Sesamoids are bones that develop within tendons. The most commonly known sesamoid is the kneecap, but sesamoids are also frequently found in the foot and hand. In the foot, two sesamoids, each about the size of a corn kernel, are typically located near the underside of the big toe.

‍

Symptoms

Pain from a sesamoid injury is concentrated under the big toe on the ball of the foot. With sesamoiditis or a stress fracture, pain may develop gradually, whereas a traumatic fracture results in immediate pain. Swelling and bruising may or may not be present. Bending and straightening the big toe can become difficult and painful.

‍

Causes

Sesamoids function like pulleys, enhancing the tendons' ability to transmit muscle forces. In the forefoot, they also assist with weight bearing and elevating the bones of the big toe. Sesamoids can break due to traumatic injury or develop stress fractures from overuse. Additionally, the tendons surrounding the sesamoids can become irritated or inflamed, leading to a condition known as sesamoiditis, a form of tendinitis or tendinosis. Sesamoiditis is common among ballet dancers, runners, and professional athletes.

‍

Diagnosis

During an examination, Dr. Kamel will check for tenderness around the sesamoid bones. They might manipulate the bone slightly or ask you to bend and straighten the toe. They may also bend the big toe upwards to see if the pain intensifies.

X-rays of the forefoot are typically requested to ensure a proper diagnosis. In some individuals, the medial sesamoid (near the center of the foot) has two parts (bipartite). The edges of a bipartite medial sesamoid are generally smooth, while the edges of a fractured sesamoid are jagged, making X-rays useful for distinguishing between the two conditions.

To compare bone structure, X-rays of the other foot might be taken. If the X-rays appear normal, additional tests such as an MRI or CT scan may be recommended. Blood tests for conditions like gout or inflammatory arthritis might also be considered.

‍

Treatment

‍

Non-Surgical Treatment

Most cases of sesamoiditis do not require surgery. Although treatment can be effective, symptom resolution may be slow. Non-surgical recommendations include:

• Activity Modification: Stop activities that cause pain.

• Pain Management: Use acetaminophen or ibuprofen.

• Rest and Ice: Rest the affected foot and apply ice (using an ice pack or a towel-wrapped ice) to reduce swelling.

• Footwear: Wear soft-soled, low-heeled shoes. Stiff-soled shoes may also be comfortable, but avoid clogs as they elevate the heel and increase pressure on the sesamoids.

• Padding: Use a felt cushioning pad around the sesamoid to alleviate stress.

• Gradual Return to Activity: Gradually resume activities while using a cushioning pad of dense foam rubber under the sesamoids. Avoid weight-bearing activities on the balls of the feet.

• Toe Taping: Tape the big toe to keep it slightly bent downward.

‍

In rare cases, a steroid injection may be appropriate, but it should not be administered through the thickened fat pad on the bottom of the foot to avoid loss of the normal fatty cushion in this area.

If symptoms persist, a removable short leg-fracture brace or a cast might be necessary for 4-6 weeks, as sesamoids tend to heal slowly.

‍

Non-Surgical Treatment for Fractured Sesamoids

For fractured sesamoids, non-surgical treatment options include:

• Immobilization: Wearing a stiff-soled shoe, a short leg-fracture brace, or a cast.
• Joint Taping: Taping the joint to limit movement of the big toe.
• Pressure Relief: Using a J-shaped pad around the sesamoid to relieve pressure as the fracture heals. Other cushioning pads or orthotic devices may also be helpful.
• Pain Relief: Taking acetaminophen or ibuprofen for pain management, with an understanding that discomfort may persist for several months.

‍

Surgical Treatment

If non-surgical measures are ineffective, surgery may be recommended. The surgeon may repair the sesamoid or remove part or all of it.

‍

Recovery

Healing of the sesamoid is typically slow, often taking up to six months. While the process can be frustrating, it is usually successful.

‍

Risks

Risks associated with sesamoid injuries include failure of healing, avascular necrosis (bone death due to lack of blood supply), development of arthritis at the joint between the sesamoid and the first metatarsal, and continued pain. If these complications arise, excision of part or all of the sesamoid can usually resolve symptoms.

Understanding sesamoid injuries and their treatment options is crucial for effective management and recovery. If you suspect a sesamoid injury, consult a foot and ankle orthopedic specialist for proper diagnosis and treatment.