Your tiny sesamoid bones play a big role in foot function – but when injured, they can cause serious pain! Learn how podiatrists diagnose and treat sesamoid issues to keep you moving comfortably. #FootHealth #Podiatry #SesamoidPain #FFLC
Joe Altepeter
Kevin Lam, DPM, FACFAS
OVERVIEW:
– What are Sesamoids?
– Common Conditions
– Diagnosis
– Treatment
– Prevention
When it comes to foot pain, most people think of issues like plantar fasciitis, bunions, or Achilles tendonitis. However, there’s a lesser-known but equally important source of foot discomfort: the sesamoid bones. These tiny bones play a crucial role in foot function, and when injured, they can lead to significant pain and mobility issues. As a podiatrist, understanding sesamoid-related
problems and their treatments is essential to keeping patients on their feet and pain-free.
What are Sesamoids?
Sesamoids are small, pea-shaped bones embedded within tendons. Unlike most bones in the body, which connect to other bones via joints, sesamoids function more like pulleys, improving the efficiency of tendons and enhancing movement. The most well-known sesamoid in the human body is the kneecap (patella), but the foot contains two sesamoids beneath the first metatarsophalangeal (MTP) joint, right under the big toe.
These bones help absorb weight-bearing stress, enhance the mechanical advantage of flexor tendons, and play a key role in balance and propulsion. Because they bear constant pressure, sesamoids are susceptible to injury, leading to conditions such as sesamoiditis, fractures, or avascular necrosis.
Common Sesamoid Conditions
Sesamoiditis is an inflammation of the sesamoid bones and surrounding tendons. It is often caused by repetitive stress and is often caused by repetitive stress and is common in athletes, dancers, and people who spend long hours on their feet. Symptoms include gradual pain beneath the big toe, tenderness when walking, and in some cases, swelling or bruising.
Treatment typically involves rest, ice, and anti-inflammatory medications. Patients may benefit from footwear modifications and orthotics to offload pressure from the sesamoids.
Sesamoid Fractures
A sesamid fracture results from direct trauma, such as a fall or an awkward landing on the foot. Unlike sesamoiditis, which develops over time, fractures cause sudden, sharp pain, often accompanied by swelling and bruising.
Treatment depends on the severity of the fracture. Immobilization with a walking boot or crutches may be necessary, along with orthotics for long-term offloading. In cases where conservative treatments fail, surgery may be required.
Avascular Necrosis (AVN) of the Sesamoid
Avascular necrosis occurs when the blood supply to a sesamoid bone is disrupted, leading to bone death. This condition can result from chronic injury or repeated stress. Patients often experience persistent pain, stiffness, and limited range of motion despite rest.
Non-surgical treatments include custom orthotics and physical therapy to maintain mobility. If symptoms persist, surgical removal of the affected sesamoid may be necessary.
Diagnosing Sesamoid Problems
A thorough clinical examination is the first step in diagnosing sesamoid-related conditions. Patients typically report pain localized beneath the first metatarsophalangeal (MTP) joint, which worsens with activities that involve push-off motions, such as walking, running, or jumping. The pain may be sharp and sudden in the case of a fracture or more of a dull, aching sensation in cases of sesamoiditis or avascular necrosis.
During a physical examination, podiatrists check for tenderness and swelling over the sesamoid bones. The dorsiflexion (upward bending) of the big toe often exacerbates pain in sesamoid-related conditions. In some cases, a podiatrist may perform the “sesamoid push test,” applying direct pressure to the area to pinpoint pain and confirm the involvement of the sesamoid bones. Gait analysis can also provide insights into how the patient’s foot mechanics contribute to the condition.
Imaging studies are essential for confirming a diagnosis and determining the severity of the issue.
X-rays: A standard set of foot X-rays, including different angles, can reveal fractures, misalignment, or arthritic changes in the sesamoids. Comparing both feet helps distinguish a true fracture from a naturally bipartite sesamid (a sesamoid bone that is naturally divided into two parts).
MRI: If an X-ray does not provide a clear diagnosis, an MRI can assess soft tissue involvement, inflammation, or early-stage avascular necrosis. This is particularly useful in differentiating a sesamoiditis from more severe conditions.
Bone Scans or CT Scans: These are sometimes used in cases of chronic pain when other imaging tests are inconclusive. A bone scan can detect increased metabolic activity in the sesamoid, while a CT scan provides a detailed view of the bone structure, helping to confirm fractures or degeneration.
Early and accurate diagnosis is crucial for effective treatment. Without proper intervention, sesamoid injuries can worsen over time, leading to chronic pain and impaired foot function,
Treatment Approaches
Most sesamoid conditions respond well to conservative treatment, especially when diagnosed early. Supportive footwear with a stiff sole and ample cushioning can help reduce pressure on the sesamoids, preventing further irritation. Custom orthotics, particularly those designed with offloading pads or cutouts for the sesamoid bones, can redistribute weight and minimize stress. Activity modifications, such as reducing high-impact exercises and incorporating low-impact alternatives like swimming or cycling, play a significant role in recovery.
Physical therapy is often recommended to maintain foot strength and flexibility. Stretching and strengthening exercises for the foot and calf muscles can help improve biomechanics and reduce the likelihood of recurring issues. In cases of persistent pain, corticosteroid injections may provide temporary relief by reducing inflammation, though they should be used cautiously due to potential weakening of surrounding soft tissues.
When conservative treatments fail to provide lasting relief, surgical intervention may be necessary. The most common procedure, sesamoidectomy, involves removing the damaged sesamoid bone to alleviate pain while preserving foot function. In some cases, partial sesamoidectomy (removing only part of the sesamoid) may be performed to maintain better foot stability. Post-surgical rehabilitation, including gradual weight-bearing exercises and custom orthotics, is essential for optimal recovery and to prevent complications such as altered gait mechanics.
Preventing Sesamoid Injuries
For patients at risk, prevention strategies include wearing proper footwear with good shock absorption, gradually increasing activity levels, maintaining a healthy weight, and incorporating stretching and strengthening exercises into their routine.
Through small, sesamoid bones play a vital role in foot function. When injured, they can cause significant pain and mobility limitations. As a podiatrist, early diagnosis and proper treatment of sesamoid injuries are essential to ensuring patients regain comfort and function. With the right approach, most sesamoid-related problems can be effectively managed, allowing patients to stay active and pain-free.
If you are experiencing pain from sesamoids, contact Dr. Altepeter’s office at (239) 430-3668 (FOOT) 
or visit www.NaplesPodiatrist.com to schedule your appointment online. Dr. Joe Altepeter is a podiatric physician and surgeon practicing in Southwest Florida. Board Certified: American Board of Foot and Ankle Surgery.
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