Sesamoid stress fractures are relatively uncommon and often confused with the more common problem of sesamoiditis combined with a congenital bipartite (split) sesamoid. When they occur sesamoid stress fractures usually result form an episode of increased repetitive loading such as a increase in running training. Symptoms are pain under the great toe that is aggravated by standing and walking. It is not uncommon for patients to have a high arched foot type. X-rays may be diagnostic although an MRI may be required to clarify the diagnosis. Non-displaced sesamoid stress fractues can be treated non-surgically with limited or no weight-bearing for 6-8 weeks. Displacaed or chronic stress fractures may need surgery which could include fixing the fracture or removing the affected bone.
Perhaps the first thing to realize about sesamoid stress fractures is that in many instances they are not actually stress fractures of one of the two sesamoid bones, but rather a “bipartite sesamoid” with an associated “sesamoiditis”. A bipartite sesamoid is a variant of a normal sesamoid where the bone remains separated into two fragments during development. “Sesamoiditis” is a general term that refers to pain under the great toe that occurs from repetitive loading to this area in a manner that is similar to metatarsalgia.
However, sesamoid stress fractures do occur and also produce chronic pain under the base of the great toe similar to that seen in sesamoiditis. Sesamoid stress fractures are believed to be caused by repetitive loading to this area such as may occur during standing, walking or running, particularly in shoes that do not provide adequate protection. A painful sesamoid stress fracture may cause an individual to limp quite noticeably. Symptoms may settle over time but they will reoccur when repetitive loading, such as running, is starting again. The pain is often quite localized and is associated with the involved sesamoid. It’s not uncommon for a sesamoid stress fracture to occur after a hard training run or another type of activity that is associated with more repetitive loading than normal such as when an individual’s activity level or training level has increased noticeably.
Sesamoid stress fractures are associated with localized tenderness over the involved sesamoid. Movement of the toe may exacerbate the symptoms. The pain is usually isolated to under the great toe region. It’s not uncommon for these injuries to occur in patients with high arched feet, as this foot shape tends to cause increased loading at the base of the great toe.
Plain x-rays of the foot can be very helpful. Typically they will demonstrate two sections of the sesamoid. What differentiates a stress fracture from the bipartite sesamoid is that the bone fragments of a bipartite sesamoid has a clearly identified margin. This is because the congenital nature of a bipartite sesamoid means that it has been present since development. Whereas a sesamoid stress fractures has a fracture like appearance on radiograph.
An MRI can help differentiate a bipartite sesamoid from a sesamoid stress fracture. An MRI may also help differentiate an acute sesamoid fracture from a chronic stress fracture. In addition, it may identify an area of avascularity as part of the sesamoid stress fracture. This is not uncommon as the sesamoid bones have a poor blood supply and a chronic stress fracture or bipartite sesamoid may leave one section of the sesamoid with a limited blood supply.
Treatment is oriented towards to making the correct diagnosis, specifically, determining whether the problem is from a sesamoid stress fracture or a bipartite sesamoid with overlying sesamoiditis. The general non-operative treatment principles are similar, although a true sesamoid stress fracture will tend to have a worse prognosis.
Non-operative treatment of a non-displaced acute sesamoid stress fracture requires a period of immobilization and protected weight bearing. Essentially, what is required is weight bearing through the heel for a period of six to eight weeks in order to optimize the chance of the sesamoid bones to heal. Displaced acute stress fractures will need surgical intervention.
More commonly, a chronic stress fracture is present and these are managed non-operatively in a manner that is similar to treatimg sesamoiditis. Specifically, the area under the base of the great toe is protected. An orthotic that helps to offload this area is used. This is typically an orthotic with a recessed area under the base of the first metatarsal head. This is combined with the cushioned insole and a very stiff sole of the shoe with a slight contour. A stiff sole with a rocker bottom contour will allow for a smoother dispersion of the force away from the base of the great toe. In addition, activity modification to help prevent excessive loading to this area should be performed. Time will often help to settle this condition when combined with activity modification.
Surgical treatment is less predictable than might be hoped for. The treatment either involves repairing the fracture with fixation or removing the fractured sesamoid bone entirely. Removing the sesamoid bone is performed in conjunction with a repair of the associated joint capsule. One of the issues with both operative and non-operative treatment is that the underlying foot shape (usually high arched) that often contributes to the development of this condition remains unchanged. Therefore, the area under the base toe is persistently repetitively loaded with standing and walking activities.
Potential complications of surgery
Complication of surgeries to repair or remove the involve sesamoid include the usual array of complications such as:
Wound healing problems
Blood clots (DVT and PE)
Complications that are specific to sesamoid surgery include:
Irritation to the nerve running to the inside of the big toe
Persistence of symptoms is also a complication as the loading to this area will continue.
Cock-up deformity of the Big Toes
If the sesamoid is resected and the capsule is not adequately repaired, a cock up toe deformity can occur, and in this instance, the big toe will tend to rise up out of position creating an uncomfortable deformity.