Sesamoid Fracture and Injuries Treated by Top Foot Surgeons in Baltimore

What are Sesamoid Bones?

Sesamoids are bones in the body that are located within a tendon, such as the knee cap. There are two sesamoid bones beneath the main joint of the big toe, the metatarsophalangeal (MTP) joint. 

These sesamoid bones have several functions. First, they act like pulleys for the tendons that help to flex the toe for strong push-off and propulsion during walking or running. Additionally, they bear weight or absorb shock as the foot hits the ground, dissipating stress. Their name derives from Latin, due to their similar appearance to a sesame seed.

What Types of Injuries Can Occur with the Sesamoid Bones?

There are several different conditions or injuries that can cause pain in the sesamoid bones of the big toe. It is possible to fracture one of these bones, often due to landing on the foot while jumping or playing sports. The patient may notice a cracking sensation and often has rapid onset of severe pain and swelling. 

The sesamoids also have very limited circulation and are prone to a condition called avascular necrosis, in which the bone actually dies due to poor blood supply. Ultimately the bone may crumble and fragment leading to worsened pain and difficulty with weight bearing. 

Stress fracture of a sesamoid is another common condition caused by repetitive exercise or running. This can be seen in runners who are rapidly increasing their mileage such as training for an upcoming race. Some patients are born with one of the sesamoid bones in two or more pieces that never fused together during childhood, a condition called a bipartite sesamoid. These can become sore due to overuse or impact. 

Since the sesamoids do have a joint surface against the overlying metatarsal bone, it is possible to develop cartilage problems of that small joint or even full-blown arthritis. Sesamoiditis is a generic term to describe pain in a sesamoid bone that is not caused by a clearly identifiable factor but nonetheless leads to pain and difficulty walking or running.

Symptoms of Sesamoid Injuries

Patients with sesamoid problems may experience:

• Difficulty with walking and daily activities
• Difficulty running or playing sports  
• Swelling in the area of the toe
• Difficulty with fitting a shoe

Very flexible shoes or shoes with a high heel concentrate more force in that area which also worsens sesamoid pain. Sesamoids bear a large amount of force with walking or running, so engaging in those activities may rapidly cause symptoms.

Diagnosis of Sesamoid Injuries

The orthopedic surgeon will examine the patient and typically identify tenderness with pressure over one of the sesamoid bones beneath the toe. There may also be a grinding sensation with motion of the toe. Due to the pain, the toe joint can be stiff and any attempt to stretch it causes pain. In some cases, irritation of one of the sesamoid bones may cause irritation to a nearby nerve on the bottom of the toe leading to numbness and tingling sensations.

X-rays are typically used to evaluate the toe for other sources of pain such as arthritis. The sesamoids themselves can be seen on X-rays, although special views to clearly look at them are sometimes necessary. The orthopedic doctor may also recommend obtaining an MRI or CT scan to look for fragmentation, arthritis, or bone bruising. These scans can also be helpful to look at adjacent structures such as the toe tendons to rule out other problems.

Non-surgical Treatment for Sesamoid Injuries

Despite the many different causes of sesamoid pain, almost all are treated similarly to relieve symptoms. The patient is often treated with relative rest and restriction from running or other high-impact activities. 

The patient may ice the toe area and also use anti-inflammatory medications. Wearing a stiff soled shoe or clog may decrease stress across the toe joint and rest the sesamoid bones. Alternatively, surgeons will sometimes prescribed a graphite or stainless steel insert to go into the shoe, sneaker, or athletic cleat to splint the joint in order to rest it. 

Use of a specialized pad that takes pressure off the sesamoid can also alleviate pain. This can be an off-the-shelf pad that is inserted into the shoe or it can be incorporated into a custom-made prescription orthotic insole. 

In the case of an acute fracture of the sesamoid, the patient may need to tape or strap the toe to decrease motion to allow the pieces to try to heal. This would usually be combined with the use of a stiff soled surgical shoe or fracture boot. 

In rare cases, the surgeon may recommend a corticosteroid injection into the toe joint to decrease any inflammation.

Surgical Treatment for Sesamoid Injuries

If nonsurgical treatments are unsuccessful in relieving pain from a sesamoid problem, the orthopedic surgeon may recommend surgical treatment as a more definitive course. 

In the vast majority of cases, this entails a sesamoidectomy, which is surgical removal of the sesamoid bone. During this surgery, the surrounding ligaments and tendons are sutured back together to allow healing and restore strength of the toe for push-off. 

This surgery typically has a very high rate of pain relief and return to daily walking, running and sports; research studies have shown that even professional, collegiate or elite athletes can usually return to sports at their prior level after this type of surgery.  

In rare cases, the surgeon may recommend a procedure to try to fix a broken or non-healed sesamoid fracture with use of bone grafting. Though the procedure is not typical, it is superior to simply removing the affected bone entirely.