Sesamoiditis can be a frustrating condition for both the patient as well as the treating physician. Making the injury even more complicated is the debate over the true cause of the pathology. The literature describes the condition as being related to a bipartite sesamoid or resulting from a fracture.1 One can order a bone scan as well as magnetic resonance imaging (MRI) to further discern between the two. If there is a fracture, clinicians can emphasize immobilization in a walking boot for six weeks or longer, and use symptoms as an indicator of improvement as radiographs sometimes do not demonstrate a complete osseous union.1
I would like to discuss the success I have had in treating sesamoiditis in my practice by identifying the cause of the injury. While we know the cause can be a bipartite or fractured sesamoid, radiographs in my practice on these patients frequently reveal a normal appearing sesamoid complex. It is also not uncommon to see bipartite sesamoid bones bilaterally yet only one side is symptomatic. In these cases, as with the majority of my patients with sesamoiditis, I tend to focus on their activities.
The most common cause that I see with these patients is excessive propulsion forces on the involved metatarsophalangeal joint (MPJ). One of the most common examples is volleyball players who jump off of their dominant leg. I also see a high incidence of sesamoiditis in those participating in the popular P90X exercise as the repetitive activities result in very excessive force to the MPJ. Weightlifters also inflict enormous amounts of force on the sesamoids during certain movements involved in powerlifting.
So what do you tell these patients? Many of them come to me after already attempting therapy with orthotics and shoegear modifications including dancer pads and doughnut-type pads. Their usual question is, “Isn’t there another type of pad we can try? These kind of worked but the pain keeps coming back.”
After reviewing their history and activities, I try to find the source of the increased force. As I mentioned previously, there are sport-specific activities that increase the force to the MPJ that result in sesamoiditis. Running can also increase the force of those who heel strike on an outstretched leg. This occurs as heel strikers need to have their entire body then pass over their foot, which requires an increased amount of dorsiflexion and stress to the MPJ of the great toe. Once we identify the source in these patients, I try to stress to them that we need to remove the source of force initially to allow the sesamoid to heal and then alter the force to prevent it from returning. This can be very challenging.
In the case of a volleyball player, an example would be to have the player propel or jump off the entire foot as opposed to the MPJ of the great toe. Plyometric strengthening activities performed barefoot can help teach this as well as increase the activation of the lesser toes, which will assist in jumping. It is important for patients to learn the activity barefoot as one’s proprioception is higher and this feedback is crucial. Athletes often can feel the pain in the great toe, notice when they are placing too much pressure there and learn to activate the lesser digits.
A paper published in August 2014 stresses the importance of doing calf raises barefoot and grasping a towel with the lesser digits to treat plantar fasciitis.2 I routinely use this now in my practice. You can also gain a wealth of knowledge in barefoot strengthening activities from fellow podiatrist Emily Splichal, DPM (www.evidencebasedfitnessacademy.com ).
By increasing the strength of the lesser toes by activating the extensor digitorum longus and brevis muscles, the foot can become stronger and take some of the load off the extensor hallucis longus and brevis tendons. In my clinical experience, I have found that strengthening the flexor hallucis longus, flexor hallucis brevis, extensor digitorum longus and extensor digitorum brevis muscles can relieve the pain within the sesamoid complex. It is without a doubt a frustrating and longstanding injury that can sometimes take months to overcome. However, I have had much more success with changing the activity and force than with padding or offloading.
As for surgical excision, I really make every attempt to avoid removing these bones, especially the entire sesamoid bone, from any runner or athlete. Taking the smaller or usually distal fracture fragment can sometimes help but more often, I am able to resolve the pain by leaving the fragment intact. The photo below is from a runner who transitioned from a heel strike gait to a midfoot strike pattern, and was able to decrease the force to the sesamoids during what many call the toe-off or propulsion phase of gait. You can see there are fragments of both the tibial and fibular sesamoid. This individual has been pain-free for five years with no surgical removal of the sesamoids.
1. Jones JL, Losito JM. Tibial sesamoid fracture in a softball player. J Am Podiatr Med Assoc. 2007; 97(1):85-88.
2. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports. 2014; epub Aug. 21.