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If you have significant pain in the bottom of your great toe joint area, you may have a fractured sesamoid. Sesamoid fractures can sometimes be difficult to diagnose and are often missed. In many cases, people get diagnosed with soft tissue injuries when in fact a fracture is present.
Chronic pain that requires you to reduce your activity could result from sesamoid fractures if they are not treated.
In this article, we’ll discuss the details of how to manage sesamoid fractures to ensure positive outcomes.
Let’s dive in…
Anatomy of the Sesamoid Bones
There are two pea-shaped bones on the bottom of the first metatarsal. The two sesamoid bones are called the “tibial” and “fibular” sesamoid bones.
The tibial sesamoid is larger than the fibular sesamoid (1).
The sesamoid bones are located slightly further back from the great toe joint. They are embedded in the flexor hallucis brevis tendons. The flexor hallucis brevis tendons help flex the great toe downwards.
The two sesamoid bones are connected by the intersesamoidal ligament. The two sesamoid bones articulate with the 1st metatarsal and are held together by the plantar plate (ligament). The sesamoid bones fully form by age 12.
Although most people have 2 sesamoid bones, some people may have more. The blood supply to the foot sesamoid bones is from the plantar medial artery.
What Is the Purpose of the Sesamoid Bones?
The sesamoid bones are incredibly important in transmitting weight-bearing forces in the foot. They are important because they help absorb shock and protect the first metatarsal when you stand and walk. The sesamoid bones also help to stabilize the first ray by aiding in the pull of the flexor hallucis brevis tendons (2).
The tibial (inner) sesamoid bone takes on most of the weight-bearing load compared to the fibular (outer) sesamoid bone.
Due to this, the tibial sesamoid bone fractures more often than the fibular sesamoid.
How Common Is a Sesamoid Fracture in the Great Toe?
“Injuries to the sesamoids comprise 12 percent of injuries to the great toe complex (3)”. A study done by C. Stein in The Physician and Sportsmedicine journal reviewed 58 patients who had sesamoid fractures. Dancing (37.9%), running (13.8%), and gymnastics (13.8%) were the most common sports reported among these patients (4).
This suggests that participating in certain sports that cause excess pressure to be placed on the ball of the foot can increase the risk for sesamoid fractures.
What Causes Sesamoid Fractures?
Sesamoid fractures can be caused by repetitive stress to the sesamoids (in the case of a stress fracture) and traumatic injuries (falls from heights/accidents).
Certain activities that cause the toe to flex upwards can increase the risk of sesamoid fractures due to its location on the ball of the foot. These activities include running, yoga, and jumping.
Sports that require pivoting with acceleration and deceleration like soccer and football can also cause sesamoid fractures.
Certain foot structures, like having a high-arched foot can increase your likelihood of developing sesamoid fractures due to high stress underneath the forefoot.
What Does a Fractured Sesamoid Feel Like?
Symptoms of a Sesamoid Fracture Include:
- Pain and swelling in the bottom of the forefoot
- Bruising of the forefoot
- Pain in the bottom of the forefoot when bearing weight
- Pain that persists when resting
- Pain when flexing the great toe upwards and downwards
How Are Sesamoid Fractures Diagnosed?
If you have pain in the ball of your foot and you suspect that you may have a sesamoid fracture, you should contact your foot doctor for evaluation.
Try to stay off of your foot using crutches. Walking on a fracture can make the fracture fragments shift.
Your doctor will obtain a history and palpate (examine by touch) the area of concern. Pain will be present upon palpation of the tibial and fibular sesamoid.
Your doctor will order radiographs of the foot to determine whether there is a fracture present in the sesamoids. An axial sesamoid x-ray view can help your doctor visualize the sesamoids.
If your doctor has difficulty visualizing the sesamoid fracture on an x-ray and believes that there may be a fracture present, he/she may order an MRI or a CT scan to evaluate the sesamoid bones.
An MRI will confirm the presence of a fracture and will also show soft tissue structures surrounding the sesamoid bones in detail. This can help rule out injury to the surrounding soft tissue structures in the sesamoid complex.
A CT scan can help evaluate the cortical bone of the sesamoids in further detail. This can help identify the fracture pattern as well as how many fracture lines are present. This becomes important for surgical planning.
How Are Sesamoid Fractures Treated?
Non-displaced Sesamoid Fractures
If you have a non-displaced (broken but in proper alignment) sesamoid fracture you will need to remain non-weight bearing in a cast boot for 6-8 weeks minimum. This is the amount of time it takes for fracture healing to take place.
