When Sesamoid Pain Complicates Hallux Limitus Cases
As I get more in tune with patient care, I find that the simple cases such as hallux limitus are more difficult than I initially thought because they are often more complicated and involved than the original examination might show. I have come to this conclusion after being burned by a couple of trouble cases and learning what to look for as a result.
A typical patient is a 47-year-old female with chronic pain in the great toe. She has trouble in dress shoes and has mild limitation of shoegear. The patient reports having mild pain when playing golf and there is some redness of the dorsum of the foot with ambulation and activity.
An examination of the region shows mild dorsal spurring and limitation of motion to 25 degrees of dorsiflexion and 20 degrees of plantar motion. She has mild dorsal pain to pressure and her end range of dorsal motion shows mild crepitus. There is no gross pain in the plantar metatarsal head and she has no medial pain and no gross stiffness or clicking of the joint.
Radiographs show a very small dorsal spur. There is no gross deviation of the joint or gross arthritic changes of the joint. The patient does have mild elevatus of the first metatarsal.
Although there is elevatus of the first ray on radiographs, the first ray is slightly plantar to the other rays when the patient is at rest or in a non-weightbearing position. With standing, the ray elevates due to some laxity of the first metatarsocuneiform region.
Discussing The Initial Treatment Options
We discuss the options with the patient. The first treatment option is a cheilectomy type spur resection. The second option is to osteotomize the region and decompress the joint although there are no severe arthritic changes. The third option is to remove the spurring from the metatarsophalangeal joint and then perform a first metatarsocuneiform fusion to stabilize the first ray. The patient understands the recovery and potential for a good outcome are best with a simple cheilectomy and she agrees to undergo that procedure.
The surgery is uneventful. After we remove the spurring, the patient’s range of motion of the great toe at the metatarsophalangeal joint increases to 70 degrees of dorsal motion. However, there is mild clicking and crepitus of the joint with motion. I check the cartilage and find it to be pristine within the joint surface. An examination of the crepitus shows the pain is from the plantar surface of the joint and dissection reveals moderate degenerative changes in between the tibial sesamoid and plantar first metatarsal region. I remove the region of poor cartilage from the plantar metatarsal head and drill the area to allow for fibrocartilage ingrowth.
I explain to the patient there are arthritic changes of the tibial sesamoid and she understands this problem. She has an uneventful recovery and begins to ambulate on the region. The dorsal pain resolves but there is continued pain in the plantar first metatarsal region. MRI shows severe arthritis of part of the tibial sesamoid on the surgical side with moderate arthritis of the plantar first metatarsal head adjacent to the tibial sesamoid.
Understanding The Causes Of Arthritic Sesamoid Pain
The question is not how to treat the arthritis but rather how one can be more aware of this problem and question the type of surgery and cause of the arthritis as a primary problem.
Why is the problem hard to diagnose in the initial visit? I believe it is due to the lack of pain in the area and the lack of gross tenderness in the tibial sesamoid region. Furthermore, there is poor motion of the great toe, limiting the gliding and rubbing of the tibial sesamoid against the arthritic metatarsal region. With the additional motion following spur resection and cheilectomy, there is greater motion of the tibial sesamoid, which results in more pain.