How To Treat Sesamoid Injuries In Athletes

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Continuing Education Course #118 — April 2004

I am very pleased to introduce the latest article, “How To Treat Sesamoid Injuries In Athletes,” in our CE series. This series, brought to you by HMP Communications, consists of regular CE activities that qualify for one continuing education contact hour (.1 CEU). Readers will not be required to pay a processing fee for this course.

In a thorough and well-written article, Eric J. Heit, DPM, and Richard T. Bouche, DPM, initially discuss the possible etiologies of sesamoid injuries and what clinicians should look for in the patient history and physical exam. Then they proceed to offer insights on diagnostic testing, guidance on conservative treatment and pertinent pearls on the surgical treatment of sesamoid injuries in athletes.

At the end of this article, you’ll find a nine-question exam. Please mark your responses on the postage-paid postcard and return it to HMP Communications. This course will be posted on Podiatry Today’s Web site (www.podiatrytoday.com) roughly one month after the publication date. I hope this CE series contributes to your clinical skills.

Sincerely,

Jeff A. Hall
Editor-In-Chief
Podiatry Today

INSTRUCTIONS: Physicians may receive one continuing education contact hour (.1 CEU) by reading the article on pg. 60 and successfully answering the questions on pg. 66. Use the postage-paid card provided to submit your answers or log on to www.podiatrytoday.com and respond electronically.
ACCREDITATION: HMP Communications, LLC is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.
DESIGNATION: This activity is approved for 1 continuing education contact hour or .1 CEU.
DISCLOSURE POLICY: All faculty participating in Continuing Education programs sponsored by HMP Communications, LLC are expected to disclose to the audience any real or apparent conflicts of interest related to the content of their presentation.
DISCLOSURE STATEMENTS: Drs. Heit and Bouché have disclosed that they have no significant financial relationship with any organization that could be perceived as a real or apparent conflict of interest in the context of the subject of their presentation.
GRADING: Answers to the CE exam will be graded by HMP Communications, LLC. Within 60 days, you will be advised that you have passed or failed the exam. A score of 70 percent or above will comprise a passing grade. A certificate will be awarded to participants who successfully complete the exam.
TARGET AUDIENCE: Podiatrists.
RELEASE DATE: April 2004.
EXPIRATION DATE: April 30, 2005.
LEARNING OBJECTIVES: At the conclusion of this activity, participants should be able to:
• discuss clinical signs and symptoms of sesamoid injuries;
• assess the merits of various diagnostic tests for detecting sesamoid injuries;
• describe conservative treatment options for sesamoid injuries;
• compare and contrast the total sesamoid excision versus the partial sesamoid excision; and
• demonstrate a knowledge of common complications of sesamoid excision.

Sponsored by HMP Communications, LLC.

This positive bone scan indicates bilateral tibial stress fractures with associated right first metatarsophalangeal joint arthritis.
This T1-weighted MRI shows decreased signal intensity in the tibial sesamoid, indicating avascular necrosis.
Any sport or activity that involves sudden starting and stopping (such as tennis) with repetitive first MTPJ extension can predispose patients to sesamoid injuries.
66
Author(s): 
By Eric J. Heit, DPM and Richard T. Bouché, DPM

It has been speculated that 50 to 75 percent of weightbearing forces are transmitted through the first metatarsophalangeal joint (MTPJ) complex during weightbearing and these forces can account for up to three times one’s body weight.1,2 Anatomical location of the hallucal sesamoids predisposes them to significant shear, pressure and ground reactive forces during weightbearing activities. As a result, sesamoids are a site for potential injury.
Sesamoid pathology is not uncommon in a typical podiatric sports medicine practice. In a study of 1,000 running injuries, the sesamoids were involved 12 times (1.2 percent incidence).3 Sesamoid injuries accounted for 12 percent (12/100) of great toe complex injuries and four percent of all foot and ankle injuries (12/300).3
Theoretically, the hallucal sesamoids protect the flexor hallucis longus during the push-off phase of gait, absorb shock, increase FHB lever action across the first MTPJ and elevate the first metatarsal to evenly distribute weightbearing forces to the lesser metatarsal heads. In two in vitro laboratory studies on hallucal sesamoid function, Aper, et. al., concluded the prime functions of the sesamoids are maintaining a constant FHL tendon leverage across the first MTPJ and allowing the FHB muscle to stabilize the hallux during stance for controlled and levered propulsion.4,5

Reviewing Potential Etiologies
Direct and indirect macrotrauma as well as recurrent microtrauma can contribute to sesamoid pathology. Direct trauma includes contusions and crushing injuries. Indirect traumatic injury occurs with forced dorsiflexion. One may see this with or without hallux abduction with resulting sesamoid compression against the metatarsal head (i.e., “turf” toe). During toe off at maximal hallux dorsiflexion, the sesamoids are in their most distal position, moving up 1 cm from their proximal resting position. Being fixed in this distal position subjects the sesamoids to significant ground reactive and tendon forces. Given this position at toe-off, recurrent microtrauma has been implicated in sesamoid pathology and this likely represents most of the sesamoid injuries one would see in a sports medicine practice.

Any sport or activity involving sudden starting and stopping with repetitive first MTPJ extension can predispose patients to sesamoid injuries. There are also certain foot types and conditions, such as excessively pronated or severe cavus feet, a plantarflexed and/or long first ray, ankle equinus deformities and bunion deformities with deviated sesamoids that can increase the risk for sesamoid disorders.

What To Look For In The
History And Physical Exam
A complete history, thorough physical exam and timely diagnostic testing are required to differentiate sesamoid pathology from other great toe joint pathology.
For the patient history, one should ascertain the duration of the problem, the mechanism of injury, aggravating factors (i.e., pain with propulsion), and any type or change in activity. One should also assess footwear, consider any sport-specific demands and obtain a summary of previous self- or professional treatment.
A general, lower extremity physical examination and focal physical examination of the sesamoid apparatus should then be performed. This should include inspection, range of motion, muscle testing, direct palpation and provocative maneuvers. You must also evaluate the patient’s gait and inspect the patient’s footwear. For the gait evaluation, one should look for any asymmetry, antalgia or compensation.
During the physical exam, these patients will commonly experience pain upon direct palpation of the involved sesamoid, pain with maximum hallux dorsiflexion, and have pain or a loss of strength when testing for hallux flexion. Hallux dorsiflexion is the most reproducible provocative maneuver as it involves stabilizing the sesamoid in its most distal position and then plantarflexing the hallux while maintaining pressure on the sesamoid.6 You may note edema, warmth, erythema, ecchymosis and crepitus but they are not specific for sesamoid dysfunction.

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