Sesamoid Pain: Causes, Diagnosis, and Treatment Strategies
The two sesamoid bones are found within the flexor hallucis brevis (1). There is a medial sesamoid bone, also known as the tibial sesamoid, and a lateral sesamoid, known as the fibular sesamoid (1). These two bones have been found to support 50% of our body weight at rest and up to three times our body weight during jumping (10). Injury can occur due to repetitive stress across the plantar aspect of the great toe and is typically seen in dancers, runners, and football players (1). Injuries to the sesamoid bones are at high risk of delayed and non union due to the variable blood supply to the sesamoid bones and the high forces the bones are subjected to (2).
Sesamoiditis is a broad term that is used to describe sesamoid pain after all other etiologies of sesamoid pain have been ruled out (5). The most common injury to the sesamoid bone is a stress fracture, followed by chondromalacia/sesamoiditis (7). Acute sesamoid fractures can also occur after trauma (8).
A patient with a sesamoid stress fracture will typically complain of plantar forefoot pain. When examining the sesamoid bones, the medial sesamoid bone is typically affected more than the lateral (2). Pain is usually palpated on the plantar aspect of the first metatarsophalangeal joint and can be exacerbated with dorsiflexion (3).
Typical radiographs in standing AP, lateral, and oblique views are recommended (5). Radiographs can also be misleading because a bipartite sesamoid can be found in 30% of patients (2). It is important to get bilateral xrays, as the bipartite sesamoid is typically bilateral in 80-90% of patients (2).
If radiographs are indeterminate, an MRI can show bone marrow edema and help diagnose a stress fracture. An MRI can also differentiate between a bipartite sesamoid verse nonunion (5).
The majority of sesamoid fractures are treated with conservative management (2). This includes activity modification, oral anti inflammatories, and shoe ware modifications (3). The toes can be taped in plantar flexion or neutral in order to avoid dorsiflexion (5). The orthotic devices typically used include gel padding the MTP joint, C shaped pads, dancer’s pad, metatarsal bars, and orthotics with a metal shank (7).
Injections have also been proposed as a treatment for sesamoiditis. Multiple techniques are described in the literature, but one common approach is a steroid injection between the metatarsal head and the sesamoid (6). However, even with use of an ultrasound, this injection can be difficult to visualize. In order to help simplify injection techniques, a study published by the American Academy of Physician Medicine and Rehabilitation looked at first MTP injections for sesamoiditis (6). Using cadavers, they injected the first MTP joint with latex and were able to identify the latex within the fibula and tibia metatarsosesamoid articulation (6).
There have also been case studies looking at the injection of PRP into the metatarsosesamoid articulation. There is not enough data to support the use of PRP for sesamoiditis at this time.
Multiple surgeries also exist depending on the etiology of sesamoid pain. Patients with pain nonresponsive to conservative options may be candidates for sesamoidectomy (6). Newer surgeries for nonunion of sesamoid fractures include curettage and grafting of the sesamoid (7).
Forefoot pain on the plantar surface is typically caused by the sesamoid bone. The sesamoid bone can be the source of pain due to acute fracture, stress fracture, AVN, and repetitive trauma. Diagnosis is typically made with radiographs or MRI. The majority of cases of sesamoid pain are treated conservatively. However, those cases where pain from the sesamoid is recalcitrant to conservative treatment, excision is sometimes considered.
1) Dean, Robert S., et al. “Functional Outcome of Sesamoid Excision in Athletes.” The American Journal of Sports Medicine, vol. 48, no. 14, Dec. 2020, pp. 3603–09. PubMed, https://doi.org/10.1177/0363546520962518
2) Stein, Cynthia J., et al. “Hallux Sesamoid Fractures in Young Athletes.” The Physician and Sportsmedicine, vol. 47, no. 4, Nov. 2019, pp. 441–47. PubMed, https://doi.org/10.1080/00913847.2019.1622246
3) Robertson, G. a. J., et al. “Return to Sport Following Stress Fractures of the Great Toe Sesamoids: A Systematic Review.” British Medical Bulletin, vol. 122, no. 1, June 2017, pp. 135–49. PubMed, https://doi.org/10.1093/bmb/ldx010
4) Mason, Lyndon W., and Andrew P. Molloy. “Turf Toe and Disorders of the Sesamoid Complex.” Clinics in Sports Medicine, vol. 34, no. 4, Oct. 2015, pp. 725–39. PubMed, https://doi.org/10.1016/j.csm.2015.06.008
5) Sims, Alex L., and Harish V. Kurup. “Painful Sesamoid of the Great Toe.” World Journal of Orthopedics, vol. 5, no. 2, Apr. 2014, pp. 146–50. PubMed Central, https://doi.org/10.5312/wjo.v5.i2.146
6) Wempe, Michael K., et al. “Feasibility of First Metatarsophalangeal Joint Injections for Sesamoid Disorders: A Cadaveric Investigation.” PM & R: The Journal of Injury, Function, and Rehabilitation, vol. 4, no. 8, Aug. 2012, pp. 556–60. PubMed, https://doi.org/10.1016/j.pmrj.2012.01.011
7) Le, Hung M., et al. “Platelet Rich Plasma for Hallux Sesamoid Injuries: A Case Series.” The Physician and Sportsmedicine, Aug. 2021, pp. 1–4. PubMed, https://doi.org/10.1080/00913847.2021.1964006.
8) Dedmond, Barnaby T., et al. “The Hallucal Sesamoid Complex.” The Journal of the American Academy of Orthopaedic Surgeons, vol. 14, no. 13, Dec. 2006, pp. 745–53. PubMed, https://doi.org/10.5435/00124635-200612000-00006
9) Richardson, E. G. “Hallucal Sesamoid Pain: Causes and Surgical Treatment.” The Journal of the American Academy of Orthopaedic Surgeons, vol. 7, no. 4, Aug. 1999, pp. 270–78. PubMed, https://doi.org/10.5435/00124635-199907000-00007
10) Prisk, Victor R., et al. “Forefoot Injuries in Dancers.” Clinics in Sports Medicine, vol. 27, no. 2, Apr. 2008, pp. 305–20. PubMed, https://doi.org/10.1016/j.csm.2007.12.005.