The medial and lateral sesamoid bones act as a pulley for the flexor hallucis longus and brevis tendons. They are necessary for the stabilization of the first MTP joint. The sesamoid bones may be injured in a number of ways including traumatic fracture, stress fracture and sprain of a bipartite sesamoid. Inflammatory changes and osteonecrosis around the sesamoid and the tendon are collectively known as sesamoiditis. The medial sesamoid is usually affected.

The patient complains of pain with forefoot weight-bearing and will often walk with weight laterally to compensate. On examination, there is usually marked tenderness and swelling in the region of the sesamoid.

Inflammation may be caused by landing after a jump, increased forefoot weight-bearing activities (e.g. sprinting and dancing) or as a result of traumatic dorsiflextion of the hallux. Pronation may cause lateral displacement or subluxation of the sesamoids within the plantar grooves of the first metatarsal. This subluxation of the sesamoids may lead to erosion of the plantar aspect of the first metatarsal resulting in pain underneath the first metatarsal head, arthritic changes and ultimately decreased dorsiflexion.

Sprain of the bipartite sesamoid also occurs. A bipartite sesamoid is present in approximately 30% of individuals.

Treatment of sesamoid pain is with ice and electrotherapeutic modalities to reduce inflammation. Padding is used to distribute the weight away from the sesamoid bones. Corticosteroid injection is often effective in reducing local inflammation. Orthotics may be required if foot mechanics are abnormal.

Surgery should be avoided if possible as the removal of a sesamoid bone causes significant muscle imbalances and may contribute to a hallux valgus deformity. However, excision is required in cases of significant osteonecrosis. Partial sesamoidectomy has been used with some success.

Stress fractures of the sesamoid bones are seen, especially in basketballers, tennis players and dancers. Radioisotopic bone scan will confirm the presence of a stress fracture. These stress fractures are prone to non-union and sometimes require non-weight bearing for a period of six weeks.

If you suffer from pain under your big toe joint, see a Podiatrist as soon as you can.








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