidectomy may be indicated for treatment of chronic sesamoiditis.Steroid injections may be an acceptable alternative for chronic sesamoiditis treatment (4).
  • Weakness
  • Digital nerve paresthesia
  • Hallux deformity ( "cock-up toe " пїЅ) (1)
  • 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 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.
  • Sudden increases in sesamoid stress can lead to recurrence and/or sesamoid stress fracture.

COMPLICATIONS

  • Missed fracture
  • Recurrence

REFERENCES

ADDITIONAL READING

  • American Academy of Orthopaedic Surgeons, American Orthopaedic Foot & Ankle Society. OrthoInfo " пїЅYour connection to expert orthopaedic information. Sesamoiditis. http://orthoinfo.aaos.org/topic.cfm?topic=A00164. Accessed 2014.
  • Garrido пїЅ пїЅIM, Bosch пїЅ пїЅMN, Gonz пїЅ пїЅlez пїЅ пїЅMS, et al. Osteochondritis of the hallux sesamoid bones. Foot Ankle Surg. 2008;14(4):175 " пїЅ179.
  • Nix пїЅ пїЅSE, Vicenzino пїЅ пїЅBT, Collins пїЅ пїЅNJ, et al. Characteristics of foot structure and footwear associated with hallux valgus: a systematic review. Osteoarthritis Cartilage. 2012;20(10):1059 " пїЅ1074.
  • Richter пїЅ пїЅRR, Austin пїЅ пїЅTM, Reinking пїЅ пїЅMF. Foot orthoses in lower limb overuse conditions: a systematic review and meta-analysis " пїЅcritical appraisal and commentary. J Athl Train. 2011;46(1):103 " пїЅ106.

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

SNOMED

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.