Following this, you can start weight bearing in the cast boot for an additional 3-4 weeks before transitioning back to athletic shoes.
Your doctor will order x-rays every 3-4 weeks to make sure your fracture is healing appropriately.
You should start RICE therapy during this period to reduce pain and swelling.
Displaced Sesamoid Fractures
If the sesamoid fracture is displaced (broken and fracture fragments are separated), then surgery may be warranted.
The sesamoid bones are very small. If your doctor believes that the fracture can be repaired, he/she will suggest surgery. This would be done in the operating room under anesthesia.
Your doctor will reduce the fracture and fixate it using small screws. Due to the poor blood supply in the sesamoid bone, your doctor may insert a bone graft (taken from the first metatarsal) into your sesamoid bone. This can help it heal better.
After the surgery, you will need to remain non-weight bearing in a cast boot for 4-6 weeks, followed by gradual weight-bearing for another 4 weeks before transitioning to athletic shoes.
If the sesamoid fractures are comminuted (broken and in multiple pieces), your doctor may choose to remove the small broken fragments and leave the larger remaining fragment intact.
If the sesamoid bone is crushed and in many small fragments, your doctor will completely remove the sesamoid bone. You can remain minimal weight bearing in a cast boot after the surgery for 4-6 weeks, followed by gradual activity into athletic shoes.
Removal of the sesamoid bone may cause some weakness in the push off of the great toe when walking. Removing a sesamoid bone can sometimes cause a bunion to form years later, or a hallux varus deformity.
How Much Does Sesamoid Surgery Cost?
According to MDSave.com, the cost of sesamoid bone removal is $5866 on average. You should call your insurance company to see if the surgery would be covered or not.
What Happens if a Sesamoid Fracture Goes Untreated?
If a sesamoid fracture is left untreated, it can cause chronic pain and post-traumatic arthritis in the great toe joint. You may feel pain when you walk and put pressure on the ball of your foot. This can make high-impact activities like sports difficult to complete due to pain.
Conclusion
In conclusion, sesamoid fractures are serious and should not be neglected. Although they can often be missed on x-ray, advanced imaging is readily available and is beneficial in identifying the fracture. It’s best to identify and treat the fracture promptly to ensure the best outcomes.
Have you ever broken a sesamoid bone? I would love to hear from you! Leave a comment below!
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References
- Mittlmeier T, Haar P. Sesamoid and toe fractures. Injury. 2004 Sep;35 Suppl 2:SB87-97.https://pubmed.ncbi.nlm.nih.gov/15315883
- Sims, A. L., & Kurup, H. V. (2014). Painful sesamoid of the great toe. World journal of orthopedics, 5(2), 146.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4017307/
- McBryde AM Jr, Anderson RB. Sesamoid foot problems in the athlete. Clin Sports Med. 1988 Jan;7(1):51-60. https://pubmed.ncbi.nlm.nih.gov/3044622/
- Stein CJ, Sugimoto D, Slick NR, Lanois CJ, Dahlberg BW, Zwicker RL, Micheli LJ. Hallux sesamoid fractures in young athletes. Phys Sportsmed. 2019 Nov;47(4):441-447. https://pubmed.ncbi.nlm.nih.gov/31109214/
- Bronner, S., Novella, T., & Becica, L. (2007). Management of a delayed union sesamoid fracture in a dancer. journal of orthopaedic & sports physical therapy, 37(9), 529-540.https://www.jospt.org/doi/abs/10.2519/jospt.2007.2472
- Blundell, C. M., Nicholson, P., & Blackney, M. W. (2002). Percutaneous screw fixation for fractures of the sesamoid bones of the hallux. The Journal of Bone and Joint Surgery. British volume, 84(8), 1138-1141.https://online.boneandjoint.org.uk/doi/abs/10.1302/0301-620X.84B8.0841138
- Daddimani RM, Madhavamurthy SK, Jeevannavar SS, Shettar CM. Fracture of the medial tibial sesamoid bone of the foot-case report. J Clin Diagn Res. 2015 Apr;9(4):RD03-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4437128/
- Stracciolini A, Dahlberg BW, Quinn B, Sugimoto D, Stein C. SESAMOID INJURIES IN PEDIATRIC AND ADOLESCENT ATHLETES PRESENTING TO SPORTS MEDICINE CLINIC. Orthopaedic Journal of Sports Medicine. 2019;7(3_suppl).https://journals.sagepub.com/doi/full/10.1177/2325967119S00183
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