Sesamoid  Pain / Fracture

• synonyms: sesamoid pain, sesamoid fracture, Ballet dancer
• can be acute fx, stress fx, sesamoiditis, chondromalacia, FHB tendonitis, OCD
• tibial sesamoid more commonly injured

Sesamoid Anatomy

• bipartite tibial sesamoid in 10% of population, 25% will be bilateral.  Fibular sesamoid rarely is bipartite.

Sesamoid Clincal Evaluation

• pain around big toe
• pain exacerbated when hallux extends in the terminal part of the stance phase of gait
• neuritic symptoms may occur if digital nerve is compressed

Sesamoid Xray

• AP, oblique xray
• medial oblique(sesamoid view) shows tibial sesamoid
• axial sesamoid view shows fibular sesamoid
• Bone scan

Sesamoid Classification / Treatment

• Sesamoiditis=NSAIDS, activity modification, full-length shoe orthosis with a metatarsal pad and a relief beneath the 1^st MT head
• tibial sesamoid stress fracture, the initial treatment of choice is cast immobilization.  Excision, partial excision, and bone grafting are reserved for refractory cases.  Cortisone injections, taping, and pads do not adequately immobilize the sesamoid. (ahss MH: The sesamoids of the hallux.  Clin Orthop 1981;157:88-97.
• Excision is the treatment of choice for persistent sesamoid pain that has failed to respond to nonsurgical management.  This is true whether the cause of the pain is sesamoiditis, fracture, or osteonecrosis.  The fibular sesamoid can be excised via a dorsal or plantar approach.  In high-level athletes who have an acute fracture that has progressed to a nonunion, bone grafting has had some success (Anderson RB, McBryde AM Jr: Autogenous bone grafting of hallux sesamoid nonunions.  Foot Ankle Int 1997;18:293-296.)
• Shaving of the tibial sesamoid is considered the treatment of choice for discreet hyperkeratotic lesions under the tibial sesamoid that fail to respond to conservative management.  Dorsiflexion osteotomy is reserved for a large, diffuse intractable plantar keratosis under the entire metatarsal head

Sesamoid Differential Diagnosis

• gout (Reber PU, Patel AG, Noesberger B, et al: Gout: Rare cause of hallucal sesamoid pain: A case report.  Foot Ankle Int 1997;18:818-820: Mair SD, Coogan AC, Speer KP, et al: Gout as a source of sesamoid pain.  Foot Ankle Int 1995;16:613-616.)

Sesamoid Complications

• The most significant complication after partial excision of the tibial sesamoid is injury to the medial plantar cutaneous nerve through the plantar medial approach

Sesamoid References

1. Coughlin MJ: Sesamoid pain: Causes and surgical treatment, in Green WB (ed): Instructional Course Lectures XXXIX.  Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, pp 23-35.