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Pertinent Insights On Evaluating And Treating Sesamoiditis

Sesamoiditis is a broad term often used to describe pain in the sesamoids in the presence of negative radiographs.1 Boike and colleagues defined sesamoiditis as any painful inflammatory condition of the sesamoid bones caused by repetitive stress but lacking radiographic changes.2 Sesamoid pain can result from a number of pathologies, such as chondromalacia, stress fractures, acute fractures, avascular necrosis, arthritis and bursitis.1-3 These injuries result most often from repetitive stress with the tibial sesamoid affected more frequently.1 The size and position of the tibial sesamoid make it more vulnerable to injury.3 Sesamoid pathologies account for approximately 9 percent of all foot and ankle injuries, and 1.2 percent of running injuries.4 Sesamoiditis in runners is typically a sequela of a plantarflexed first metatarsal or restricted dorsiflexion of the first metatarsophalangeal joint (MPJ).4 Though sesamoid pain can occur in any patient, active patients most commonly experience it.5 The clinical presentation in patients suffering from sesamoid disorders is variable. Patients may report pain that is constant or pain that is exacerbated by activity and weightbearing, especially running, jumping or climbing stairs.1,2 Erythema, edema and ecchymosis may be present. Patients may prescribe pain as “burning” and “pins and needles,” indicating a neuritis from increased edema and inflammation.2 Patients often are unable to identify a specific inciting event.1 Physical evaluation of patients with sesamoid pain reveals pain to the plantar aspect of the first MPJ, pinpoint tenderness over one or both of the sesamoid bones, and pain with end range of dorsiflexion of the hallux at the MPJ.1 Weakness with plantarflexion and loss of active and passive dorsiflexion are symptoms of sesamoiditis.2 It is important to assess for forefoot cavus deformity. A plantarflexed first ray increases the load on the sesamoids.2 Thus, sesamoiditis is a common complaint for these patients. Obtain standing AP, oblique and sesamoid axial views to assess the sesamoids for pathology in the presence of pain.1 It is important not to confuse a bipartite sesamoid with an acute fracture of a sesamoid. A bipartite sesamoid will demonstrate smooth cortical edges while a fractured sesamoid will have irregular or jagged edges.1 Additionally, it may be beneficial to obtain views of the contralateral limb. This is especially helpful when uncertainty exists in determining if a sesamoid is bipartite or fractured. When radiographs are devoid of pathology, one may utilize bone scans, computerized tomography (CT) and magnetic resonance imaging (MRI). A CT scan can further evaluate the sesamoid bones for fractures or arthritic changes.2 A MRI can be useful in identifying pathologies of the soft tissue structures surrounding the sesamoids, such as the flexor tendons and the plantar plate.2 Conservative treatment of sesamoiditis begins with modification of activities, non-steroidal anti-inflammatories, rest, ice and immobilization.1,2 One should recommend shoe gear modifications and avoidance of shoes with increased heel height. In the football player, attempt to alleviate pain by removing the cleat directly beneath the affected sesamoid.3 Since sesamoid disorders are most often caused by repetitive stress and biomechanical abnormalities, patients respond well to custom orthoses. Podiatrists can fabricate these orthoses in a variety of ways. One can build in a Morton’s extension or carbon fiber plate to stiffen the shoe, and eliminate motion, especially in the presence of arthritis or hallux rigidus. Patients with a forefoot cavus may benefit from the placement of a dancer’s pad or cutout under the first metatarsal head to allow plantarflexion and offloading of the metatarsal. References

1. Hunt KJ, McCormick JJ, Anderson RB. Management of forefoot injuries in the athlete. Oper Tech Sports Med. 2010; 18(1):34-45. 2. Boike A, Schnirring-Judge M, McMillin S. Sesamoid disorders of the first metatarsophalangeal joint. Clin Podiatr Med Surg. 2011; 28(2):269-285. 3. Atiya S, Quah C, Pillai A. Sesamoiditis of the metatarsophalangeal joint. OA Orthopaedics. 2013; 1:19. 4. Lillich JS, Baxter DE. Common forefoot problems in runners. Foot Ankle. 1986; 7(3):145-151. 5. Dedmond BT, Cory JW, McBryde Jr A. The hallucal sesamoid complex. J Am Acad Orthop Surg. 2006; 14(13):745-753. 6. Kubitz KR. Athletic injuries of the first metatarsophalangeal joint. J Am Podiatr Med Assoc. 2003; 93(4):325-332. 7. Richardson EG. Injuries to the hallucal sesamoids in the athlete. Foot Ankle. 1987; 7(4):229-244. 8. Axe MJ, Ray RL. Orthotic treatment of sesamoid pain. Am J Sports Med. 1988; 16(4):411-416. 9. Van Hal ME, Keene JS, Lange TA, Clancy WG Jr. Stress fractures of the great toe sesamoids. Am J Sports Med. 1982; 10(2):122-128. 10. Biedert R, Hintermann B. Stress fractures of the medial great toe sesamoids in athletes. Foot Ankle Int. 2003; 24(2):137-141.

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