Big Toe Pain: Sesamoid Pathology
The sesamoids are two small round or oval bones situated in the thick soft tissue ligamentous plantar plate under the first metatarsaophalangeal (big toe) joint (Figure 1) and provide attachments for multiple important ligaments and muscle-tendinous units that provide critical stability, strength, and function to the big toe during ambulation and propulsion. They fully ossify by the age of 7. They usually ossify by multiple centers of ossification and rarely this bone can develop an incomplete fusion and bipartide sesamoids have been reported from 7-30% of the time and usually involve the tibial (medial and larger of the two bones) and are usually found to be bilateral. They are infrequently symptomatic however, their tortuous circulation make them prone to slow healing and potential for avascular necrosis when injured.
Type of Sesamoid Injuries
- Sesamoid fracture
- Sesamoid Stress Fracture
- Symptomatic Bipartide Sesamoids
- Irregular Shaped or Enlarged Sesamoids
- Subluxation or Dislocation of the Sesamoids
Sesamoiditis is defined as inflammation and swelling of the peritendinous structures that inserts around the sesamoid bones. It often occurs in young adults and can be related to acute traumatic event or repetitive weight-bearing load during various exercises. Jumping or falling from a height, unsupportive or high-heeled shoes, excessive activity, or dancing have been reported to cause inflammtion to sesamoid bones. There can be a gradual or sudden onset of pain, swelling, and inflammation to the area under the big toe joint worse with or after periods of activity. It is commonly a diagnosis of exclusion because early in the disease process routine foot x-rays will be normal. A bone scan or MRI can be beneficial to aid in the diagnosis. It is important to educate patients that symptoms usually resolve slowly with the below mentioned conservative therapy. If symptoms continue to be painful then surgical excision of the involved sesamoid (Figure 5) may be warranted, however this does cause inherent imbalance of the big toe and deviation can occur.
Symptomatic bipartide fractures, and irregular or enlarged sesamoids usually became painful in a similar fashion and usually respond with conservative fashion. If they fail conservative measures the excision of the involved sesamoid may be warranted. Enlarged or prominent sesamoids can undergo complete excision or shaving of the invlolved bone.
- Activity modification
- Supportive shoes
- Metatarsal pads
- Toe strapping
- Stiff soled, rocker bottom shoes with steel shank insert
- Custom orthotics with pathology specific cutout design to decrease pressure under the sesamoids (Figures 3 and 4)
Surgical or Invasive options
- Local steroid injections
- PRP injections
- Surgical excision of painful sesamoid
Sesamoid fractures (Figure 6) can develop from acute fracture or secondary to progression or un-treated stress fractures or osteochondritis. Acute fractures including fall from heights, big toe hyper-extension injuries, and other injuries can result in one or multiple fracture fragments of the involved sesamoid. Recurrent micro-trauma such as running, dancing, sporting activities, can cause stress injuries to the bone and compromise circulation resulting in osteochondritis or stress fractures of the sesamoid bones. X-rays can demonstrate acute fractures, however if it is unclear between a bi-partide or sesamoid fracture then MRI and bone scan are beneficial. These pathologies are notorious to slow healing, and usually require an extensive healing period with at least prolonged protective weight bearing in a short leg fracture boot or non-weight bearing in a cast and crutches. It is important to educate patients on the longer recovery with this diagnosis. The transition to a stiff soled shoe and/or custom functional foot orthotic to decrease pressure to the area is required for the following several weeks with activity modification to ensure proper healing. RICE, NSAIDS are encouraged as well. The use of a bone stimulator may be utilized as well in certain cases.
Surgical recommendation is recommended after failure of extensive conservative options as mentioned above. This can include partial excision of the small or large symptomatic fracture fragments or complete excision of the involved sesamoid bone. Again, it should be re-iterated that there are certain inherent muscle imbalances that develops after excision these bones and adjunctive procedures or further surgeries may be in order to maintain a normal position of the big toe.
University Foot and Ankle Institute
University Foot and Ankle Institute offers comprehensive care for sesamoid pain and fracture. From injection therapy and orthotic care to surgical treatment options, count on our experts to offer you state of the art care in a comfortable and friendly environment.
Dr. Baravarian been involved in athletics his entire life and played competitive tennis in high school and college. He has an interest in sports medicine, arthritis therapy and trauma/reconstructive surgery of the foot and ankle. He servers as a consultant to the ATP (Association of Tennis Professionals) tour, multiple running organizations and several shoe manufacturers. He is also fluent in five languages (English, French, Spanish, Farsi and Hebrew),
Podiatrist Dr. Bob Baravarian is available for consultation at the Santa Monica, Sherman Oaks and UCLA Westwood offices.
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