How To Treat Sesamoid Injuries

Author(s): 
By Mark A. Caselli, DPM and Mohsen Khoshneviszadeh

Stress fractures occur when an athlete applies abnormal repetitive stress to normal bone or applies normal repetitive stress to a weakened bone. Fractures are more common in long-distance runners. Stress fractures account for 40 percent of all sesamoid injuries. These patients will complain of increasing pain and have point tenderness of the involved sesamoid. Keep in mind the pain usually develops gradually and is exacerbated by faster running or walking up and down stairs.
It’s important to differentiate sesamoid stress fractures from bipartite or multipartite sesamoids. Employing bone scans or CT scans may be necessary for early confirmation of an abnormal bony sesamoid process, as plain radiographs will not be abnormal until approximately three weeks after the injury has occurred.
As far as treatment goes, you would emphasize rest and use a 1/4- to 3/8-inch weight dispersion felt padding or a specially modified foot orthosis with a sesamoid “cutout” that decreases stress on the sesamoid while transferring weight along the shaft of the first metatarsal. Using a rigid soled shoe is also helpful. If the fracture has not united after six months of treatment and symptoms are sufficiently severe, you should consider surgical treatment. This may include performing open reduction with internal fixation of the fractured sesamoid or excising the involved sesamoid.
What To Look For In Osteochondritis Of The Sesamoids
Osteochondritis or avascular necrosis of the sesamoids may occur as a primary disorder, possibly related to recurrent stress, or as a secondary problem following a stress fracture and subsequent fragmentation. Be aware sesamoidal osteochondritis is less commonly a complication of traumatic fracture and more often the result of chronic stress. In either case, resulting avascular necrosis may lead to fragmentation and collapse of the sesamoid. You should treat such lesions conservatively for at least six months with splinting and activity modification.
Use functional orthoses and paddings similar to those you would use for sesamoid fractures. It may be necessary to fabricate a custom shoe with a protective toe box roomy enough to permit splinting of the toe. You also may emphasize other modalities such as icing, physical therapy and non-steroidal anti-inflammatory medications if necessary. If the symptoms continue to be disabling, you may use bone grafting from the adjacent first metatarsal. If the sesamoids are too fragmented for bone grafting, partial or complete excision may be a last resort.
How To Relieve Sesamoiditis
Sesamoiditis is a clinical diagnosis usually related to repetitive stress to the hallucal sesamoids. It occurs more frequently in the high arch or cavus foot type. In diagnosing sesamoiditis, keep in mind that it is marked by point tenderness on one or both of the sesamoids in the absence of radiographic evidence of a specific bony abnormality such as stress fracture or avascular necrosis.
At times, it’s tough to differentiate between a symptomatic and fractured partite sesamoid. In such cases, you may find contralateral X-rays or previous X-rays of the same foot valuable. Bipartite sesamoids have smoother edges and usually occur bilaterally.
Treatment options for curing or controlling sesamoiditis include temporary rest, icing, non-steroid anti-inflammatory drugs, physical therapy, splinting or foot orthoses. In severe cases, up to three weeks of rest and casting may be necessary to reduce symptoms in order to achieve pain-free foot function.




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